Point-of-care Resource Use in the Emergency Department: A Developmental Model.
Patocka C, Lin M, Voros J, Chan T. | AEM Educ Train. 2018 May 30;2(3):221-228
DOI: https://doi.org/10.1002/aet2.10101  | Télécharger l'article au format  
Keywords: Aucun

Original Contributions

Introduction : Technologic advances, free open-access medical education (FOAM or #FOAMed), and social media have increased access to clinician-oriented medical education resources and interactions at the point of care (POC); yet, how, when, and why medical providers use these resources remains unclear. To facilitate the development and design of intuitive POC resources, it is imperative that we expand our understanding of physician knowledge-seeking behavior at the POC.

Méthode : Individual semistructured interviews were conducted and analyzed using a qualitative, grounded theory approach. Twelve emergency medicine providers (three medical students, three residents, and six attending physicians) were interviewed in person or via video chat to explore how POC resources are used in the emergency department (ED). A coding system was developed by two investigators and merged by consensus. A third investigator audited the analysis.

Résultats : A conceptual framework emerged from the data describing the four main uses of POC resources (deep-dive, advanced clinical decision making, teaching patients, and teaching learners) and how practitioners' main use varied based on medical expertise. Junior learners prioritize their own broad learning. Experienced learners and physicians prefer to 1) seek answers to specific focused clinical questions and 2) disseminate POC information to teach patients and learners, allowing them to devote more of their time to other clinical and teaching tasks.

Conclusion : The conceptual framework describes how physician knowledge-seeking behavior using POC resources in the ED evolves predictably throughout training and practice. Knowledge of this evolution can be used to enhance POC resource design and guide bedside teaching strategies.

Conclusion (proposition de traduction) : Le cadre conceptuel décrit comment le comportement de recherche de connaissances des médecins utilisant les ressources au lit du malade aux urgences évolue de façon prévisible tout au long de la formation et de la pratique. La connaissance de cette évolution peut être utilisée pour améliorer la conception des ressources au lit du malade et guider les stratégies d'enseignement au chevet du patient.

Does Family Presence in the Trauma Bay Help or Hinder Care?.
Joyner BL Jr | AMA J Ethics. 2018 May 1;20(5):507-512
DOI: https://doi.org/10.1001/journalofethics.2018.20.5.sect1-1805  | Télécharger l'article au format  
Keywords: Aucun

SECOND THOUGHTS

Editorial : Family presence during a pediatric resuscitation remains somewhat controversial. Opponents express concern that family presence would be detrimental to team performance and that exposure to such a traumatic event could put family members at risk of posttraumatic stress. Proponents argue that family presence affords families a sense of closure by easing their anxieties and assuring them that everything was done for their loved ones in addition to improving clinicians' professional behavior by humanizing the patient. This article will review the literature on the potential benefits and pitfalls of family presence during a pediatric resuscitation.

Conclusion : The various impacts of family presence during resuscitation can be analyzed using a structured, principled approach. Although it is an extremely complex issue with many potential impacts on the patient, family, and trauma team, FPDR is ethically permissible given its significant potential benefits (and minimal risk) for pediatric patients and their families. For this reason, a more structured global approach to this topic should be undertaken to address the inequities that currently exist in our system—a system in which family presence in the trauma bay is dependent upon geography and level of advocacy.

Conclusion (proposition de traduction) : Les divers impacts de la présence de la famille pendant la réanimation peuvent être analysés à l'aide d'une approche structurée et fondée sur des principes. Bien qu'il s'agisse d'une question extrêmement complexe qui peut avoir de nombreuses répercussions sur le patient, la famille et l'équipe de traumatologie, la présence de la famille pendant la réanimation est acceptable sur le plan éthique étant donné ses avantages potentiels importants (et son risque minimal) pour les patients pédiatriques et leurs familles. Pour cette raison, une approche globale plus structurée de ce sujet devrait être adoptée pour s'attaquer aux inégalités qui existent actuellement dans notre système - un système dans lequel la présence de la famille en salle de traumatologie dépend de la géographie et du niveau de défense des droits.

The Technology of Video Laryngoscopy.
Berkow LC, Morey TE, Urdaneta F. | Anesth Analg. 2018 May;126(5):1527-1534
DOI: https://doi.org/10.1213/ANE.0000000000002490
Keywords: Aucun

Special Article

Editorial : Tracheal intubation via laryngeal exposure has evolved over the past 150 years and has greatly expanded in the last decade with the introduction and development of newer, more sophisticated optical airway devices. The introduction of indirect and video-assisted laryngoscopes has significantly impacted airway management as evidenced by the presence of these devices in the majority of published difficult airway algorithms. However, it is quite possible that many airway managers do not have a thorough comprehension of how these devices actually function, an understanding that is vital not only for their use but also for assessing the devices' limitations.

Conclusion : This article discusses the development of video laryngoscopy, how the video laryngoscope works, and the impact of video laryngoscopy on difficult airway management.

Conclusion (proposition de traduction) : Cet article traite du développement de la video laryngoscopie, du fonctionnement du video laryngoscope et de l'impact de la video laryngoscopie sur la gestion des voies aériennes difficiles à intuber.

Incidence of Anaphylaxis Associated With Sugammadex.
Miyazaki Y, Sunaga H, Kida K, Hobo S, Inoue N, Muto M, Uezono S. | Anesth Analg. 2018 May;126(5):1505-1508
DOI: https://doi.org/10.1213/ANE.0000000000002562
Keywords: aucun

Brief Report

Introduction : We retrospectively investigated the incidence of potential sugammadex-induced anaphylaxis at a single center in Japan over a period of 3 years.

Résultats : The overall incidence of intraoperative hypersensitivity reaction was 0.22% (95% confidence interval [CI], 0.17%-0.29%), and the incidence of anaphylaxis was 0.059% (95% CI, 0.032%-0.10%). The total number of patients who received sugammadex during the study period was 15,479, and the incidence of anaphylaxis associated with sugammadex was 0.039% (n = 6; 95% CI, 0.014%-0.084%).

Conclusion : This result implies that the incidence of sugammadex-associated anaphylaxis could be as high as that for succinylcholine or rocuronium. A prospective study, including testing for identification of cause, is necessary to confirm the exact incidence of sugammadex-induced anaphylaxis; however, the present finding calls attention to this potential.

Conclusion (proposition de traduction) : Ce résultat montre que l'incidence de l'anaphylaxie associée au sugammadex pourrait être aussi élevée que celle de la succinylcholine ou du rocuronium.
Une étude prospective, incluant des tests d'identification de la cause, est nécessaire pour confirmer l'incidence exacte de l'anaphylaxie induite par le sugammadex ; Cependant, la présente constatation attire l'attention sur ce potentiel.

Commentaire : Voir l'article de Takazawa T en al. Sugammadex and rocuronium-induced anaphylaxis. J Anesth. 2016 Apr;30(2):290-7     (accès libre).

Videolaryngoscopy for Physician-Based, Prehospital Emergency Intubation: A Prospective, Randomized, Multicenter Comparison of Different Blade Types Using A.P. Advance, C-MAC System, and KingVision.
Cavus E, Janssen S, Reifferscheid F, Caliebe A, Callies A, von der Heyden M, Knacke PG, Doerges V. | Anesth Analg. 2018 May;126(5):1565-1574
DOI: https://doi.org/10.1213/ANE.0000000000002735
Keywords: Aucun

Original Clinical Research Report

Introduction : Videolaryngoscopy is a valuable technique for endotracheal intubation. When used in the perioperative period, different videolaryngoscopes vary both in terms of technical use and intubation success rates. However, in the prehospital environment, the relative performance of different videolaryngoscopic systems is less well studied.

Méthode : We conducted this prospective, randomized, multicenter study at 4 German prehospital emergency medicine centers. One hundred sixty-eight adult patients requiring prehospital emergency intubation were treated by an emergency physician and randomized to 1 of 3 portable videolaryngoscopes (A.P. Advance, C-MAC PM, and channeled blade KingVision) with different blade types. The primary outcome variable was overall intubation success and secondary outcomes included first-attempt intubation success, glottis visualization, and difficulty with handling the devices. P values for pairwise comparisons are corrected by the Bonferroni method for 3 tests (P[BF]). All presented P values are adjusted for center.

Résultats : Glottis visualization was comparable with all 3 devices. Overall intubation success for A.P. Advance, C-MAC, and KingVision was 96%, 97%, and 61%, respectively (overall: P < .001, A.P. Advance versus C-MAC: odds ratio [OR], 0.97, 95% confidence interval [CI], 0.13-7.42, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001; C-MAC versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001). Intubation success on the first attempt with A.P. Advance, C-MAC, and KingVision was 86%, 85%, and 48%, respectively (overall: P < .001, A.P. Advance versus C-MAC: OR, 0.89, 95% CI, 0.31-2.53, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.24, 95% CI, 0.055-0.38, P[BF] = 0.0054; C-MAC versus KingVision: OR, 0.21, 95% CI, 0.043-.34, P[BF] < 0.003). Direct laryngoscopy for successful intubation with the videolaryngoscopic device was necessary with the A.P. Advance in 5 patients, and with the C-MAC in 4 patients. In the KingVision group, 21 patients were intubated with an alternative device.

Conclusion : During prehospital emergency endotracheal intubation performed by emergency physicians, success rates of 3 commercially available videolaryngoscopes A.P. Advance, C-MAC PM, and KingVision varied markedly. We also found that although any of the videolaryngoscopes provided an adequate view, actual intubation was more difficult with the channeled blade KingVision.

Conclusion (proposition de traduction) : Au cours de l'intubation orotrachéale en urgence préhospitalière réalisée par des médecins urgentistes, les taux de réussite avec les trois vidéolaryngoscopes disponibles dans le commerce, A.P. Advance, C-MAC PM et KingVision, variaient considérablement.
Nous avons également constaté que, bien que l'un des vidéolaryngoscopes fournisse une vision adéquate, l'intubation réelle était plus difficile avec la lame cannelée KingVision.

Colloids and the Microcirculation.
He H, Liu D, Ince C. | Anesth Analg. 2018 May;126(5):1747-1754
DOI: https://doi.org/10.1213/ANE.0000000000002620
Keywords: Aucun

Narrative Review Article

Editorial : Colloid solutions have been advocated for use in treating hypovolemia due to their expected effect on improving intravascular retention compared with crystalloid solutions. Because the ultimate desired effect of fluid resuscitation is the improvement of microcirculatory perfusion and tissue oxygenation, it is of interest to study the effects of colloids and crystalloids at the level of microcirculation under conditions of shock and fluid resuscitation, and to explore the potential benefits of using colloids in terms of recruiting the microcirculation under conditions of hypovolemia. This article reviews the physiochemical properties of the various types of colloid solutions (eg, gelatin, dextrans, hydroxyethyl starches, and albumin) and the effects that they have under various conditions of hypovolemia in experimental and clinical scenarios.

Conclusion : -

Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment.
Mistry B, Stewart De Ramirez S, Kelen G, Schmitz PSK, Balhara KS, Levin S, Martinez D, Psoter K, Anton X, Hinson JS. | Ann Emerg Med. 2018 May;71(5):581-587.e3
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.036
Keywords: Aucun

The Practice of Emergency Medicine

Introduction : We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites.

Méthode : This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed.

Résultats : Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%).

Conclusion : In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.

Conclusion (proposition de traduction) : Dans cette étude multinationale, la concordance du score ESI attribué par l'infirmière avec l'étalon de référence était universellement médiocre et la variabilité était élevée. Bien que l'ESI soit l'outil de triage aux urgences le plus utilisé aux États-Unis et qu'il soit de plus en plus utilisé dans le monde entier, nos résultats soulignent le besoin d'outils de triage aux urgences plus fiables.

Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest.
Kawano T, Grunau B, Scheuermeyer FX, Gibo K, Fordyce CB, Lin S, Stenstrom R, Schlamp R, Jenneson S, Christenson J. | Ann Emerg Med. 2018 May;71(5):588-596
DOI: https://doi.org/10.1016/j.annemergmed.2017.11.015  | Télécharger l'article au format  
Keywords: Aucun

Emergency Medical Services

Introduction : We seek to determine the effect of intraosseous over intravenous vascular access on outcomes after out-of-hospital cardiac arrest.

Méthode : This secondary analysis of the Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed (PRIMED) study included adult patients with nontraumatic out-of-hospital cardiac arrests treated during 2007 to 2009, excluding those with any unsuccessful attempt or more than one access site. The primary exposure was intraosseous versus intravenous vascular access. The primary outcome was favorable neurologic outcome on hospital discharge (modified Rankin Scale score ≤3). We determined the association between vascular access route and out-of-hospital cardiac arrest outcome with multivariable logistic regression, adjusting for age, sex, initial emergency medical services-recorded rhythm (shockable or nonshockable), witness status, bystander cardiopulmonary resuscitation, use of public automated external defibrillator, episode location (public or not), and time from call to paramedic scene arrival. We confirmed the results with multiple imputation, propensity score matching, and generalized estimating equations, with study enrolling region as a clustering variable.

Résultats : Of 13,155 included out-of-hospital cardiac arrests, 660 (5.0%) received intraosseous vascular access. In the intraosseous group, 10 of 660 patients (1.5%) had favorable neurologic outcome compared with 945 of 12,495 (7.6%) in the intravenous group. On multivariable regression, intraosseous access was associated with poorer out-of-hospital cardiac arrest survival (adjusted odds ratio 0.24; 95% confidence interval 0.12 to 0.46). Sensitivity analyses revealed similar results.

Conclusion : In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access.

Conclusion (proposition de traduction) : Chez les patients adultes en arrêt cardiaque extra-hospitalier, l'accès vasculaire intraosseux était associé à de moins bons résultats neurologiques que l'accès intraveineux.

Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies.
Wang HE, Donnelly JP, Barton D, Jarvis JL. | Ann Emerg Med. 2018 May;71(5):597-607.e3
DOI: https://doi.org/10.1016/j.annemergmed.2017.12.012
Keywords: Aucun

Emergency Medical Services

Introduction : Although often the focus of quality improvement efforts, emergency medical services (EMS) advanced airway management performance has few national comparisons, nor are there many assessments with benchmarks accounting for differences in agency volume or patient mix. We seek to assess variations in advanced airway management and conventional intubation performance in a national cohort of EMS agencies.

Méthode : We used EMS data from ESO Solutions, a national EMS electronic health record system. We identified EMS emergency responses with attempted advanced airway management (conventional intubation, rapid sequence intubation, sedation-assisted intubation, supraglottic airway insertion, and cricothyroidotomy). We also separately examined cases with initial conventional intubation. We determined EMS agency risk-standardized advanced airway management and initial conventional intubation success rates by using mixed-effects regression models, fitting agency as a random intercept, adjusting for patient age, sex, race, cardiac arrest, or trauma status, and use of rapid sequence or sedation-assisted intubation, and accounting for reliability variations from EMS agency airway volume. We assessed changes in agency advanced airway management and initial conventional intubation performance rank after risk and reliability adjustment. We also identified high and low performers (reliability-adjusted and risk-standardized success confidence intervals falling outside the mean).

Résultats : During 2011 to 2015, 550 EMS agencies performed 57,209 advanced airway management procedures. Among 401 EMS agencies with greater than or equal to 10 advanced airway management procedures, there were a total of 56,636 procedures. Median reliability-adjusted and risk-standardized EMS agency advanced airway management success was 92.9% (interquartile range 90.1% to 94.8%; minimum 58.2%; maximum 99.0%). There were 56 advanced airway management low-performing and 38 high-performing EMS agencies. Among 342 agencies with greater than or equal to 10 initial conventional intubations, there were a total of 37,360 initial conventional intubations. Median reliability-adjusted and risk-standardized EMS agency initial conventional intubation success was 77.3% (interquartile range 70.9% to 83.6%; minimum 47.1%; maximum 95.8%). There were 64 initial conventional intubation low-performing and 45 high-performing EMS agencies.

Conclusion : In this national series, EMS advanced airway management and initial conventional intubation performance varied widely. Reliability adjustment and risk standardization may influence EMS airway management performance assessments.

Conclusion (proposition de traduction) : Dans cette série nationale, la gestion spécialisée des voies aériennes par les SMU et les performances d'intubation conventionnelles initiales variaient de façon importante. L'ajustement de la fiabilité et la normalisation des risques peuvent influencer les évaluations de la performance de la gestion des voies respiratoires par les EMS.

Managing Peripheral Facial Palsy.
Garro A, Nigrovic LE. | Ann Emerg Med. 2018 May;71(5):618-624
DOI: https://doi.org/10.1016/j.annemergmed.2017.08.039  | Télécharger l'article au format  
Keywords: Aucun

Neurolgy

Introduction : Physicians frequently encounter patients with acute-onset peripheral facial palsy in the emergency department (ED). Although many cases are idiopathic (eg, Bell’s palsy), others are associated with identifiable causes. Regardless of the cause, 85% of patients recover some function, with more than 70% achieving complete recovery. The most appropriate treatment depends on the cause, which is often unknown at the ED evaluation. We discuss our approach to patients with peripheral facial palsy according to available evidence and, when the evidence is less clear, our expertise in this area.

Conclusion : Patients with acute-onset peripheral facial palsy commonly present to the ED for evaluation and treatment. ED clinicians should promptly initiate appropriate therapy to improve long-term recovery. For patients with high risk for Lyme disease facial palsy, we recommend empiric antibiotics while awaiting Lyme disease test results. All other patients should be treated with corticosteroids, and those with severe facial palsy should also be treated with antivirals.

Conclusion (proposition de traduction) : Les patients atteints d'une paralysie faciale périphérique aiguë consultent souvent aux urgence pour évaluation et traitement. Les cliniciens des urgences doivent rapidement initier un traitement approprié pour améliorer le rétablissement à long terme.
Pour les patients présentant un risque élevé de paralysie faciale de le cadre d'une maladie de Lyme, nous recommandons des antibiotiques probabilistes en attendant les résultats des tests sanguins concernant la maladie de Lyme. Tous les autres patients doivent être traités par des corticostéroïdes, et ceux qui ont une paralysie faciale sévère doivent également être traités par des antiviraux.

Diagnosing Patients With Acute-Onset Persistent Dizziness.
Edlow JA. | Ann Emerg Med. 2018 May;71(5):625-631
DOI: https://doi.org/10.1016/j.annemergmed.2017.10.012  | Télécharger l'article au format  
Keywords: Aucun

Neurology

Introduction : Three percent of emergency department (ED) patients present with dizziness, vertigo, lightheadedness, or imbalance. These words are not diagnostically meaningful. Rather, it is the timing and the factors that trigger the dizziness that best inform the differential diagnosis. Asking a patient, “What do you mean by ‘dizzy’?” is less important than defining the rapidity of onset, the context, presence of associated symptoms, the intermittent or persistent nature of the dizziness, and triggers of intermittent symptoms.

Discussion : Various general medical and neurologic conditions rarely cause an isolated acute vestibular syndrome. Context (eg, anticonvulsant toxicity) or associated symptoms and signs (eg, confusion in Wernicke’s syndrome) usually suggest the diagnosis. Some patients with Wernicke’s syndrome present with acute vestibular syndrome without encephalopathy. High-risk patients should be empirically treated with thiamine. A new multiple sclerosis diagnosis accounts for less than 2 % of patients presenting with an acute vestibular syndrome.

Conclusion : For emergency physicians, the crucial differential diagnosis is vestibular neuritis versus stroke. Vestibular neuritis is inflammation of the vestibular portion of the eighth nerve, similar in pathophysiology to Bell’s palsy. Labyrinthitis is inflammation of both the vestibular and cochlear components of the eighth nerve.

Conclusion (proposition de traduction) : Pour les urgentistes, le diagnostic différentiel crucial est la névrite vestibulaire par rapport à l'accident vasculaire cérébral. La névrite vestibulaire est une inflammation de la partie vestibulaire du VIII, similaire en physiopathologie à la paralysie de Charles Bell. La labyrinthite est une inflammation des structures vestibulaire et cochléaire du VIII.

Commentaire : Document pédagogique sur la prise en charge des vertiges aux urgences

Does Bed Rest or Fluid Supplementation Prevent Post-Dural Puncture Headache?.
April MD, Long B. | Ann Emerg Med. 2018 May;71(5):e55-e57
DOI: https://doi.org/10.1016/j.annemergmed.2017.12.011  | Télécharger l'article au format  
Keywords: Aucun

Neurology

Méthode : Review authors searched the Cochrane Central Register of Controlled Trials, MEDLINE (1966 to February 2015), EMBASE (1974 to February 2015), and Literatura Latino Americana em Ciências da Saúde (LILACS) (inception to February 2015). Authors also hand searched reference lists from retrieved studies and the World Health Organization International Clinical Trials Registry platform (through February 2015). Authors included randomized controlled trials of patients undergoing dural puncture that compared interventions to prevent post–dural puncture headache. Two authors independently reviewed studies with the Web-based Early Review Organizing Software. They retrieved the full text of studies identified as potentially eligible for meta-analysis inclusion in accordance with review of the title and abstract. A third study author resolved disagreements in regard to study inclusion.

Discussion : This meta-analysis does not include data for several alternative interventions reported by some studies to have efficacy in preventing post–dural puncture headache. A 2017 Cochrane review suggested that smaller needles or needles designed with atraumatic tips may be effective interventions for prevention of post–dural puncture headache, although incomplete methodology reporting precludes interpretation of the risk of bias for many of these studies.12 Additionally, another meta-analysis reported that orientation of the bevel parallel to the longitudinal fibers of the dura when lumbar puncture is performed with a cutting needle may reduce the incidence of post–dural puncture headache, although this systematic review did not assess the study quality of the included studies.13 Finally, reinsertion of the stylet before removal of the needle may decrease the risk of subsequent headache.14 Ongoing study of these strategies will be useful to further assess the efficacy of these interventions, which show more promise than bed rest and fluid supplementation.

Conclusion : Neither bed rest nor fluid supplementation decreases the incidence of headache after dural puncture.

Conclusion (proposition de traduction) : Ni le repos au lit ni l'apport de liquide ne réduisent l'incidence des maux de tête après la ponction lombaire.

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease.
Wolf SJ, American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thromboembolic Disease:, Wolf SJ, Hahn SA, Nentwich LM, Raja AS, Silvers SM, Brown MD. | Ann Emerg Med. 2018 May;71(5):e59-e109
DOI: https://doi.org/10.1016/j.annemergmed.2018.03.006  | Télécharger l'article au format  
Keywords: Aucun

Clinical Policy

Editorial : This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult patients with suspected venous thromboembolism. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions:
- In adult patients with suspected acute pulmonary embolism, can a clinical prediction rule be used to identify a group of patients at very low risk for the diagnosis of pulmonary embolism for whom no additional diagnostic workup is required?
- In adult patients with low to intermediate pretest probability for acute pulmonary embolism, does a negative age-adjusted D-dimer result identify a group of patients at very low risk for the diagnosis of pulmonary embolism for whom no additional diagnostic workup is required?
- In adult patients with subsegmental pulmonary embolism, is it safe to withhold anticoagulation?
- In adult patients diagnosed with acute pulmonary embolism, is initiation of anticoagulation and discharge from the emergency department safe?
- In adult patients diagnosed with acute lower-extremity deep venous thrombosis who are discharged from the ED, is treatment with a non–vitamin K antagonist oral anticoagulant safe and effective compared with treatment with low-molecular-weight heparin and vitamin K antagonist?
Evidence was graded and recommendations were made based on the strength of the available data.

Conclusion : -

Severe metabolic acidosis after out-of-hospital cardiac arrest: risk factors and association with outcome.
Jamme M, Ben Hadj Salem O, Guillemet L, Dupland P, Bougouin W, Charpentier J, Mira JP, Pène F, Dumas F, Cariou A, Geri G. | Ann Intensive Care. 2018 May 8;8(1):62
DOI: https://doi.org/10.1186/s13613-018-0409-3  | Télécharger l'article au format  
Keywords: Metabolic acidosis; Out-of-hospital cardiac arrest; Outcome; Post-resuscitation syndrome

Research

Introduction : Metabolic acidosis is frequently observed as a consequence of global ischemia-reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assess the impact of metabolic acidosis on outcome after OHCA.

Méthode : We included all consecutive OHCA patients admitted between 2007 and 2012. Using admission data, metabolic acidosis was defined by a positive base deficit and was categorized by quartiles. Main outcome was survival at ICU discharge. Factors associated with acidosis severity and with main outcome were evaluated by linear and logistic regressions, respectively.

Résultats : A total of 826 patients (68.3% male, median age 61 years) were included in the analysis. Median base deficit was 8.8 [5.3, 13.2] mEq/l. Male gender (p = 0.002), resuscitation duration (p < 0.001), initial shockable rhythm (p < 0.001) and post-resuscitation shock (p < 0.001) were associated with an increased level of acidosis. ICU mortality rate increased across base deficit quartiles (39.1, 59.2, 76.3 and 88.3%, p for trend < 0.001), and base deficit was independently associated with ICU mortality (p < 0.001). The proportion of CPC 1 patients among ICU survivors was similar across base deficit quartiles (72.8, 67.1, 70.5 and 62.5%, p = 0.21), and 7.3% of patients with a base deficit higher than 13.2 mEq/l survived to ICU discharge with complete neurological recovery.

Conclusion : Severe metabolic acidosis is frequent in OHCA patients and is associated with poorer outcome, in particular due to refractory shock. However, we observed that about 7% of patients with a very severe metabolic acidosis survived to ICU discharge with complete neurological recovery.

Conclusion (proposition de traduction) : L'acidose métabolique sévère est fréquente chez les patients après un arrêt cardiaque extra-hospitalier et est associée à de moins bons résultats, en particulier en raison d'un choc réfractaire. Cependant, nous avons observé qu'environ 7 % des patients ayant une acidose métabolique très sévère qui ont survécu à la sortie des soins intensifs avec une récupération neurologique complète.

Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis.
Msolli MA, Msolli MA, Beltaief K, Bouida W, Jerbi N, Grissa MH, Boubaker H, Boukef R, Nouira S. | BMC Emerg Med. 2018 May 24;18(1):15
DOI: https://doi.org/10.1186/s12873-018-0166-5  | Télécharger l'article au format  
Keywords: Acute appendicitis; Alvarado score; C-reactive protein

Research article

Introduction : The aim of this study is to test the diagnostic value of baseline and early change of C-reactive protein (CRP) concentrations, evaluated separately or in combination with the modified Alvarado score (MAS), in patients with clinically suspected acute appendicitis.

Méthode : This is a prospective observational study including all patients presenting to the emergency department with an equivocal diagnosis of acute appendicitis. After inclusion, clinical and demographic data are recorded and blood samples were taken at baseline and 3 h after for serum CRP measurements (3 h CRP). The MAS is also calculated for all patients. The ultimate diagnosis of appendicitis was based on the histologic findings of the excised appendix in operated patients and clinical follow-up in emergency department discharged patients. Diagnostic accuracy of admission CRP, early change of CRP 3 h CRP minus admission CRP, MAS and the combination of these parameters was expressed by sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating characteristics curve.

Résultats : Five hundred patients were included from January 2010 to December 2013. Overall, 387 patients were operated the negative appendectomy rate was 8,3%. CRP concentrations were higher in patients with acute appendicitis. However, the diagnostic value of admission CRP, delta CRP and MAS was moderate with area under ROC curve respectively equal to 0.63, 0.53 and 0.6. Combining admission CRP and delta CRP values to MAS did not result in a better performance. The area under ROC curve did not exceed 0.7 with the different combinations.

Conclusion : Early change of CRP has a moderate diagnostic value in patients with clinically suspected acute appendicitis. Combining CRP values to MAS did not improve diagnostic accuracy.

Conclusion (proposition de traduction) : L'élévation précoce de la CRP a une valeur diagnostique modérée chez les patients présentant une appendicite aiguë suspectée cliniquement. La combinaison des valeurs de CRP au score Alvarado modifié n'a pas amélioré la précision du diagnostic.

HEMS inter-facility transfer: a case-mix analysis.
Di Rocco D, Pasquier M, Albrecht E, Carron PN, Dami F. | BMC Emerg Med. 2018 May 16;18(1):13
DOI: https://doi.org/10.1186/s12873-018-0163-8  | Télécharger l'article au format  
Keywords: Case-mix; Helicopter emergency medical services (HEMS); Inter-facility transfer (IFT); Over-triage

Research article

Introduction : Helicopter emergency medical services (HEMS) are popular rescue systems despite inconsistent evidence in the scientific literature to support their use for primary interventions, as well as for inter-facility transfer (IFT). There is little research about IFT by HEMS, hence questions remain about the appropriateness of this method of transport. The aim of this study was to describe a case-mix of operational and medical characteristics for IFT activity of a sole HEMS base, and identify indicators of over-triage.

Méthode : This is a retrospective study on HEMS IFT over 36 months, from January 1st 2013 to December 31st 2015. Medical and operational data from the database of the Emergency Department of Lausanne University Hospital, which provides the emergency physicians for this helicopter base, were reviewed. It included distance and time of flight transport, type of care during flight, and estimated distance of transport if conducted by ground.

Résultats : There were 2194 HEMS missions including 979 IFT (44.6%). Most transfers involved adults (> 17 years old; 799 patients, 81.6%). Forty patients (4.1%) were classified as having benefitted from resuscitation or life-saving measures performed in flight, 615 (62.8%) from emergency treatment and 324 (33.1%) from simple clinical examination. The median distance by air between hospitals was 35.4 km. The estimated median distance by road was 47.7 km. The median duration time from origin to destination by air was 12 min.

Conclusion : This case-mix of IFTs by HEMS presents a high severity. There are many signs in favour of over-triage. We propose indicators to help choosing whether HEMS is the most appropriate mean of transport to perform the transfer regarding patient condition, geography, and medical competences available aboard ground ambulances; this may reduce over-triage.

Conclusion (proposition de traduction) : Cette comparaison de groupe de patients comparables de TIH par SMUH est de gravité élevée. Il y a beaucoup de signes en faveur du sur-tri. Nous proposons des indicateurs pour aider à choisir si le SMUH est le moyen de transport le plus approprié pour effectuer le transfert en ce qui concerne l'état du patient, la géographie et les compétences médicales disponibles à bord des ambulances terrestres; cela peut réduire le sur-tri.

Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study.
Staerk L, Wang B, Preis SR, Larson MG, Lubitz SA, Ellinor PT, McManus DD, Ko D, Weng LC, Lunetta KL, Frost L, Benjamin EJ, Trinquart L. | BMJ. 2018 Apr 26;361:k1453
DOI: https://doi.org/10.1136/bmj.k1453
Keywords: Aucun

Research

Introduction : To examine the association between risk factor burdens-categorized as optimal, borderline, or elevated-and the lifetime risk of atrial fibrillation.
DESIGN: Community based cohort study.
SETTING: Longitudinal data from the Framingham Heart Study.

Méthode : Individuals free of atrial fibrillation at index ages 55, 65, and 75 years were assessed. Smoking, alcohol consumption, body mass index, blood pressure, diabetes, and history of heart failure or myocardial infarction were assessed as being optimal (that is, all risk factors were optimal), borderline (presence of borderline risk factors and absence of any elevated risk factor), or elevated (presence of at least one elevated risk factor) at index age.
MAIN OUTCOME MEASURE: Lifetime risk of atrial fibrillation at index age up to 95 years, accounting for the competing risk of death.

Résultats : At index age 55 years, the study sample comprised 5338 participants (2531 (47.4%) men). In this group, 247 (4.6%) had an optimal risk profile, 1415 (26.5%) had a borderline risk profile, and 3676 (68.9%) an elevated risk profile. The prevalence of elevated risk factors increased gradually when the index ages rose. For index age of 55 years, the lifetime risk of atrial fibrillation was 37.0% (95% confidence interval 34.3% to 39.6%). The lifetime risk of atrial fibrillation was 23.4% (12.8% to 34.5%) with an optimal risk profile, 33.4% (27.9% to 38.9%) with a borderline risk profile, and 38.4% (35.5% to 41.4%) with an elevated risk profile. Overall, participants with at least one elevated risk factor were associated with at least 37.8% lifetime risk of atrial fibrillation. The gradient in lifetime risk across risk factor burden was similar at index ages 65 and 75 years.

Conclusion : Regardless of index ages at 55, 65, or 75 years, an optimal risk factor profile was associated with a lifetime risk of atrial fibrillation of about one in five; this risk rose to more than one in three a third in individuals with at least one elevated risk factor.

Conclusion (proposition de traduction) : Indépendamment de la tranche d'âge de 55, 65 ou 75 ans, un profil de facteur de risque optimal était associé à un risque à vie de fibrillation auriculaire d'environ un sur cinq ; ce risque s'élevait à plus d'un tiers sur trois chez les individus présentant au moins un facteur de risque élevé.

Commentaire : Dans cette étude, le tabagisme, la consommation d'alcool, l'indice de masse corporelle, la pression artérielle, le diabète et les antécédents d'insuffisance cardiaque ou d'infarctus du myocarde ont été jugés optimaux (c.-à-d. tous les facteurs de risque sont optimaux), limites (absence de facteur de risque), ou élevé (présence d'au moins un facteur de risque élevé) à la tranche d'âge.

CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.
Stiell IG, Scheuermeyer FX, Vadeboncoeur A, Angaran P. | CJEM. 2018 May;20(3):334-342
DOI: https://doi.org/10.1017/cem.2018.26  | Télécharger l'article au format  
Keywords: Aucun

CAEP Position Statement

Editorial : The CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist was created to assist emergency physicians in Canada and elsewhere manage patients who present to the emergency department (ED) with acute/recent- onset atrial fibrillation or flutter. The checklist focuses on symptomatic patients with acute atrial fibrillation (AAF) or flutter (AAFL), i.e. those with recent-onset episodes (either first detected, recurrent paroxysmal or recurrent persistent episodes) where the onset is generally less than 48 hours but may be as much as seven days. These are the most common acute arrhythmia cases requiring care in the ED. Canadian emergency physicians are known for publishing widely on this topic and for managing these patients quickly and efficiently in the ED.

Conclusion : Our hope is that the CAEP Acute Atrial Fibrillation/ Flutter Best Practices Checklist will standardize and improve care of AAF and AAFL in large and small EDs alike. We believe that these patients can be managed rapidly and safely, with early ED discharge and return to normal activities.

Conclusion (proposition de traduction) : Nous espérons que la Checklist des meilleures pratiques en matière de fibrillation auriculaire/de flutter auriculaire de l'ACMU normalisera et améliorera la prise en charge de la fibrillation atrial et du fluter chez les grandes et petites éditions des urgences. Nous croyons que ces patients peuvent être gérés rapidement et en toute sécurité, avec un congé précoce et un retour aux activités normales.

Emergency department ultrasound for the detection of B-lines in the early diagnosis of acute decompensated heart failure: a systematic review and meta-analysis.
McGivery K, Atkinson P, Lewis D, Taylor L, Harris T, Gadd K, Fraser J, Stoica G. | CJEM. 2018 May;20(3):343-352
DOI: https://doi.org/10.1017/cem.2018.27
Keywords: B-lines; dyspnea; emergency department; heart failure; lung ultrasound

Original Research

Introduction : Dyspnea is a common presenting problem that creates a diagnostic challenge for physicians in the emer- gency department (ED). While the differential diagnosis is broad, acute decompensated heart failure (ADHF) is a frequent cause that can be challenging to differentiate from other etiologies. Recent studies have suggested a potential diagnostic role for emergency lung ultrasound (US). The objective of this systematic review was to assess the accuracy of early bedside lung US in patients presenting to the ED with dyspnea.

Méthode : A systematic search of EMBASE, PubMed, and the Cochrane Library was performed in addition to a grey literature search. We selected prospective studies that reported on the sensitivity and specificity of B-lines from early lung ultrasound in dyspneic patients presenting to the ED. Selected studies underwent quality assessment using the Critical Appraisal and Skills Program (CASP) questionnaire.

Résultats : The search yielded 3674 articles; seven studies met inclusion criteria and fulfilled CASP requirements for a total of 1861 patients. Summary statistics from the meta-analysis showed that as a diagnostic test for ADHF, bedside lung US had a pooled sensitivity of 82.5% (95% confidence interval [CI]=66.4% to 91.8%) and a pooled specificity of 83.6% (95% CI = 72.4% to 90.8%).

Conclusion : Our results suggest that in patients presenting to the ED with undifferentiated dyspnea, B-lines from early bedside lung US may be reliably used as an adjunct to current diagnostic methods. The incorporation of lung US may lead to more appropriate and timely diagnosis of patients with undifferentiated ADHF.

Conclusion (proposition de traduction) : Les résultats de l’étude donnent à penser que l’échographie précoce des poumons en vue de la détection de lignes B chez les patients souffrant de dyspnée d’origine indéterminée au service des urgences pourrait compléter, de manière fiable, les méthodes actuelles de diagnostic. L’intégration de l’échogra- phie des poumons au SU pourrait donc faciliter et accélérer la pose du diagnostic d’insuffisance cardiaque décompensée aiguë chez les patients souffrant de dyspnée d’origine indéterminée.

Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.
Clinkard D, Stiell I, Lang E, Rose S, Clement C, Brison R, Rowe BH, Borgundvaag B, Langhan T, Magee K, Stenstrom R, Perry JJ, Birnie D, Wells G, McRae A. | CJEM. 2018 May;20(3):370-376
DOI: https://doi.org/10.1017/cem.2017.20  | Télécharger l'article au format  
Keywords: cardioversion, sedation, adverse events, propofol, fentanyl

Original Research

Introduction : Bien que le recours à la sédation interventionnelle soit chose courante au service des urgences (SU), il existe peu de données sur le choix des médicaments. Aussi avons- nous tenté d’évaluer les différences géographiques et temporelles quant aux choix des sédatifs dans plusieurs centres au Canada, et d’estimer le risque d’événement indésirable lié au choix des sédatifs.

Méthode : Il s’agit d’une analyse secondaire d’un examen de dossiers médicaux, le Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n = 420; 2008]), ainsi que d’une étude de cohorte, prospective, la Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n = 565; 2010-2012]), menés respective- ment dans huit et dans six SU, au Canada. Les choix des sédatifs ont été quantifiés entre les SU et dans les SU eux- mêmes, et les risques d’événement indésirable, examinés à l’aide de comparaisons rajustées et non rajustées entre différents schémas posologiques de sédatifs.

Résultats : Dans le RAFF-0 et la RAFF-1, l’association de propofol et de fentanyl était le schéma le plus fréquent (63,8 % et 52,7 %), suivi du propofol seul (27,9 % et 37,3 %). Il y avait sensiblement plus d’événements indésirables relevés dans la base de données du RAFF-0 (13,5 %) que dans celle de la RAFF-1 (3,3 %). Toutefois, dans les deux bases de données, la mixtion de propofol et de fentanyl n’a pas été associée à un risque accru d’événement indésirable comparativement au propofol seul.

Conclusion : There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

Conclusion (proposition de traduction) : Il existe des différences importantes entre les SU, au Canada, quant aux choix des médicaments utilisés pour les sédations interventionnelles en vue des cardioversions électriques, et l’emploi du propofol seul comme agent de sédation a gagné du terrain au fil du temps. Le risque d’événement indésirable découlant de la sédation interventionnelle durant la cardioversion est faible, mais non insignifiant. D’après les résultats de l’étude, l’adjonction de fentanyl au propofol, comme analgésique, n’est pas associée à un risque accru d’événement indésirable.

Commentaire : En France, les experts de la Recommandations formalisées d’experts de 2010 : « Sédation et analgésie en structure d’urgence   » proposent d’effectuer le CEE sous sédation brève par l’administration IV, lente et titrée de propofol, à une faible posologie (0,5 à 0,8 mg/kg IV) sans association à un morphinomimétique.

Determining the clinical significance of errors in pediatric radiograph interpretation between emergency physicians and radiologists.
Taves J, Skitch S, Valani R. | CJEM. 2018 May;20(3):420-424
DOI: https://doi.org/10.1017/cem.2017.34
Keywords: X-ray; discrepancy; pediatric; quality improvement

Original Research

Introduction : Emergency physicians (EPs) interpret plain radiographs for management and disposition of patients. Radiologists subsequently conduct their own interpretations, which may differ. The purposes of this study were to review the rate and nature of discrepancies between radiographs interpreted by EPs and those of radiologists in the pediatric emergency department, and to determine their clinical significance.

Méthode : We conducted a retrospective review of discrepant radiology reports from a single-site pediatric emergency department from October 2012 to December 2014. All radiographs were interpreted first by the staff EP, then by a radiologist. The report was identified as a "discrepancy" if these reports differed. Radiographs were categorized by body part and discrepancies classified as false positive, false negative, or not a discrepancy. Clinically significant errors that required a change in management were tracked.

Résultats : There were 25,304 plain radiographs completed during the study period, of which 252 (1.00%) were identified as discrepant. The most common were chest radiographs (41.7%) due to missed pneumonia, followed by upper and lower extremities (26.2% and 17.5%, respectively) due to missed fractures. Of the 252 discrepancies, 207 (82.1%) were false negatives and 45 (17.9%) were false positives. In total, 105 (0.41% of all radiographs) were clinically significant.

Conclusion : There is a low rate of discrepancy in the interpretation of pediatric emergency radiographs between emergency department physicians and radiologists. The majority of errors occur with radiographs of the chest and upper extremities. The low rate of clinically significant discrepancy allows safe management based on EP interpretation.

Conclusion (proposition de traduction) : Il y a un faible taux de divergence dans l'interprétation des radiographies pédiatriques d'urgence entre les médecins du service des urgences et les radiologues. La majorité des erreurs se produisent avec des radiographies du thorax et des membres supérieurs. Le faible taux de divergence cliniquement significative permet une gestion sûre basée sur l'interprétation de l'urgentiste.

Commentaire : Les conclusions de cette article rejoignent celles, plus anciennes, sur les urgences adultes.

Dental injuries in younger emergency department patients.
James V, Vandersluis YR, Zhang EWJ, Scolnik D. | CJEM. 2018 May;20(3):425-431
DOI: https://doi.org/10.1017/cem.2017.52
Keywords: Canada; dental injury; trauma

Original research

Introduction : Les traumas dentaires sont chose relativement courante durant l’enfance, et ils ont des conséquences qui vont au-delà des parodontopathies. Ils imposent un lourd fardeau au système public de soins de santé en raison de leur fréquence élevée, de leurs répercussions sur la qualité de vie et de l’utilisation des ressources.
Objectifs : L’étude visait à cerner les changements de tendance en ce qui concerne les traumas dentaires chez les enfants de 0 à 18 ans au Canada, et à fournir une évaluation détaillée des différents types de blessures aux dents chez les patients traités dans un grand centre hospitalier de soins tertiaires pour enfants.

Méthode : Il s’agit d’une étude rétrospective, menée en deux parties : tout d’abord, il y a eu collecte de données sur les patients traités dans les services des urgences des 15 hôpitaux canadiens participant au Système canadien hospitalier d’information et de recherche en prévention des traumatismes (SCHIRPT), pour la période du 1er janvier 1990 au 31 décembre 2013; ensuite, il y a eu une collecte complémentaire de données cliniques, tirées des dossiers de patients repérés dans la base de données précitée, à l’Hospital for Sick Children, pour les années 2008, 2012 et 2015.

Résultats : D’après les données recueillies dans le SCHIRPT, il semble y avoir une augmentation des cas de trauma dentaire, au service des urgences, à l’échelle nationale. La participation accrue aux activités sportives et au cyclisme explique en grande partie les blessures aux dents, tandis que le port de matériel de protection comme les casques munis d’une grille faciale et d’un protège-dents, lui, est faible.

Conclusion : Our study demonstrates a rising incidence of dental injuries in young patients. Most dental injuries occurred during sports and playground related activities. The low rate of use of safety equipment and playground safety measures suggests that Canadian Standards Association standards for playgrounds could be more effective if strengthened by mandatory legislation.

Conclusion (proposition de traduction) : Les résultats de l’étude démontrent une fréquence accrue des traumas dentaires chez les jeunes. La plupart des accidents surviennent durant les activités sportives et les activités récréatives sur les terrains de jeux. Le faible taux du port de matériel de protection et le faible degré d’application des mesures de sécurité sur les terrains de jeux donnent à penser que les normes de l’Association canadienne de normalisation pourraient être plus efficaces si elles étaient renforcées par des lois impératives.

Clinical Evaluation of Sepsis-1 and Sepsis-3 in the ICU.
Fang X, Wang Z, Yang J, Cai H, Yao Z, Li K, Fang Q. | Chest. 2018 May;153(5):1169-1176
DOI: https://doi.org/10.1016/j.chest.2017.06.037
Keywords: SIRS; SOFA; diagnosis; infection; sepsis

Original research article

Introduction : There has been considerable controversy between sepsis-1 and sepsis-3 criteria.

Méthode : Patients with infection meeting two or more systemic inflammatory response syndrome (SIRS) criteria (sepsis-1) or a Sequential Organ Failure Assessment (SOFA) score ≥ 2 (sepsis-3) on the first day after ICU admission were selected from the Medical Information Mart for Intensive Care-III database, and their outcomes were compared using all-cause death as the end point. Subgroup analysis was also performed based on prior chronic organ dysfunction.

Résultats : There were 21,491 infected patients included. Of those meeting the diagnostic criteria for sepsis-1, 13.42% did not satisfy sepsis-3 criteria, and this population had a 21-day mortality rate of 6.96%. In contrast, 7.00% of the patients meeting sepsis-3 criteria did not meet sepsis-1 criteria, and their 21-day mortality rate was 10.76%. When excluding preexisting organ conditions, 18.41% of patients with sepsis-1 did not meet sepsis-3 criteria, with a 21-day mortality rate of 6.39%, and 6.00% of patients with sepsis-3 did not meet sepsis-1 criteria, with a 21-day mortality rate of 9.11%. When two or more SIRS criteria or SOFA score ≥ 2 were applied to predict 21-day all-cause mortality in infected patients without prior chronic organ dysfunction, the sensitivity was 96.0% or 91.0%, respectively. Although the areas under the receiver operator curve of both SOFA and SIRS criteria could be used for predicting mortality, SOFA score represented the severity of the condition, whereas SIRS score represented a clinically evident host response to infection.

Conclusion : Sepsis-3 diagnostic criteria narrow the sepsis population at the expense of sensitivity, and the resulting false negatives may delay disease diagnosis. It may be inappropriate to compare the prediction performance of SIRS and SOFA criteria when sepsis-3 is defined.

Conclusion (proposition de traduction) : Les critères diagnostiques de Sepsis-3 réduisent la population de sepsis au détriment de la sensibilité, et les faux négatifs qui en résultent peuvent retarder le diagnostic de la maladie. Il peut être inapproprié de comparer la performance de prédiction des critères du SIRS et du SOFA lorsque le sepsis-3 est définie.

A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax.
Chang SH, Kang YN, Chiu HY, Chiu YH. | Chest. 2018 May;153(5):1201-1212
DOI: https://doi.org/10.1016/j.chest.2018.01.048
Keywords: chest tube; pigtail; pneumothorax; thoracentesis; thoracostomy

Original research article

Introduction : The optimal initial treatment approach for pneumothorax remains controversial. This systemic review and meta-analysis investigated the effectiveness of small-bore pigtail catheter (PC) drainage compared with that of large-bore chest tube (LBCT) drainage as the initial treatment approach for all subtypes of pneumothorax.

Méthode : PubMed and Embase were systematically searched for observational studies and randomized controlled trials published up to October 9, 2017, that compared PC and LBCT as the initial treatment for pneumothorax. The investigative outcomes included success rates, recurrence rates, complication rates, drainage duration, and hospital stay.

Résultats : Of the 11 included studies (875 patients), the success rate was similar in the PC (79.84%) and LBCT (82.87%) groups, with a risk ratio of 0.99 (95% CI, 0.93 to 1.05; I2 = 0%). Specifically, PC drainage was associated with a significantly lower complication rate following spontaneous pneumothorax than LBCT drainage (Peto odds ratio: 0.49 [95% CI, 0.28 to 0.85]; I2 = 29%). In the spontaneous subgroup, PC drainage was associated with a significantly shorter drainage duration (mean difference, -1.51 [95% CI, -2.93 to -0.09]) and hospital stay (mean difference: -2.54 [95% CI, -3.16 to -1.92]; P < .001) than the LBCT group.

Conclusion : Collectively, results of the meta-analysis suggest PC drainage may be considered as the initial treatment option for patients with primary or secondary spontaneous pneumothorax. Ideally, randomized controlled trials are needed to compare PC vs LBCT among different subgroups of patients with pneumothorax, which may ultimately improve clinical care and management for these patients.

Conclusion (proposition de traduction) : Collectivement, les résultats de la méta-analyse suggèrent que le drainage par cathéter à queue de cochon peut être considéré comme l'option de traitement initial pour les patients atteints de pneumothorax spontané primaire ou secondaire. Idéalement, des essais contrôlés randomisés sont nécessaires pour comparer le cathéter à queue de porc et le drain thoracique de gros calibre dans différents sous-groupes de patients présentant un pneumothorax, ce qui pourrait améliorer les soins cliniques et la prise en charge de ces patients.

Impact of Bystander Automated External Defibrillator Use on Survival and Functional Outcomes in Shockable Observed Public Cardiac Arrests.
Pollack RA, Brown SP, Rea T, Aufderheide T, Barbic D, Buick JE, Christenson J, Idris AH, Jasti J, Kampp M, Kudenchuk P, May S1, Muhr M, Nichol G, Ornato JP, Sopko G, Vaillancourt C, Morrison L, Weisfeldt M; ROC Investigators. | Circulation. 2018 May 15;137(20):2104-2113
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.030700  | Télécharger l'article au format  
Keywords: cardiac arrest; cardiopulmonary resuscitation; defibrillators; mortality; public policy

Original Research Articles

Introduction : Survival following out-of-hospital cardiac arrest (OHCA) with shockable rhythms can be improved with early defibrillation. Although shockable OHCA accounts for only ≈25% of overall arrests, ≈60% of public OHCAs are shockable, offering the possibility of restoring thousands of individuals to full recovery with early defibrillation by bystanders. We sought to determine the association of bystander automated external defibrillator use with survival and functional outcomes in shockable observed public OHCA.

Méthode : From 2011 to 2015, the Resuscitation Outcomes Consortium prospectively collected detailed information on all cardiac arrests at 9 regional centers. The exposures were shock administration by a bystander-applied automated external defibrillator in comparison with initial defibrillation by emergency medical services. The primary outcome measure was discharge with normal or near-normal (favorable) functional status defined as a modified Rankin Score ≤2. Survival to hospital discharge was the secondary outcome measure.

Résultats : Among 49 555 OHCAs, 4115 (8.3%) observed public OHCAs were analyzed, of which 2500 (60.8%) were shockable. A bystander shock was applied in 18.8% of the shockable arrests. Patients shocked by a bystander were significantly more likely to survive to discharge (66.5% versus 43.0%) and be discharged with favorable functional outcome (57.1% versus 32.7%) than patients initially shocked by emergency medical services. After adjusting for known predictors of outcome, the odds ratio associated with a bystander shock was 2.62 (95% confidence interval, 2.07-3.31) for survival to hospital discharge and 2.73 (95% confidence interval, 2.17-3.44) for discharge with favorable functional outcome. The benefit of bystander shock increased progressively as emergency medical services response time became longer.

Conclusion : Bystander automated external defibrillator use before emergency medical services arrival in shockable observed public OHCA was associated with better survival and functional outcomes. Continued emphasis on public automated external defibrillator utilization programs may further improve outcomes of OHCA.

Conclusion (proposition de traduction) : L'utilisation d'un défibrillateur automatisé externe avant l'arrivée des services médicaux d'urgence dans un arrêt cardiaque extrahospitalier a été associée à une meilleure survie et à de meilleurs résultats fonctionnels. Le fait de continuer à mettre l'accent sur les programmes publics d'utilisation de défibrillateurs automatisés externes pourrait améliorer davantage les résultats dans l'arrêt cardiaque extrahospitalier.

Association Between Early Hyperoxia Exposure After Resuscitation From Cardiac Arrest and Neurological Disability: Prospective Multicenter Protocol-Directed Cohort Study.
Roberts BW, Kilgannon JH, Hunter BR, Puskarich MA, Pierce L, Donnino M, Leary M, Kline JA, Jones AE, Shapiro NI, Abella BS, Trzeciak S. | Circulation. 2018 May 15;137(20):2114-2124
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.032054  | Télécharger l'article au format  
Keywords: brain injuries; heart arrest; hyperoxia; nervous system

Original Research Articles

Introduction : Studies examining the association between hyperoxia exposure after resuscitation from cardiac arrest and clinical outcomes have reported conflicting results. Our objective was to test the hypothesis that early postresuscitation hyperoxia is associated with poor neurological outcome.

Méthode : This was a multicenter prospective cohort study. We included adult patients with cardiac arrest who were mechanically ventilated and received targeted temperature management after return of spontaneous circulation. We excluded patients with cardiac arrest caused by trauma or sepsis. Per protocol, partial pressure of arterial oxygen (Pao2) was measured at 1 and 6 hours after return of spontaneous circulation. Hyperoxia was defined as a Pao2 >300 mm Hg during the initial 6 hours after return of spontaneous circulation. The primary outcome was poor neurological function at hospital discharge, defined as a modified Rankin Scale score >3. Multivariable generalized linear regression with a log link was used to test the association between Pao2 and poor neurological outcome. To assess whether there was an association between other supranormal Pao2 levels and poor neurological outcome, we used other Pao2 cut points to define hyperoxia (ie, 100, 150, 200, 250, 350, 400 mm Hg).

Résultats : Of the 280 patients included, 105 (38%) had exposure to hyperoxia. Poor neurological function at hospital discharge occurred in 70% of patients in the entire cohort and in 77% versus 65% among patients with versus without exposure to hyperoxia respectively (absolute risk difference, 12%; 95% confidence interval, 1-23). Hyperoxia was independently associated with poor neurological function (relative risk, 1.23; 95% confidence interval, 1.11-1.35). On multivariable analysis, a 1-hour-longer duration of hyperoxia exposure was associated with a 3% increase in risk of poor neurological outcome (relative risk, 1.03; 95% confidence interval, 1.02-1.05). We found that the association with poor neurological outcome began at ≥300 mm Hg.

Conclusion : Early hyperoxia exposure after resuscitation from cardiac arrest was independently associated with poor neurological function at hospital discharge.

Conclusion (proposition de traduction) : L'exposition précoce à l'hyperoxie après une réanimation d'un arrêt cardiaque était un facteur indépendant de mauvais pronostic neurologique à la sortie de l'hôpital.

Worsening Renal Function in Patients With Acute Heart Failure Undergoing Aggressive Diuresis Is Not Associated With Tubular Injury.
Ahmad T, Jackson K, Rao VS, Tang WHW, Brisco-Bacik MA, Chen HH, Felker GM, Hernandez AF, O'Connor CM, Sabbisetti VS, Bonventre JV, Wilson FP, Coca SG, Testani JM. | Circulation. 2018 May 8;137(19):2016-2028
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.030112  | Télécharger l'article au format  
Keywords: acute kidney injury; biomarkers; heart failure; renal insufficiency

Original Research Articles

Introduction : Worsening renal function (WRF) in the setting of aggressive diuresis for acute heart failure treatment may reflect renal tubular injury or simply indicate a hemodynamic or functional change in glomerular filtration. Well-validated tubular injury biomarkers, N-acetyl-β-d-glucosaminidase, neutrophil gelatinase-associated lipocalin, and kidney injury molecule 1, are now available that can quantify the degree of renal tubular injury. The ROSE-AHF trial (Renal Optimization Strategies Evaluation-Acute Heart Failure) provides an experimental platform for the study of mechanisms of WRF during aggressive diuresis for acute heart failure because the ROSE-AHF protocol dictated high-dose loop diuretic therapy in all patients. We sought to determine whether tubular injury biomarkers are associated with WRF in the setting of aggressive diuresis and its association with prognosis.

Méthode : Patients in the multicenter ROSE-AHF trial with baseline and 72-hour urine tubular injury biomarkers were analyzed (n=283). WRF was defined as a ≥20% decrease in glomerular filtration rate estimated with cystatin C.

Résultats : Consistent with protocol-driven aggressive dosing of loop diuretics, participants received a median 560 mg IV furosemide equivalents (interquartile range, 300-815 mg), which induced a urine output of 8425 mL (interquartile range, 6341-10 528 mL) over the 72-hour intervention period. Levels of N-acetyl-β-d-glucosaminidase and kidney injury molecule 1 did not change with aggressive diuresis (both P>0.59), whereas levels of neutrophil gelatinase-associated lipocalin decreased slightly (-8.7 ng/mg; interquartile range, -169 to 35 ng/mg; P<0.001). WRF occurred in 21.2% of the population and was not associated with an increase in any marker of renal tubular injury: neutrophil gelatinase-associated lipocalin (P=0.21), N-acetyl-β-d-glucosaminidase (P=0.46), or kidney injury molecule 1 (P=0.22). Increases in neutrophil gelatinase-associated lipocalin, N-acetyl-β-d-glucosaminidase, and kidney injury molecule 1 were paradoxically associated with improved survival (adjusted hazard ratio, 0.80 per 10 percentile increase; 95% confidence interval, 0.69-0.91; P=0.001).

Conclusion : Kidney tubular injury does not appear to have an association with WRF in the context of aggressive diuresis of patients with acute heart failure. These findings reinforce the notion that the small to moderate deteriorations in renal function commonly encountered with aggressive diuresis are dissimilar from traditional causes of acute kidney injury.

Conclusion (proposition de traduction) : Une détérioration de la fonction rénale au cours d'une diurèse agressive ne semblent pas être associées à des lésions tubulaires rénales chez les patients atteints d'insuffisance cardiaque aiguë.
Ces résultats renforcent la notion selon laquelle les altérations de la fonction rénale, petites à modérées, que l'on rencontre fréquemment lors d'une diurèse agressive sont d'étiologies différentes des causes traditionnelles de lésions rénales aiguës.

Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults.
Hansen M, Schmicker RH, Newgard CD, Grunau B, Scheuermeyer F, Cheskes S, Vithalani V, Alnaji F, Rea T, Idris AH, Herren H, Hutchison J, Austin M, Egan D, Daya M; Resuscitation Outcomes Consortium Investigators. | Circulation. 2018 May 8;137(19):2032-2040
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.033067  | Télécharger l'article au format  
Keywords: cardiopulmonary resuscitation; epinephrine; heart arrest; out-of-hospital cardiac arrest; resuscitation

Original Research Articles

Introduction : Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms.

Méthode : We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site.

Résultats : From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine.

Conclusion : Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

Conclusion (proposition de traduction) : Parmi les arrêts cardiaques extrahospitaliers dont le rythme initial n'était pas choquable, la majorité des patients ont reçu de l'épinéphrine plus de 10 minutes après l'arrivée des services médicaux d'urgence. Le retard dans l'administration d'épinéphrine était associée à une diminution de la survie et à des résultats neurologiques défavorables. Les organismes de services médicaux d'urgence devraient envisager des stratégies pour réduire les temps d'administration d'épinéphrine chez les patients présentant des rythmes initiaux non choquables.

Association Between Prompt Defibrillation and Epinephrine Treatment With Long-Term Survival After In-Hospital Cardiac Arrest.
Patel KK, Spertus JA, Khariton Y, Tang Y, Curtis LH, Chan PS; American Heart Association’s Get With the Guidelines–Resuscitation Investigators. | Circulation. 2018 May 8;137(19):2041-2051
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.030488  | Télécharger l'article au format  
Keywords: electric countershock; heart arrest; survival

Original Research Articles

Introduction : Prior studies have reported higher in-hospital survival with prompt defibrillation and epinephrine treatment in patients with in-hospital cardiac arrest (IHCA). Whether this survival benefit persists after discharge is unknown.

Méthode : We linked data from a national IHCA registry with Medicare files and identified 36 961 patients ≥65 years of age with an IHCA at 517 hospitals between 2000 and 2011. Patients with IHCA caused by pulseless ventricular tachycardia or ventricular fibrillation were stratified by prompt (≤2 minutes) versus delayed (>2 minutes) defibrillation, whereas patients with IHCA caused by asystole or pulseless electric activity were stratified by prompt (≤5 minutes) versus delayed (>5 minutes) epinephrine treatment. The association between prompt treatment and long-term survival for each rhythm type was assessed with multivariable hierarchical modified Poisson regression models.

Résultats : Of 8119 patients with an IHCA caused by ventricular tachycardia or ventricular fibrillation, the rate of 1-year survival was higher in those treated with prompt defibrillation than with delayed defibrillation (25.7% [1466 of 5714] versus 15.5% [373 of 2405]; adjusted relative risk [RR], 1.49; 95% confidence interval [CI] 1.32-1.69; P<0.0001). This survival advantage persisted at 3 years (19.1% versus 11.0%; adjusted RR, 1.45; 95% CI, 1.23-1.69; P<0.0001) and at 5 years (14.7% versus 7.9%; adjusted RR, 1.50; 95% CI, 1.22-1.83; P<0.0001). Of 28 842 patients with an IHCA caused by asystole/pulseless electric activity, the rate of 1-year survival with prompt epinephrine treatment was higher than with delayed treatment (5.4% [1341 of 24 885] versus 4.3% [168 of 3957]; adjusted RR, 1.20; 95% CI, 1.02-1.41; P=0.02), but this survival benefit was no longer present at 3 years (3.5% versus 2.9%; adjusted RR, 1.17; 95% CI, 0.95-1.45; P=0.15) and at 5 years (2.3% versus 1.9%; adjusted RR, 1.18; 95% CI, 0.88-1.58; P=0.27).

Conclusion : Prompt defibrillation for IHCA caused by ventricular tachycardia or ventricular fibrillation was associated with higher rates of long-term survival throughout 5 years of follow-up, whereas prompt epinephrine treatment for asystole/pulseless electric activity was associated with greater survival at 1 year but not at 3 or 5 years. By quantifying the greater survival associated with timely defibrillation and epinephrine administration, these findings provide important insights into the durability of survival benefits for 2 process-of-care measures in current resuscitation guidelines.

Conclusion (proposition de traduction) : La défibrillation rapide pour un arrêt cardiaque intra-hospitalier causé par une tachycardie ventriculaire ou une fibrillation ventriculaire était associée à des taux plus élevés de survie à long terme tout au long des cinq années de suivi, alors qu'un traitement rapide par épinéphrine pour une activité électrique sans pouls était associé à une plus grande survie à un an, mais pas à trois ou cinq ans. En quantifiant la plus grande survie associée à la défibrillation et à l'administration d'épinéphrine en temps opportun, ces résultats donnent un aperçu important sur la durabilité des bénéfices de survie pour deux mesures du processus de soins dans les guidelines actuelles de réanimation.

Mechanical CPR: Who? When? How?.
Poole K, Couper K, Smyth MA, Yeung J, Perkins GD. | Crit Care. 2018 May 29;22(1):140
DOI: https://doi.org/10.1186/s13054-018-2059-0  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Mechanical CPR; Review

Review

Editorial : In cardiac arrest, high quality cardiopulmonary resuscitation (CPR) is a key determinant of patient survival. However, delivery of effective chest compressions is often inconsistent, subject to fatigue and practically challenging.Mechanical CPR devices provide an automated way to deliver high-quality CPR. However, large randomised controlled trials of the routine use of mechanical devices in the out-of-hospital setting have found no evidence of improved patient outcome in patients treated with mechanical CPR, compared with manual CPR. The limited data on use during in-hospital cardiac arrest provides preliminary data supporting use of mechanical devices, but this needs to be robustly tested in randomised controlled trials.In situations where high-quality manual chest compressions cannot be safely delivered, the use of a mechanical device may be a reasonable clinical approach. Examples of such situations include ambulance transportation, primary percutaneous coronary intervention, as a bridge to extracorporeal CPR and to facilitate uncontrolled organ donation after circulatory death.The precise time point during a cardiac arrest at which to deploy a mechanical device is uncertain, particularly in patients presenting in a shockable rhythm. The deployment process requires interruptions in chest compression, which may be harmful if the pause is prolonged. It is recommended that use of mechanical devices should occur only in systems where quality assurance mechanisms are in place to monitor and manage pauses associated with deployment.In summary, mechanical CPR devices may provide a useful adjunct to standard treatment in specific situations, but current evidence does not support their routine use.

Conclusion : The use of mechanical devices in specific circum- stances (e.g. ambulance/helicopter transport, pPCI) where high-quality chest compressions cannot be safely delivered may be a reasonable strategy. In all situations where mechanical devices are used, clinicians must en- sure that the device is deployed with minimal interrup- tion to chest compression delivery.

Conclusion (proposition de traduction) : L'utilisation de planches à masser mécaniques dans des circonstances spécifiques (par exemple pour le transport en ambulance/hélicoptère, intervention coronarienne percutanée primaire) où des compressions thoraciques de haute qualité ne peuvent être effectuées en toute sécurité peut être une stratégie raisonnable.
Dans toutes les situations où des dispositifs mécaniques sont utilisés, les cliniciens doivent s'assurer que le dispositif est déployé avec une interruption minimale de la compression thoracique.

The role of adrenaline in cardiopulmonary resuscitation.
Gough CJR, Nolan JP. | Crit Care. 2018 May 29;22(1):139
DOI: https://doi.org/10.1186/s13054-018-2058-1  | Télécharger l'article au format  
Keywords: Adrenaline; Cardiac arrest; Cardiopulmonary resuscitation; Epinephrine; Outcome

Review

Editorial : Adrenaline has been used in the treatment of cardiac arrest for many years. It increases the likelihood of return of spontaneous circulation (ROSC), but some studies have shown that it impairs cerebral microcirculatory flow. It is possible that better short-term survival comes at the cost of worse long-term outcomes. This narrative review summarises the rationale for using adrenaline, significant studies to date, and ongoing research

Conclusion : Although the administration of adrenaline remains one of the most common ALS interventions, and likely in- creases rate of ROSC after cardiac arrest, its effect on long-term outcomes is far less certain. Several animal studies indicate that whilst global blood flow to vital or- gans is generally increased, microcirculatory flow may be made worse by adrenaline. Many clinical observational studies document an association between the injection of adrenaline and worse long-term outcomes, yet others show an association between early injection of adren- aline and better long-term outcome. Ultimately, it is hoped that the recently completed large RCT comparing adrenaline with placebo will provide some clarity on the role of adrenaline, if any, in the treatment of cardiac arrest.

Conclusion (proposition de traduction) : Bien que l'administration d'adrénaline demeure l'une des interventions de survie les plus courantes et qu'elle augmente probablement le taux de retour de la circulation spontanée après un arrêt cardiaque, son effet sur les résultats à long terme est beaucoup moins certain. Plusieurs études chez l'animal indiquent que si le flux sanguin global vers les organes vitaux est généralement augmenté, le flux microcirculatoire peut être aggravé par l'adrénaline. De nombreuses études observationnelles cliniques mettent en évidence une association entre l'injection d'adrénaline et de plus mauvais résultats à long terme, alors que d'autres montrent une association entre l'injection précoce d'adrénaline et de meilleurs résultats à long terme.
En fin de compte, il est à espérer que le grand essai contrôlé randomisé récemment achevé comparant l'adrénaline au placebo fournira une certaine clarté sur le rôle de l'adrénaline, le cas échéant, dans le traitement de l'arrêt cardiaque.

Influence of pathogen and focus of infection on procalcitonin values in sepsis patients with bacteremia or candidemia.
Thomas-Rüddel DO, Poidinger B, Kott M, Weiss M, Reinhart K, Bloos F; MEDUSA study group. | Crit Care. 2018 May 13;22(1):128
DOI: https://doi.org/10.1186/s13054-018-2050-9  | Télécharger l'article au format  
Keywords: Bacteremia; Focal infection; Gram-negative bacteria; Gram-positive bacteria; Procalcitonin; Sepsis

Research

Introduction : This study aimed to evaluate the accuracy of procalcitonin (PCT) serum concentrations to diagnose Gram-negative bacteremia and the association of PCT serum concentrations with more specific pathogens and the focus of infection.

Méthode : Secondary analysis of the prospectively collected patient-level dataset from a cluster randomized quality improvement trial was performed. The trial included sepsis patients with organ dysfunction treated in the participating intensive care units from 2011 to 2015. Test performance for the prediction of Gram-negative bacteremia was assessed by receiver operating curve analysis. Independent effects of specific pathogen groups and foci of infection on PCT concentrations were assessed by linear logistic regression models.

Résultats : Blood cultures (BC) and PCT concentrations had been taken in 4858 of 6561 documented patients. PCT was significantly higher in Gram-negative bacteremia compared to Gram-positive bacteremia or candidemia (p < 0.001). The area under the curve was 0.72 (95% confidence interval 0.71-0.74) for the prediction of Gram-negative bacteremia compared to all other blood culture results including negative blood cultures. The optimized cutoff value was 10 ng/ml (sensitivity 69%, specificity 35%). PCT differed significantly between specific groups of pathogens (p < 0.001) with highest concentrations in Escherichia coli, Streptococcus species and other Enterobacteriaceae. PCT was highest in urogenital followed by abdominal infection and lowest in respiratory infection (p < 0.001). In a linear regression model, Streptococci, E. coli and other Enterobacteriaceae detected from BC were associated with three times higher PCT values. Urogenital or abdominal foci of infection were associated with twofold increased PCT values independent of the pathogen.

Conclusion : Serum PCT concentrations are higher in patients with Gram-negative bacteremia than in patients with Gram-positive bacteremia or candidemia. However, the discriminatory power of this difference is too low to guide therapeutic decisions. Variations in PCT serum concentrations are not determined solely by Gram-negative or Gram-positive bacteria but are also affected by distinct groups of pathogens and different foci of infection.

Conclusion (proposition de traduction) : Les concentrations sériques de PCT sont plus élevées chez les patients atteints de bactériémie à Gram négatif que chez les patients atteints de bactériémie à Gram positif ou de candidémie. Cependant, le pouvoir discriminatoire de cette différence est trop faible pour guider les décisions thérapeutiques. Les variations des concentrations sériques de PCT ne sont pas déterminées uniquement par des bactéries Gram-négatives ou Gram-positives, mais sont également affectées par des groupes distincts d'agents pathogènes et différents foyers d'infection.

Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula.
Mauri T, Mauri T, Galazzi A, Binda F, Masciopinto L, Corcione N, Carlesso E, Lazzeri M, Spinelli E, Tubiolo D, Volta CA, Adamini I, Pesenti A, Grasselli G. | Crit Care. 2018 May 9;22(1):120
DOI: https://doi.org/10.1186/s13054-018-2039-4  | Télécharger l'article au format  
Keywords: Acute hypoxemic respiratory failure; High-flow nasal oxygen; Nursing; Patient comfort; Spontaneous breathing

Review

Introduction : The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort.

Méthode : A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO2/FiO2 ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO2 unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO2 ≥ 45%.

Résultats : Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p < 0.0001). Higher flow, however, was not associated with poorer comfort. In the subgroup of patients with clinical FiO2 ≥ 45%, both lower temperature (31 °C) and higher HFNC flow (60 l/min) led to higher comfort (p < 0.01).

Conclusion : HFNC temperature seems to significantly impact the comfort of AHRF patients: for equal flow, lower temperature could be more comfortable. Higher flow does not decrease patient comfort; at variance, it improves comfort in the more severely hypoxemic patient.

Conclusion (proposition de traduction) : La température élevée de l'HFNC (canules nasales à haut débit d'oxygène) semble avoir un impact significatif sur le confort des patients atteints d'insuffisance respiratoire hypoxémique aiguë : à débit égal, une température plus basse pourrait être plus confortable. Un débit plus élevé ne diminue pas le confort du patient, néanmoins, il améliore le confort chez le patient plus sévèrement hypoxémique.

Best PEEP trials are dependent on tidal volume.
McKown AC, Semler MW, Rice TW. | Crit Care. 2018 May 2;22(1):115
DOI: https://doi.org/10.1186/s13054-018-2047-4  | Télécharger l'article au format  
Keywords: Aucun

Letter

Editorial : Determining the optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome remains an area of active investigation. Most trials individualizing PEEP optimize one physiologic parameter (e.g., driving pressure) by titrating PEEP while holding other ventilator settings constant. Optimal PEEP, however, may depend on the tidal volume, and changing the tidal volume with which a best PEEP trial is performed may lead to different best PEEP settings in the same patient.

Conclusion : How to individualize PEEP for patients with ARDS remains a conundrum. Our finding is important because it implies that carefully titrated PEEP may not apply outside of the ventilator parameters with which PEEP was tested and that changes in tidal volume likely influence optimal PEEP.

Conclusion (proposition de traduction) : La façon d'individualiser la PEEP pour les patients atteints de SDRA demeure une énigme. Notre conclusion est importante parce qu'elle implique que la PEEP soigneusement titrée peut ne pas s'appliquer en dehors des paramètres du ventilateur avec lesquels la PEEP a été testée et que les changements de volume courant influencent probablement la PEEP optimale.

Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma.
Hamada SR, Rosa A3, Gauss T, Desclefs JP, Raux M, Harrois A, Follin A, Cook F, Boutonnet M; Traumabase® Group, Attias A, Ausset S, Boutonnet M, Dhonneur G, Duranteau J, Langeron O, Paugam-Burtz C, Pirracchio R, de St Maurice G, Vigué B, Rouquette A, Duranteau J. | Crit Care. 2018 May 5;22(1):113
DOI: https://doi.org/10.1186/s13054-018-2026-9  | Télécharger l'article au format  
Keywords: Anticipation; Organization; Protocol; Severe haemorrhage; Severe trauma

Research

Introduction : Haemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures.

Méthode : A multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort.

Résultats : Among the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72-79%), specificity 79% (77-80%) and area under the receiver operating characteristic curve 0.83 (0.81-0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients.

Conclusion : The Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.

Conclusion (proposition de traduction) : L'alerte Red Flag (Drapeau rouge) développée et validée dans cette étude a des performances élevées pour prédire ou exclure avec précision l'hémorragie sévère.

Commentaire : Voir l'analyse de l'article sur le site BLOCKCHOC, Pas sur ma garde : Quand le SMUR lance le protocole de transfusion massive : 5 drapeaux rouges  .

Influence of pathogen and focus of infection on procalcitonin values in sepsis patients with bacteremia or candidemia.
Thomas-Rüddel DO, Poidinger B, Kott M, Weiss M, Reinhart K, Bloos F; MEDUSA study group. | Crit Care. 2018 May 13;22(1):128
DOI: https://doi.org/10.1186/s13054-018-2050-9  | Télécharger l'article au format  
Keywords: Bacteremia; Focal infection; Gram-negative bacteria; Gram-positive bacteria; Procalcitonin; Sepsis

Research

Introduction : This study aimed to evaluate the accuracy of procalcitonin (PCT) serum concentrations to diagnose Gram-negative bacteremia and the association of PCT serum concentrations with more specific pathogens and the focus of infection.

Méthode : Secondary analysis of the prospectively collected patient-level dataset from a cluster randomized quality improvement trial was performed. The trial included sepsis patients with organ dysfunction treated in the participating intensive care units from 2011 to 2015. Test performance for the prediction of Gram-negative bacteremia was assessed by receiver operating curve analysis. Independent effects of specific pathogen groups and foci of infection on PCT concentrations were assessed by linear logistic regression models.

Résultats : Blood cultures (BC) and PCT concentrations had been taken in 4858 of 6561 documented patients. PCT was significantly higher in Gram-negative bacteremia compared to Gram-positive bacteremia or candidemia (p < 0.001). The area under the curve was 0.72 (95% confidence interval 0.71-0.74) for the prediction of Gram-negative bacteremia compared to all other blood culture results including negative blood cultures. The optimized cutoff value was 10 ng/ml (sensitivity 69%, specificity 35%). PCT differed significantly between specific groups of pathogens (p < 0.001) with highest concentrations in Escherichia coli, Streptococcus species and other Enterobacteriaceae. PCT was highest in urogenital followed by abdominal infection and lowest in respiratory infection (p < 0.001). In a linear regression model, Streptococci, E. coli and other Enterobacteriaceae detected from BC were associated with three times higher PCT values. Urogenital or abdominal foci of infection were associated with twofold increased PCT values independent of the pathogen.

Conclusion : Serum PCT concentrations are higher in patients with Gram-negative bacteremia than in patients with Gram-positive bacteremia or candidemia. However, the discriminatory power of this difference is too low to guide therapeutic decisions. Variations in PCT serum concentrations are not determined solely by Gram-negative or Gram-positive bacteria but are also affected by distinct groups of pathogens and different foci of infection.

Conclusion (proposition de traduction) : Les concentrations sériques en PCT sont plus élevées chez les patients atteints de bactériémie à Gram négatif que chez les patients atteints de bactériémie à Gram positif ou de candidémie. Cependant, le pouvoir discriminant de cette différence est trop faible pour guider les décisions thérapeutiques. Les variations dans les concentrations sériques en PCT ne sont pas déterminées uniquement par les bactéries Gram-négatives ou Gram-positives, mais sont également affectées par des groupes distincts d'agents pathogènes et des foyers d'infection différents.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Ne demander à la procalcitonine que ce qu’elle peut apporter !  . Rédigé par le Dr Olivier Leroy.

Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials.
Belletti A, Benedetto U, Putzu A, Martino EA, Biondi-Zoccai G, Angelini GD, Zangrillo A, Landoni G. | Crit Care Med. 2018 May;46(5):e443-e451
DOI: https://doi.org/10.1097/CCM.0000000000003049
Keywords: Aucun

Online Review Articles

Introduction : Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome.

Méthode : Design: Network meta-analysis.
Patients: Adult patients undergoing cardiopulmonary resuscitation.
Interventions: PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival.

Résultats : Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator.

Conclusion : In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest.

Conclusion (proposition de traduction) : Dans les essais contrôlés randomisés évaluant les vasopresseurs chez les adultes ayant subi un arrêt cardiaque, seule une combinaison d'adrénaline, de vasopressine et de méthylprednisolone a été associée à une amélioration de la survie et à un bon résultat neurologique par rapport à tout autre médicament ou placebo, en particulier dans les arrêts cardiaques à l'hôpital. Il n'y avait aucune preuve randomisée significative pour appuyer ni décourager l'utilisation de l'adrénaline lors d'un arrêt cardiaque.

Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal.
Pizon A, Lynch MJ, Benedict NJ, Yanta JH, Frisch A, Menke NB, Swartzentruber GS, King AM, Abesamis MG, Kane-Gill SL. | Crit Care Med. 2018 May 8;Volume Online First - Issue
DOI: https://doi.org/10.1097/CCM.0000000000003204
Keywords: Aucun

Online Clinical Investigation

Introduction : Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal.
Design: Retrospective observational cohort study.
Setting: Academic tertiary care hospital.
Patients: Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic and Statistical Manual of Mental Disorders V criteria.

Méthode : Pre and post guideline, all patients were treated in a symptom-triggered fashion with benzodiazepines and/or phenobarbital. Postguideline, standard symptom-triggered dosing continued as preguideline, plus, the patient was initiated on an IV ketamine infusion at 0.15–0.3 mg/kg/hr continuously until delirium resolved. Based upon withdrawal severity and degree of agitation, a ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some patients.

Résultats : A total of 63 patients were included (29 preguideline; 34 postguideline). Patients treated with ketamine were less likely to be intubated (odds ratio, 0.14; p < 0.01; 95% CI, 0.04–0.49) and had a decreased ICU stay by 2.83 days (95% CI, –5.58 to –0.089; p = 0.043). For ICU days outcome, correlation coefficients were significant for alcohol level and total benzodiazepine dosing. For hospital days outcome, correlation coefficients were significant for patient age, aspartate aminotransferase, and alanine aminotransferase level. Regression revealed the use of ketamine was associated with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, –8.40 to 1.08; p = 0.13).

Conclusion : Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated–sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.

Conclusion (proposition de traduction) : Mécaniquement, un traitement adjuvant par kétamine peut atténuer les démonstrations neuroexcitatrice de la stimulation du récepteur N-méthyl-D-aspartate dans le sevrage sévère à l'éthanol, réduire la nécessité d'une sédation médiée par l'agoniste gamma-aminobutyrique et limiter la morbidité associée. Une perfusion de kétamine chez des patients atteints de delirium tremens était associée à une réduction des besoins en agonistes de l'acide gamma-aminobutyrique, à une durée de séjour en USI plus courte, à une probabilité moindre d'intubation et à une hospitalisation plus courte.

Evaluation of the use of analgesics for blunt thoracic trauma in the accident and emergency department.
Valli R, Maino C, Etteri M, Maj M. | Emerg Care J. 2018 May;14:18-21
DOI: https://doi.org/10.4081/ecj.2018.7336336  | Télécharger l'article au format  
Keywords: Aucun

Original Articles

Editorial : Proper pain management is an essential process when dealing with a patient suffering from blunt thoracic trauma, because it blocks the vicious circle that leads to the development of trauma related complications. This retrospective study deals with the use of pain killers administered in the Accidents and Emergency Department (ED) and prescribed at discharge to patients suffering from blunt thoracic trauma. The analysis confirms the existence of oligoanalgesia, that is an inadequate pain treatment, in clinical practice. Out of 214 patients involved in the study, only 78 patients (36.4%) received at least one pain killing drug during their stay in the ED. More than half of the patients discharged within 24 hours of admittance to the ED received no detailed advice about pain relief therapy and 8% of them (11 out of 136) returned to the ED within 15 days for persisting symptoms. Four were eventually admitted to hospital due to deterioration in their clinical conditions.

Conclusion : This retrospective analysis, even with its limitations, shows that inadequate recognition and treatment of pain is still a problem in the ED of a large secondary level Hospital in Italy. In particular, with regard to the treatment of patients suffering from blunt thoracic trauma, drugs that were probably inappropriate or not proportional to the intensity of the patient’s pain were used. No locoregional therapy was ever performed and, even in the discharge phase, there were problems in terms of non-prescriptions or incomplete therapeutic advice. In consideration of the fact that inadequate pain treatment may favor the insurgence of complications of blunt thoracic trauma, it is necessary to increase our efforts to improve the quality and timeliness of pain therapy in the ED.

Conclusion (proposition de traduction) : Cette analyse rétrospective, même avec ses limites, montre qu'une reconnaissance et un traitement inadéquats de la douleur sont toujours un problème aux urgences d'un grand hôpital secondaire en Italie. En particulier, en ce qui concerne le traitement des patients souffrant d'un traumatisme thoracique contondant, des médicaments qui étaient probablement inappropriés ou non proportionnels à l'intensité de la douleur du patient ont été utilisés. Aucune thérapie locorégionale n'a jamais été mise en oeuvre et, même à la sortie des urgences, il y avait des problèmes en termes de non-prescription ou de conseil thérapeutique incomplet.
Compte tenu du fait qu'un traitement de la douleur inadéquat peut favoriser la survenue de complications du traumatisme thoracique contondant, il est nécessaire d'augmenter nos efforts pour améliorer la qualité et la rapidité de la prise en charge thérapeutique de la douleur aux urgences.

Comparison of epidemiology, treatments and outcomes of ST segment elevation myocardial infarction between young and elderly patients.
Pek PP, Zheng H, Ho AFW, Wah W, Tan HC, Foo LL, Ong MEH. | Emerg Med J. 2018 May;35(5):289-296
DOI: https://doi.org/10.1136/emermed-2017-206754
Keywords: acute myocardial infarct; aged; cardiac care, acute coronary syndrome; treatment

Original article

Introduction : With an ageing population, there is a need to understand the relative risk/benefit of interventions for elderly ST segment elevation myocardial infarction (STEMI) patients. The primary aim of this study was to compare epidemiology, treatments and outcomes between young and elderly STEMI patients. Our secondary aim was to determine the cut-off age when the benefits of primary percutaneous coronary intervention (PCI) were less pronounced.

Méthode : Data were collected by the Singapore Myocardial Infarction Registry. Patients were categorised into young (age <65 years) and elderly STEMI (age ≥65 years) patients.

Résultats : We analysed 14 006 STEMI cases collected between January 2007 and December 2014; 33.9% were elderly STEMI patients. Elderly STEMI patients had longer median door to balloon (73 vs 64 min, P<0.001) time and were less likely to receive PCI (proportion difference=-23.6%, 95% CI -25.3 to -22.0). In the absence of PCI, elderly STEMI patients had a higher mortality within 30 days (elderly: HR 1.65, 95% CI 1.36 to 1.99, P<0.001; young: HR 1.10, 95% CI 0.79 to 1.54, P=0.573) and 1 year (elderly: HR 1.83, 95% CI 1.57 to 2.14, P<0.001; young: HR 1.41, 95% CI 1.09 to 1.83, P=0.009) of admission. The 1 year survival benefit of PCI started to decline after the age of 65 years.

Conclusion : Elderly STEMI patients were less likely to receive PCI and had longer door to balloon times. Survival benefit of PCI decreased after the age of 65 years, with the decline most evident from age 85 years onwards. The risks of PCI need to be weighed carefully against its benefits, especially in very elderly patients.

Conclusion (proposition de traduction) : Les patients ayant un infarctus du myocarde avec sus-décalage du segment ST étaient moins susceptibles de bénéficier d'une intervention coronarienne percutanée et avaient des temps de « porte to ballon raquo; plus longs. Le bénéfice de survie de l'intervention coronarienne percutanée a diminué après l'âge de 65 ans, le déclin étant plus évident à partir de l'âge de 85 ans. Les risques de l'intervention coronarienne percutanée doivent être soigneusement pesés contre ses avantages, en particulier chez les patients très âgés.

New decision formulas for predicting endotracheal tube depth in children: analysis of neck CT images.
Lee SU, Jung JY, Kim DK, Kwak YH, Kwon H, Cho JH, Park JW, Choi YJ. | Emerg Med J. 2018 May;35(5):303-308
DOI: https://doi.org/10.1136/emermed-2017-206795
Keywords: Ct/mri; airway; paediatric resuscitation

Original article

Introduction : The purpose of this study was to construct a prediction model for endotracheal tube depth using neck CT images.

Méthode : A retrospective image review was conducted that included patients who had undergone neck CT. Using sagittal neck CT images, we calculated the length between upper incisor and mid-trachea and then derived the model via regression analysis. The model was validated externally using chest radiographs of patients who had undergone endotracheal intubation. We compared performance of our model with that of other methods (Broselow tape and APLS formula) via Bland-Altman analysis and the percentage of estimations within 10% of the measured values.

Résultats : A total of 1111 children were included in this study. The tube depth obtained from CT images was linearly related to body weight (tube depth (cm)=5.5+0.5×body wt (kg)) in children younger than 1 year and to height (tube depth (cm)=3+0.1×height (cm)) in children older than 1 year. External validation demonstrated that our new model showed better agreement with the desired tube depth than Broselow tape and APLS formula. The mean differences in children younger than 1 year were 0.61 cm and -1.24 cm for our formula and Broselow tape, respectively. The mean differences in children older than 1 year were -0.43 cm, -1.98 and -1.64 cm for our formula, Broselow tape and APLS formula, respectively. The percentages of estimates within 10% of the measured values were 52.7% and 35.8% for our formula and Broselow tape in children younger than 1 year, respectively, and 54.3%, 33.8% and 37.2% for our formula, Broselow tape and APLS formula in children older than 1 year, respectively (P<0.01).

Conclusion : Our new formula is useful and more accurate than the currently available methods.

Conclusion (proposition de traduction) : Notre nouvelle formule est utile et plus précise que les méthodes actuellement disponibles.

Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis.
D'Souza RS, Mercogliano C, Ojukwu E, D'Souza S, Singles A, Modi J, Short A, Donato A. | Emerg Med J. 2018 May;35(5):325-331
DOI: https://doi.org/10.1136/emermed-2017-206944
Keywords: admission avoidance; clincial management; emergency care system; emergency care systems; emergency departments; headache; treatment

Review

Introduction : To determine the effectiveness of prophylactic anticholinergic medications in reducing extrapyramidal symptoms in patients taking acute antiemetics with a dopamine D2 receptor antagonist effect.

Méthode : Systematic searches of all published studies through March 2017 were identified from PubMed, Cochrane library, Embase, Web of Science and Scopus. Only randomised controlled trials of patients receiving dopamine D2 antagonist antiemetic therapy for acute migraine in which an anticholinergic or placebo was compared were included. Pooled ORs were calculated for incidence of extrapyramidal symptoms and sedation.

Résultats : Four placebo-controlled randomised controlled trials consisting of 737 patients met the inclusion criteria for our meta-analysis. The effect of diphenhydramine differed depending on the method of administration of the antiemetic. When the antiemetic was delivered as a 2 min antiemetic bolus, the odds of extrapyramidal symptoms were significantly reduced in the diphenhydramine group compared with placebo (OR 0.42; 95% CI 0.22 to 0.81; P=0.01). However, when the antiemetic was given as a 15 min infusion, there was no significant difference in extrapyramidal symptoms with or without diphenhydramine (OR 1.06; 95% CI 0.58 to 1.91; P=0.85). The lowest incidence of extrapyramidal symptoms was observed in patients receiving a 15 min antiemetic infusion without diphenhydramine prophylaxis (9.8%). In two trials including 351 patients that dichotomously reported sedation scales, diphenhydramine had significantly higher rates of sedation (31.6%vs19.2%, OR 2.01, 95% CI 1.21 to 3.33; P=0.007).

Conclusion : Prophylactic diphenhydramine reduces extrapyramidal symptoms in patients receiving bolus antiemetic therapy with a dopamine D2 antagonist effect, but not when it is given as an infusion. Because of significantly greater sedation with diphenhydramine, the most effective strategy is to administer the D2 antagonist antiemetic as a 15 min infusion without prophylaxis.

Conclusion (proposition de traduction) : La diphenhydramine prophylactique réduit les symptômes extrapyramidaux chez les patients recevant un traitement antiémétique en bolus avec un effet antagoniste de la dopamine D2, mais pas lorsqu'elle est administrée en perfusion. En raison d'une sédation significativement plus importante avec la diphénhydramine, la stratégie la plus efficace consiste à administrer l'antiémétique de l'antagoniste D2 sous la forme d'une perfusion de 15 minutes sans prophylaxie.

EMS providers do not use FOAM for education.
Bucher J, Donovan C, McCoy J. | Int J Emerg Med. 2018 May 24;11(1):27
DOI: https://doi.org/10.1186/s12245-018-0189-4  | Télécharger l'article au format  
Keywords: EMS; Education; Emergency medical services; FOAM; FOAMed; Social media

Original Research

Introduction : Free open access to medical education (FOAM, #FOAM) is the free availability of educational materials on various medicine topics. We hope to evaluate the use of social media and FOAM by emergency medical services (EMS) providers.

Méthode : We designed an online survey distributed to EMS providers with questions about demographics and social media/FOAM use by providers. The survey was sent to the American College of Emergency Physicians (ACEP) EMS Listserv of medical directors and was asked to be distributed to their respective agencies. The survey was designed to inquire about the providers' knowledge of FOAM and social media and their use of the above for EMS education.

Résultats : There were 169 respondents out of a total of 523 providers yielding a response rate of 32.3%. Fifty-three percent of respondents are paramedics, 37% are EMT-Basic trained, and the remainder (16%) were "other." The minority (20%) of respondents had heard of FOAM. However, 54% of respondents had heard of "free medical education online" regarding pertinent topics. Of the total respondents who used social media for education, 31% used Facebook and 23% used blogs and podcasts as resources for online education. Only 4% of respondents stated they produced FOAM content. Seventy-six percent of respondents said they were "interested" or "very interested" in using FOAM for medical education. If FOAM provided continuing medical education (CME), 83% of respondents would be interested in using it.

Conclusion : Social media is not used frequently by EMS providers for the purposes of FOAM. There is interest within EMS providers to use FOAM for education, even if CME was not provided. FOAM can provide a novel area of education for EMS.

Conclusion (proposition de traduction) : Les médias sociaux ne sont pas souvent utilisés par les urgentistes comme accès libre et gratuit à l'éducation médicale. Les urgentistes sont intéressés par l'utilisation de l'accès libre et gratuit à la formation médicale (FOAM) pour l'éducation, même si la formation médicale continue (Continuing Medical Education - CME) n'était pas proposée. L'accès libre et gratuit à l'éducation médicale (FOAM) peut fournir un nouveau domaine d'éducation pour les services médicaux d'urgence.

Frequency of return visits to the emergency department in patients discharged following hypoglycemia episodes.
Betten DP, Castle DJ, Hughes MJ, Henney JN. | Int J Emerg Med. 2018 May 24;11(1):28
DOI: https://doi.org/10.1186/s12245-018-0186-7  | Télécharger l'article au format  
Keywords: Emergency department; Hypoglycemia; Insulin; Sulfonylurea

Original Research

Introduction : In-hospital observation is typically recommended for patients who present to the emergency department with symptomatic hypoglycemia who are taking oral diabetes medications or long acting insulin. Individuals considered to be at low risk of further hypoglycemic episodes by treating providers are however on occasion discharged to home when a low suspicion of recurrence and close observation is available. We describe the frequency of hypoglycemia recurrence requiring further emergency department evaluation who have been recently discharged from the emergency department and are taking oral diabetes medications or long-acting insulin.

Méthode : A retrospective chart review was performed over a 2-year period of time at a large community-based academic emergency department for patients with an ICD-9 diagnosis of hypoglycemia who were taking oral or injectable diabetes medications. Patients were included with symptomatic blood sugar readings less than 55 mg/dL measured by prehospital or hospital providers. For those discharged from the emergency department, medical records from the study hospital and nearby health care facilities, Emergency Medical Service reports, and county death records were reviewed to determine recurrence of symptoms requiring care.

Résultats : There were 196 patients discharged over the study period with 10 (5.1%) patients returning to the emergency department within 48 h with recurrent hypoglycemia. Return visits occurred in 4 of 144 taking insulin alone; 2.8% (CI 1.1-6.9%), in 3 of 19 patients taking oral agents alone; 15.8% (CI 5.5-37.5%), and in 3 of 33 patients taking both insulin and oral medications; 9.1% (CI 3.1-23.6%). Frequency of hypoglycemia recurrence requiring repeat ED visits was more common in those taking oral agents compared to individuals taking insulin alone (p = 0.04). All 7 individuals with recurrent hypoglycemia who were taking insulin were taking long-acting insulin preparations. No discharged patients were identified on Emergency Medical Service refusal of care reports or county death records.

Conclusion : Individuals discharged from the emergency department following hypoglycemic episodes who were taking oral diabetes medications are at a greater risk than individuals taking insulin alone of a return emergency department visit within 48 h for recurrent hypoglycemia.

Conclusion (proposition de traduction) : Les patients qui sortent des urgences à la suite d'épisodes d'hypoglycémie et qui prenaient des antidiabétiques oraux courent un plus grand risque de reconsulter aux urgences dans les 48 heures pour une récidive d'hypoglycémie que les personnes qui prennent de l'insuline seule.

Reprint of: Asymptomatic Brugada syndrome: From diagnosis to treatment.
Amara W, Feki A, Monsel F. | JEUR. 2018 May 30 - In Press
DOI: https://doi.org/10.1016/j.jeurea.2018.05.005
Keywords: Brugada; Ablation; Diagnosis

Mise au point

Editorial : Brugada syndrome management may be a difficult question. This article reviews diagnosis, prognosis evaluation, current and investigated treatments.

Conclusion (proposition de traduction) : La question de la prise en charge du syndrome de Brugada asymptomatique reste une question de pratique courante. Diagnostic, facteurs d’évaluation pronostique, traitements actuels en cours de développement. Cet article de synthèse passe en revue les points clés à retenir pour la pratique, de même que les nouvelles pistes thérapeutiques et de recherche.

Commentaire : Voir l'article original : Amara W, Feki A, Monsel F. Asymptomatic Brugada syndrome: From diagnosis to treatment. Annales de Cardiologie et d'Angéiologie. 2017 November;66(5):295-298.   

Reprint of: How to manage vertigo in adult?.
Vuong Chaney H, Rohmer D, Charpiot A. | JEUR. 2018 May 30 - In Press
DOI: https://doi.org/10.1016/j.jeurea.2018.05.002
Keywords: Aucun

Mise au point

Editorial : The interrogation and the clinical examination are critical in the research of vertigo etiology. In the context of vertigo, the vital emergencies are of neurological and vascular origins. It is therefore necessary to be able to identify them quickly and simply. Vertigo is a symptom to relieve and the cause is to be diagnosed. Careful questioning combined with neurological examination, nystagmus study, Halmagyi test and skew deviation search are more reliable than imaging in the first 48 hours to detect a stroke. There are 12% false negatives in cerebral MRI and 74% false negative in cerebral CT-scan in the first 48 hours of an ischemic stroke. Labyrinth emergencies are infectious labyrinthitis, perilymphatic fistula and aeroembolism of the vestibule.

Conclusion (proposition de traduction) : L'interrogatoire et l'examen clinique sont rois dans l'enquête étiologique d'un vertige. Dans le cadre de vertiges, les urgences vitales sont d'étiologies neurologiques et vasculaires. Il faut donc pouvoir les identifier rapidement et simplement. Le vertige est un symptôme à soulager et la cause est à diagnostiquer. Un interrogatoire minutieux associé à une examen neurologique, une étude du nystagmus, un test d'Halmagyi et une recherche de skew deviation sont plus fiables que l'imagerie dans les 48 premières heures pour dépister un accident vasculaire cérébral. On retrouve 12 % de faux négatifs à l'IRM cérébrale et 74 % de faux négatif au TDM cérébral dans les 48 premières heures d'un accident vasculaire ischémique. Les urgences labyrinthiques sont la labyrinthite infectieuse, la fistule périlymphatique et l'aéroembolisme du vestibule.

Commentaire : Voir l'article original : Vuong Chaney H, Rohmer D, Charpiot A. Comment prendre en charge un vertige chez l’adulte ? La Presse Médicale. 2017 November;46(11):1055-1063.   

Modelization of phone-guided cardiopulmonary resuscitation for out-of-hospital cardiac arrest in the call center of the Yvelines Emergency Medical Service (SAMU 78).
Couchot J, Da Costa Silva S, Berton L, Durand S, Koukabi-Fradelizi M, Richard O. | JEUR. 2018 May 26 - In Press
DOI: https://doi.org/10.1016/j.jeurea.2018.05.001
Keywords: Out-of-hospital cardiac arrest; Cardiopulmonary resuscitation; Telephone guidance; Dispatcher

Article original

Introduction : Les recommandations de l’European Resuscitation Council (octobre 2015), réaffirment l’importance du guidage téléphonique de la réanimation cardiopulmonaire. L’objectif de cette étude est d’évaluer si un guidage téléphonique systématique de la réanimation cardiopulmonaire jusqu’à l’arrivée des secours augmente le taux de charge des assistants de régulation médicale au SAMU 78.

Méthode : Il s’agit d’une étude observationnelle, descriptive, prospective, de la gestion des suspicions d’arrêt cardiaque. Le critère d’inclusion était la suspicion d’arrêt cardiaque lors d’un appel. Le critère de jugement principal est le taux de charge moyen sur les tranches horaires sur lesquelles ont été gérées des suspicions d’arrêt cardiaque.

Résultats : Du 1er au 31 mars 2016, sur 121 appels pour suspicion d’arrêt cardiaque, un guidage téléphonique aurait été réalisable pour 24 d’entre eux. Un guidage téléphonique systématique de la réanimation cardiopulmonaire jusqu’à l’arrivée des secours augmente le taux de charge horaire de 2 %, (intervalle de confiance à 95 % : [1,72 ; 2,3], p < 0,001). Cela correspond à une durée moyenne de guidage de 6 minutes et 53 secondes par appel.

Conclusion : A phone-guided cardiopulmonary resuscitation protocol within SAMU 78 would significantly increase the workload of the dispatchers, but the difference is small and of little practical relevance. This result allows us to consider the implementation of the telephone guidance procedure without waiting for a major impact on the overall quality of the SAMU 78.

Conclusion (proposition de traduction) : Un protocole de guidage téléphonique de la réanimation cardiopulmonaire au sein du SAMU 78 augmenterait significativement le taux de charge des assistants de régulation médicale, mais la différence est faible et peu pertinente sur le plan pratique. Ce résultat nous permet d’envisager la mise en place de la procédure de guidage téléphonique sans attendre un retentissement majeur sur la qualité globale du SAMU 78.

Adjunctive Use of Ketamine for Benzodiazepine-Resistant Severe Alcohol Withdrawal: a Retrospective Evaluation.
Shah P, McDowell M, Ebisu R, Hanif T, Toerne T. | J Med Toxicol. 2018 May 10
DOI: https://doi.org/10.1007/s13181-018-0662-8  | Télécharger l'article au format  
Keywords: Alcohol withdrawal; Benzodiazepines; Delirium tremens; Ketamine

Original Article

Introduction : Benzodiazepine (BZD)-resistant alcohol withdrawal remains a challenge for most institutions due to limited evidence with available agents. One published study currently exists utilizing the N-methyl-D-aspartate antagonist, ketamine, for alcohol withdrawal.
OBJECTIVE: The purpose of our study was to evaluate the effect of adjunctive ketamine continuous infusion on symptom control and lorazepam infusion requirements for BZD-resistant alcohol withdrawal patients in the intensive care unit.

Méthode : A retrospective review was conducted of patients receiving ketamine adjunctively with a lorazepam infusion for severe alcohol withdrawal between August 2012 and August 2014. Outcomes included time to symptom control, lorazepam infusion requirements, ketamine initial and maximum daily infusion rates, and adverse effects of ketamine.

Résultats : Thirty patients were included in the analysis. Mean time to initiation of ketamine after the initiation of a lorazepam infusion was 41.4 h. All patients achieved initial symptom control within 1 h of ketamine initiation. Median initial ketamine infusion rate was 0.75 mg/kg/h and the average maximum daily rate was 1.6 mg/kg/h. Significant decreases in lorazepam infusion rates from baseline were observed at 24 h (- 4 mg/h; p = 0.01) after ketamine initiation. No patients experienced documented CNS adverse effects. Two patients experienced hypertension and no patients experienced tachycardia related to ketamine.

Conclusion : Adjunctive ketamine could provide symptom control for BZD-refractory patients and may potentially reduce lorazepam infusion requirements. Future studies to determine optimal dosing, timing of initiation, and place in therapy for BZD-resistant alcohol withdrawal are needed. The mechanism of action via the NMDA receptor with ketamine may provide benefit for BZD-resistant alcohol withdrawal.

Conclusion (proposition de traduction) : L'utilisation de la kétamine comme thérapeutique adjuvante chez les patients réfractaires aux benzodiazépines pourrait assurer le contrôle des symptômes et pourrait réduire les besoins en perfusion de lorazépam.
Des études futures sont nécessaires visant à déterminer la posologie optimale, le moment de l'initiation et la place de la thérapeutique pour le sevrage alcoolique résistant aux benzodiazépines. Le mécanisme d'action via le récepteur NMDA de la kétamine peut être utile pour le sevrage alcoolique résistant aux benzodiazépines.

Commentaire : Wong A, Benedict N, Armahizer M, Kane-Gill S. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome.   Ann Pharmacother. 2015;49(1):14-19. et Pizon A, Lynch M, Benedict N, et al. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal.   Crit Care Med. May 2018.

Sleep duration and mortality – Does weekend sleep matter?.
Åkerstedt T, Ghilotti F, Grotta A, Zhao H, Adami HO, Trolle-Lagerros Y, Bellocco R. | J Sleep Res. 2018 May 22:e12712
DOI: https://doi.org/10.1111/jsr.12712
Keywords: aging; compensation; long; rested; short; weekday; weekend

REGULAR RESEARCH PAPER

Introduction : Previous studies have found a U-shaped relationship between mortality and (weekday) sleep duration. We here address the association of both weekday and weekend sleep duration with overall mortality.

Méthode : A cohort of 43,880 subjects was followed for 13 years through record-linkages. Cox proportional hazards regression models with attained age as time-scale were fitted to estimate multivariable-adjusted hazard ratios and 95% confidence intervals for mortality; stratified analyses on age (<65 years, ≥65 years) were conducted.

Résultats : Among individuals <65 years old, short sleep (≤5 hr) during weekends at baseline was associated with a 52% higher mortality rate (hazard ratios 1.52; 95% confidence intervals 1.15-2.02) compared with the reference group (7 hr), while no association was observed for long (≥9 hr) weekend sleep. When, instead, different combinations of weekday and weekend sleep durations were analysed, we observed a detrimental association with consistently sleeping ≤5 hr (hazard ratios 1.65; 95% confidence intervals 1.22-2.23) or ≥8 hr (hazard ratios 1.25; 95% confidence intervals 1.05-1.50), compared with consistently sleeping 6-7 hr per day (reference). The mortality rate among participants with short sleep during weekdays, but long sleep during weekends, did not differ from the rate of the reference group. Among individuals ≥65 years old, no association between weekend sleep or weekday/weekend sleep durations and mortality was observed.

Conclusion : In conclusion, short, but not long, weekend sleep was associated with an increased mortality in subjects <65 years. In the same age group, short sleep (or long sleep) on both weekdays and weekend showed increased mortality. Possibly, long weekend sleep may compensate for short weekday sleep.

Conclusion (proposition de traduction) : En conclusion, le sommeil de fin de semaine court, mais pas long, a été associé à une augmentation de la mortalité chez les sujets de moins de 65 ans. Dans le même groupe d'âge, le sommeil court (ou long) en semaine et en fin de semaine a entraîné une augmentation de la mortalité.
Il est possible qu'un long sommeil de fin de semaine puisse compenser pour un sommeil de courte durée.

Commentaire : Voir les commentaires de l'article, L’intérêt de la grasse matinée du week-end a des fondements scientifiques  , sur Medscape du 18 juin 2018.

F. Brunee F, Raffetin A, Roujansky A, Corne P, Tridon C, Llitjos JF, Mourvillier B, Laurent V, et Jauréguiberry S. | Méd Intensive Réa. 2018 May;27(3):228-238
DOI: https://doi.org/10.3166/rea-2018-0051
Keywords: Malaria; Artesunate; Critical care

Update

Editorial : In France, severe imported malaria concerns around 12–14% of the malaria episodes, mainly due to Plasmodium falciparum. From the WHO definition of severe malaria in endemic areas, the French definition of severe imported malaria has been elaborated considering an European context. Severe malaria is a diagnostic and therapeutic emergency and the initial management must be conducted in intensive care unit. The curative treatment of severe malaria is based on intravenous artesunate, which now must be available everywhere in France. Consequently, intravenous quinine is a second line treatment, with some residual indications. Management of organ dysfunctions in intensive care unit remains crucial, particularly during the most severe forms of imported malaria. Currently, no adjunctive therapy has proved its effectiveness in clinical practice.

Conclusion (proposition de traduction) : En France, le paludisme grave d’importation concerne environ 12 à 14 % des accès palustres et implique très majoritairement Plasmodium falciparum. À partir de la définition du paludisme grave de l’Organisation mondiale de la santé utilisée en zone d’endémie palustre, la définition française du paludisme grave d’importation de l’adulte a été adaptée aux données et au contexte européens. La prise en charge du paludisme grave est une urgence diagnostique et thérapeutique qui doit être réalisée initialement en réanimation. Le traitement curatif du paludisme grave d’importation repose maintenant sur l’artésunate intraveineux (IV) qui doit être disponible dans chaque hôpital susceptible de recevoir ces patients. Dès lors, la quinine IV devient un traitement de seconde ligne réservé à quelques circonstances. La prise en charge symptomatique des défaillances d’organes est primordiale, notamment au cours des formes les plus sévères. Enfin, aucun traitement adjuvant n’a prouvé, à ce jour, son efficacité en pratique clinique.

Safety of Terbutaline for Treatment of Acute Severe Pediatric Asthma.
Doymaz S, Schneider J. | Pediatr Emerg Care. 2018 May;34(5):299-302
DOI: https://doi.org/10.1097/PEC.0000000000000677
Keywords: Aucun

Original Articles

Introduction : The use of continuous intravenous terbutaline treatment in severe asthma attacks has been hampered by the lack of well-powered clinical trials where effects of such treatment are described in detail. Here, we aimed to provide a descriptive report on the largest cohort of severe pediatric asthma patients treated with terbutaline.

Méthode : The study was conducted in a pediatric intensive care unit in a large metropolitan tertiary care university hospital on 124 patients receiving terbutaline infusion. To stratify the effect of, and determine any age-related differences of, terbutaline, the patients were divided into 3 age groups (0-6 years, 7-12 years, and 13-18 years). Clinical response and the potential harmful effects of terbutaline infusion were determined.

Résultats : There were significant reductions in systolic (varying between 86% and 93% of the baseline) and diastolic blood pressures (varying between 74% and 86% of the baseline level). However, the values returned to baseline level shortly after discontinuation of infusion. Terbutaline increased heart rates in all groups shortly after initiation (9%-13% above baseline), which returned to below baseline levels 1 hour after discontinuation. Serum potassium levels were also reduced in all patients compared to their baseline values after initiation of terbutaline infusion. However, none of the subjects required potassium replacement.

Conclusion : The results indicate that overall, terbutaline infusion was well tolerated without irreversible adverse effects of the treatment. Although hemodynamic and metabolic disturbances occurred, these were clinically easily managed and posed little risk in emergency department or pediatric intensive care unit.

Conclusion (proposition de traduction) : Les résultats indiquent que, dans l'ensemble, la perfusion de terbutaline a été bien tolérée sans effets indésirables irréversibles. Bien que des troubles hémodynamiques et métaboliques soient survenus, ils ont été facilement gérés cliniquement et posaient peu de risques aux urgences ou en unité de soins intensifs pédiatriques.

Timely Hemodynamic Resuscitation and Outcomes in Severe Pediatric Traumatic Brain Injury: Preliminary Findings.
Kannan N, Wang J, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Rivara FP, Rowhani-Rahbar A, Vavilala MS; PEGASUS (Pediatric Guideline Adherence Outcomes) Study. | Pediatr Emerg Care. 2018 May;34(5):325-329
DOI: https://doi.org/10.1097/PEC.0000000000000803  | Télécharger l'article au format  
Keywords: Aucun

Original articles

Introduction : Early resuscitation may improve outcomes in pediatric traumatic brain injury (TBI). We examined the association between timely treatment of hypotension and hypoxia during early care (prehospital or emergency department locations) and discharge outcomes in children with severe TBI.

Méthode : Hypotension was defined as systolic blood pressure less than 70 + 2 (age in years), and hypoxia was defined as PaO2 less than 60 mm Hg or oxygen saturation less than 90% in accordance with the 2003 Brain Trauma Foundation guidelines. Timely treatment of hypotension and hypoxia during early care was defined as the treatment within 30 minutes of a documented respective episode. Two hundred thirty-six medical records of children younger than 18 years with severe TBI from 5 regional pediatric trauma centers were examined. Main outcomes were in-hospital mortality and discharge Glasgow Outcome Scale (GOS) score.

Résultats : Hypotension occurred in 26% (60/234) during early care and was associated with in-hospital mortality (23.3% vs 8.6%; P = 0.01). Timely treatment of hypotension during early care occurred in 92% (55/60) by use of intravenous fluids, blood products, or vasopressors and was associated with reduced in-hospital mortality [adjusted relative risk (aRR), 0.46; 95% confidence interval, 0.24-0.90] and less likelihood of poor discharge GOS (aRR, 0.54; 95% confidence interval, 0.39-0.76) when compared to children with hypotension who were not treated in a timely manner. Early hypoxia occurred in 17% (41/236) and all patients received timely oxygen treatment.

Conclusion : Timely resuscitation during early care was common and associated with lower in-hospital mortality and favorable discharge GOS in severe pediatric TBI.

Conclusion (proposition de traduction) : La réanimation en temps opportun pendant les soins initiaux était courante et associée à une mortalité plus faible à l'hôpital et à des résultats favorables à la sortie dans les cas de traumatisme cérébral grave chez l'enfant.

Helicopter Transport From the Scene of Injury: Are There Improved Outcomes for Pediatric Trauma Patients?.
Farach SM, Walford NE, Bendure L, Amankwah EK, Danielson PD, Chandler NM. | Pediatr Emerg Care. 2018 May;34(5):344-348
DOI: https://doi.org/10.1097/PEC.0000000000001190
Keywords: Aucun

Original articles

Introduction : There is conflicting data to support the routine use of helicopter transport (HT) for the transfer of trauma patients. The purpose of this study was to evaluate outcomes for trauma patients transported via helicopter from the scene of injury to a regional pediatric trauma center.

Méthode : The institutional trauma registry was queried for trauma patients presenting from January 2000 through March 2012. Of 9119 patients, 1709 patients who presented from the scene were selected for further evaluation. This cohort was stratified into HT and ground transport (GT) for analysis. Associations between mode of transport and outcomes were estimated using odds ratios and 95% confidence intervals from multivariable logistic regression models.

Résultats : Seven hundred twenty-five patients (42.4%) presented via HT, whereas 984 (57.6%) presented via GT. Patients arriving by HT had a higher Injury Severity Score, lower Glasgow Coma Scale, were less likely to undergo surgery within 3 hours, more likely to present after motorized trauma, and had longer intensive care unit (ICU) and hospital length of stay (LOS). Multivariate analysis controlling for Injury Severity Score, Glasgow Coma Scale, mechanism of injury, scene distance, and time to arrive to the hospital revealed that patients arriving by HT were more likely to have longer hospital LOS compared with those arriving by GT (odds ratios = 2.3, 95% confidence interval = 1.00-5.28, P = 0.049). However, no statistically significant association was observed for prehospital intubation, surgery within 3 hours, ICU admissions, or ICU LOS.

Conclusion : Although patients arriving by helicopter are more severely injured and arrive from greater distances, when controlling for injuries, scene distance, and time to hospital arrival, only hospital LOS was significantly affected by HT.

Conclusion (proposition de traduction) : Bien que les patients arrivant par hélicoptère soient plus gravement blessés et arrivent de plus grandes distances, lorsqu'on tient compte des blessures, de la distance de la scène et de l'heure d'arrivée à l'hôpital, seule la durée du séjour à l'hôpital de l'hôpital a été affectée de façon significative par le transport héliporté.

Current Approach to the Diagnosis and Management of Shoulder Dislocation in Children.
Gottlieb M | Pediatr Emerg Care. 2018 May;34(5):357-362
DOI: https://doi.org/10.1097/PEC.0000000000001474
Keywords: Aucun

CME Review Article

Editorial : Shoulder dislocations are a common presentation to the emergency department. Although many cases may be diagnosed by history and clinical examination alone, imaging may help diagnose more challenging cases. Three-view radiographs are important for identifying subtle posterior dislocations, and ultrasonography has been gaining evidence as an alternate diagnostic modality. Intra-articular lidocaine and nerve blocks may improve pain control and reduce the need for procedural sedation. Multiple, evidence-based reduction techniques are described including tips for improving success. Immobilization strategies and follow-up are also discussed.

Conclusion : All pediatric patients with dislocations should be provided with orthopedic surgery follow-up, because younger age is associ- ated with significantly increased risk of recurrent dislocations. Limited evidence suggests that young, active patients older than 14 years may benefit from surgical intervention after a first-time dislocation. However, because of the greater elasticity of the capsular structures in skeletally immature patients, surgery may not be necessary after a first-time dislocation in younger patients.

Conclusion (proposition de traduction) : Tous les patients de pédiatrie présentant des luxations devraient faire l'objet d'un suivi chirurgical orthopédique, car le jeune âge est associé à un risque significativement accru de luxations récidivantes. Des données limitées suggèrent que les jeunes patients actifs de plus de 14 ans peuvent bénéficier d'une intervention chirurgicale après une première luxation. Cependant, en raison de la plus grande élasticité des structures capsulaires chez les patients immatures au niveau du squelette, la chirurgie peut ne pas être nécessaire après une première luxation chez les patients plus jeunes.

Impact of Peripheral Venous Catheter Placement With Vein Visualization Device Support on Success Rate and Pain Levels in Pediatric Patients Aged 0 to 3 Years.
Inal S, Demir D. | Pediatr Emerg Care. 2018 May 15
DOI: https://doi.org/10.1097/PEC.0000000000001493
Keywords: Aucun

Original articles

Introduction : Pediatric nurses should be able to use techniques that increase the success rate or shorten the procedural duration of peripheral intravenous catheterization (PIVC).
Objectifs :This study was performed to define the effect of the infrared vein visualization device support on the success of PIVC in pediatric patients aged 0 to 3 years. Success was determined based on the number of attempts per patient, the duration of the procedure, the success rate of first attempts, and the pain levels of the children.

Méthode : The study was a randomized, controlled experimental study on 54 children aged 0 to 3 years.

Résultats : Peripheral intravenous catheterization in the study group was performed with fewer attempts (study group: 1.44 ± 0.85 [median, 1]; control group: 2.41 ± 1.99 [median, 2]; P = 0.016) and in a shorter period (study group: 44.37 ± 32.22 [median, 40 seconds]; control group: 168.89 ± 171.54 [median, 112 seconds; P = 0.001), and the first attempt success rate in the study group (74.1%) was higher than in the control group (40.7%; P = 0.028). Also, the pain level of the children in the study group was significantly lower than that in the control group (P < 0.05).

Conclusion : In conclusion, PIVC supported by the infrared vein visualization device reduces the number of attempts per patient, reduces the duration of the procedure, and increases the success rate of first attempts, and there is procedural pain; therefore, vein visualization improves the success of PIVC.

Conclusion (proposition de traduction) : En conclusion, le cathétérisme intraveineux périphérique guidé par le dispositif infrarouge de visualisation des veines réduit le nombre de tentatives par patient, réduit la durée de la procédure, augmente le taux de réussite des premières tentatives et c'est une procédure douloureuse; par conséquent, la visualisation veineuse améliore le succès du cathétérisme intraveineux périphérique.

Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis.
Bronsky ES, Koola C, Orlando A, Redmond D, D'Huyvetter C, Sieracki H, Tanner A 2nd, Fowler R, Mains C, Bar-Or D. | Prehosp Emerg Care. 2018 May 18:1-8
DOI: https://doi.org/10.1080/10903127.2018.1469704
Keywords: fentanyl; intravenous; low-dose ketamine; pain control; prehospital

Original Articles

Introduction : A few studies report comparable analgesic efficacy between low-dose ketamine and opioids such as morphine or fentanyl; however, limited research has explored the safety and effectiveness of intravenous low-dose ketamine as a primary analgesic in a civilian prehospital setting. The objective of this study is to compare pain control between low-dose ketamine and fentanyl when administered intravenously (IV) for the indication of severe pain.

Méthode : This was a retrospective, observational review of prehospital adult patients (≥18 years) who presented with severe pain (numeric rating scale, 7-10) and were treated solely with either low-dose ketamine IV or fentanyl IV between January 1, 2014 and December 31, 2016. Propensity matched analysis was performed adjusting for all baseline variables with p ≤ 0.10 and for baseline pain score to match ketamine and fentanyl patients on a one-to-one ratio. The primary outcome was change in pain score from baseline to after treatment and evaluated with a paired t-test. Secondary outcomes were changes in vital signs and Glasgow coma scale (GCS) from baseline to after treatment, as well as incidence of clinically significant adverse events (AEs); AEs were followed from scene arrival through emergency department discharge.

Résultats : Propensity matched analysis produced 79 matched pairs. Ketamine IV patients, receiving a mean (SD) dose of 0.3 (0.1) mg/kg, showed a significantly larger mean decrease in pain after treatment, compared to the fentanyl IV patients (-5.5 (3.1) vs. -2.5 (2.4), p < 0.001). A significantly greater proportion of patients receiving ketamine IV achieved at least a 50% reduction in pain compared to those receiving fentanyl IV (67% vs. 19%, p < 0.001), marking 52 ketamine IV patients as responders to treatment. Vital signs demonstrated a nonsignificant decrease in blood pressure, respiratory rate, heart rate, and GCS. No clinically significant AEs were reported for patients receiving ketamine IV.

Conclusion : The significant reduction in pain, significantly high proportion of ketamine responders, and the lack of clinically significant AEs characterizing patients receiving low-dose ketamine IV compared to fentanyl IV, all provide further support for its use as an effective prehospital analgesic.

Conclusion (proposition de traduction) : La réduction significative de la douleur, la proportion considérablement élevée de répondants à la kétamine et l'absence d'EI cliniquement significatifs caractérisant les patients recevant une faible dose de kétamine IV par rapport au fentanyl IV, sont autant d'arguments supplémentaires en faveur de son utilisation en tant qu'analgésique préhospitalier efficace.

Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis.
Bronsky ES, Koola C, Orlando A, Redmond D, D'Huyvetter C, Sieracki H, Tanner A 2nd, Fowler R, Mains C, Bar-Or D. | Prehosp Emerg Care. 2018 May 18:1-8
DOI: https://doi.org/10.1080/10903127.2018.1469704
Keywords: fentanyl; intravenous; low-dose ketamine; pain control; prehospital

Article

Introduction : A few studies report comparable analgesic efficacy between low-dose ketamine and opioids such as morphine or fentanyl; however, limited research has explored the safety and effectiveness of intravenous low-dose ketamine as a primary analgesic in a civilian prehospital setting. The objective of this study is to compare pain control between low-dose ketamine and fentanyl when administered intravenously (IV) for the indication of severe pain.

Méthode : This was a retrospective, observational review of prehospital adult patients (≥18 years) who presented with severe pain (numeric rating scale, 7-10) and were treated solely with either low-dose ketamine IV or fentanyl IV between January 1, 2014 and December 31, 2016. Propensity matched analysis was performed adjusting for all baseline variables with p ≤ 0.10 and for baseline pain score to match ketamine and fentanyl patients on a one-to-one ratio. The primary outcome was change in pain score from baseline to after treatment and evaluated with a paired t-test. Secondary outcomes were changes in vital signs and Glasgow coma scale (GCS) from baseline to after treatment, as well as incidence of clinically significant adverse events (AEs); AEs were followed from scene arrival through emergency department discharge.

Résultats : Propensity matched analysis produced 79 matched pairs. Ketamine IV patients, receiving a mean (SD) dose of 0.3 (0.1) mg/kg, showed a significantly larger mean decrease in pain after treatment, compared to the fentanyl IV patients (-5.5 (3.1) vs. -2.5 (2.4), p < 0.001). A significantly greater proportion of patients receiving ketamine IV achieved at least a 50% reduction in pain compared to those receiving fentanyl IV (67% vs. 19%, p < 0.001), marking 52 ketamine IV patients as responders to treatment. Vital signs demonstrated a nonsignificant decrease in blood pressure, respiratory rate, heart rate, and GCS. No clinically significant AEs were reported for patients receiving ketamine IV.

Conclusion : The significant reduction in pain, significantly high proportion of ketamine responders, and the lack of clinically significant AEs characterizing patients receiving low-dose ketamine IV compared to fentanyl IV, all provide further support for its use as an effective prehospital analgesic.

Conclusion (proposition de traduction) : Une réduction significative de la douleur, une proportion significativement élevée de répondeurs à la kétamine et l'absence d'EI cliniquement significatifs caractérisant les patients recevant de la kétamine IV à faible dose par rapport au fentanyl IV renforcent encore son utilisation comme analgésique préhospitalier efficace.

Chest compression-only versus conventional cardiopulmonary resuscitation for bystander-witnessed out-of-hospital cardiac arrest of medical origin: A propensity score-matched cohort from 143,500 patients.
Kitamura T, Kiyohara K, Nishiyama C, Kiguchi T, Kobayashi D, Kawamura T, Iwami T. | Resuscitation. 2018 May;126:29-35
DOI: https://doi.org/10.1016/j.resuscitation.2018.02.017
Keywords: Bystander; Cardiopulmonary resuscitation; Chest compression; Out-of-hospital cardiac arrest; Rescue breathing

Clinical papers

Introduction : Current cardiopulmonary resuscitation (CPR) guidelines do not define the optimal type of CPR (chest compression-only CPR [CCCPR] or conventional CPR with rescue breathing [CCRB]) to be performed by bystanders when they witness someone collapse.

Méthode : Using a nationwide database of 1.17 million patients who underwent out-of-hospital cardiac arrest (OHCA) in Japan, we enrolled consecutive bystander-witnessed OHCAs of medical origin with resuscitation attempts from January 2005 through December 2014. Multivariable logistic regression analysis was used to assess the association between the type of bystander CPR and the OHCA outcome after one-to-one propensity score matching for CCCPR versus CCRB. The primary outcome measure was one-month survival with a favorable neurological outcome, defined as a cerebral performance category of 1 or 2.

Résultats : Among 143,500 eligible patients with bystander-witnessed OHCAs receiving bystander-initiated CPR, 71.4% received CCCPR and 28.6% received CCRB. In the univariate analysis, the proportion of one-month survival cases with favorable neurological outcome was lower in the CCCPR group than the CCRB group (5.6% [5749/102,487] vs. 6.5% [2682/41,013], odds ratio [OR]; 0.85 [95% confidence interval {CI}; 0.81-0.89]). However, in the multivariate analysis, the CCCPR group showed a more favorable neurological outcome than the CCRB group (adjusted OR 1.12, 95% CI; 1.06-1.19). In the propensity-matched cohort, the CCCPR group also showed a more favorable neurological outcome than the CCRB group (7.2% [2894/40,096] vs. 6.5% [2610/40,096], adjusted OR 1.14, 95% CI; 1.09-1.22).

Conclusion : CCCPR is an acceptable resuscitation technique for lay-rescuers responding to bystander witnessed OHCA of presumed medical origin.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire par le massage cardiaque seul est une technique de réanimation acceptable pour les témoins non professionnel qui interviennent sur un arrêt cardiaque extrahospitalier supposé d'origine médicale.

Benefit of immediate coronary angiography after out-of-hospital cardiac arrest in France: A nationwide propensity score analysis from the RéAC Registry.
Jaeger D, Dumas F, Escutnaire J, Sadoune S, Lauvray A, Elkhoury C, Bassand A, Girerd N, Gueugniaud PY, Tazarourte K, Hubert H, Cariou A, Chouihed T; Reac Group. | Resuscitation. 2018 May;126:90-97
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.003
Keywords: Angiography; Cardiac arrest; Out-of-hospital; Urgent

Clinical papers

Introduction : The survival rate of out-of-hospital cardiac arrest (OHCA) remains extremely low, generally under 10%. Post-resuscitation care, and particularly early coronary reperfusion, may improve this outcome. The main objective of the present study was to determine whether patients with immediate coronary angiography at hospital admission (CAA) had a better outcome than patients without immediate CAA.

Méthode : This cohort analysis study was based on data extracted from the French National Cardiac Arrest registry (RéAC). To control for attribution bias, patients were matched using a propensity score, which included age clusters, low flow and no flow delays, initial rhythm and bystander cardiopulmonary resuscitation (CPR). The main endpoint was survival at day 30 (D30). Secondary endpoint was neurological recovery of survivors assessed by the Cerebral Performance Category (CPC) scale, with CPC 1 and 2 at D30 considered as a favorable outcome.

Résultats : From July 1st, 2011 to October 1st, 2016, 63394 OHCA were registered in the database, of which 39444 were of an unknown or suspected cardiac origin. After on-site resuscitation by a mobile medical team, 7584 patients were transported to a hospital facility. Among these patients, 4046 were retained in the analysis after matching for the aforementioned factors and constituted into 2 groups: immediate coronary angiography (iCAA) group (n = 2023) and non-immediate coronary angiography (niCAA) group (n = 2023). The survival rate at D30 after matching was 43.3% in the iCAA group versus 34.5% in the niCAA group (OD = 0.66 [0.58; 0.75], p < 0.001). In the iCAA group, (n = 707) 36% of the patients at D30 were CPC 1-2 comparatively to (n = 539) 27.3% in the niCAA group (p < 0.01).

Conclusion : Both the survival and proportion of patients with favorable neurological recovery were significantly higher in patients who underwent an immediate coronary angiography after a resuscitated OHCA. These observational results warrant further exploration of the benefit of this invasive strategy in randomized studies.

Conclusion (proposition de traduction) : La survie et la proportion de patients avec récupération neurologique favorable étaient de façon significative plus élevées chez les patients qui ont bénéficié d'une angiographie coronaire immédiate après un arrêt cardiaque extrahospitalier.
Ces résultats d'étude observationnelle justifient une exploration plus approfondie des avantages de cette stratégie invasive dans des études randomisées.

Impella support compared to medical treatment for post-cardiac arrest shock after out of hospital cardiac arrest.
Karatolios K, Chatzis G, Markus B, Luesebrink U, Ahrens H, Dersch W, Betz S, Ploeger B, Boesl E, O'Neill W, Kill C, Schieffer B. | Resuscitation. 2018 May;126:104-110
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.008
Keywords: Impella; Medical treatment; Out of hospital cardiac arrest; Post-cardiac arrest shock

Clinical papers

Introduction : To compare survival outcomes of Impella support and medical treatment in patients with post-cardiac arrest cardiogenic shock related to acute myocardial infarction (AMI).

Méthode : Retrospective single center study of patients resuscitated from out of hospital cardiac arrest (OHCA) due to AMI with post-cardiac arrest cardiogenic shock between September 2014 and September 2016. Patients were either assisted with Impella or received medical treatment only. Survival outcomes were compared using propensity score-matched analysis to account for differences in baseline characteristics between both groups.

Résultats : A total of 90 consecutive patients with post-cardiac arrest shock due to AMI were included; 27 patients in the Impella group and 63 patients in the medical treatment group. Patients with Impella support had a longer duration of low-flow time (29.54 ± 10.21 versus 17.57 ± 8.3 min, p < 0.001), higher lactate levels on admission (4.75 [IQR 3.8-11] versus 3.6 [IQR 2.6-3.9] mmol/L, p = 0.03) and lower baseline systolic LVEF (25% [IQR 25-35] versus 45% [IQR 35-51.25], p < 0.001) as compared to patients without circulatory support. After propensity score matching, patients with Impella support had a significantly higher survival to hospital discharge (65% versus 20%, p = 0.01) and 6-months survival (60% versus 20%, p = 0.02).

Conclusion : The results from our study suggest that Impella support is associated with significantly better survival to hospital discharge and at 6 months compared to medical treatment in OHCA patients admitted with post-cardiac arrest cardiogenic shock and AMI.

Conclusion (proposition de traduction) : Les résultats de notre étude suggèrent que le dispositif (d'assistance antérograde) Impella est associé à une survie significativement meilleure à la sortie de l'hôpital et à 6 mois par rapport au traitement médical chez les patients en arrêt cardiaque extrahospitalier admis en choc cardiogénique dans les suites de l'arrêt cardiaque et d'un syndrome coronarien aigu.

Commentaire : Pour se renseigner sur the Impella® heart pump  

Severity of chronic obstructive pulmonary disease and presenting rhythm in patients with out-of-hospital cardiac arrest.
Granfeldt A, Wissenberg M, Hansen SM, Lippert FK, Torp-Pedersen C, Skaarup SH, Andersen LW, Christensen EF, Christiansen CF. | Resuscitation. 2018 May;126:111-117
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.006
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Chronic disease; Chronic obstructive pulmonary disease; Medication use; Non-shockable rhythm; Shockable rhythm

Clinical papers

Introduction : Chronic obstructive pulmonary disease (COPD) is associated with a non-shockable rhythm as presenting rhythm in out-of-hospital cardiac arrest (OHCA). Whether the severity of the underlying disease is related to presenting rhythm is unknown. We hypothesized that increased severity of COPD in OHCA patients is associated with an increased prevalence of non-shockable rhythm.

Méthode : This study included OHCA patients ≥40 years from the Danish Cardiac Arrest Registry (2001-2014). Population-based registries were used to identify chronic diseases and drug prescriptions. COPD was defined as a COPD diagnosis or pharmacological therapy for COPD. The severity of COPD was based on either 1) pharmacological therapy (mild/moderate/severe), 2) admission for exacerbation, 3) prescription for corticosteroids, or 4) forced expiratory volume in 1 s (FEV1). For each of these, a multivariable logistic regression model was used to estimate odds ratios (ORs) for a non-shockable rhythm.

Résultats : Of 33,228 patients with OHCA 7789 (23.4%) had COPD. Of these 6702 (86.0%) had a non-shockable rhythm. Compared to patients without COPD, mild COPD was associated with a non-shockable rhythm (OR = 1.46, 95%CI 1.29-1.65). This association was more pronounced for moderate (OR = 1.78, 95%CI 1.45-2.19) and severe COPD (OR = 2.01 95%CI 1.82-2.20). Recent admission for exacerbation (OR = 2.12, OR 95%CI 1.81-2.49) or prescription for corticosteroids (OR = 1.82, 95%CI 1.55-2.14) was also associated with a non-shockable rhythm. FEV1 ≤ 50% was associated with a non-shockable rhythm compared to FEV1 > 50% (OR = 1.74, 95%CI 1.07-2.82, n = 1122).

Conclusion : Incremental severity of COPD is associated with increasing prevalence of a non-shockable rhythm as presenting rhythm in OHCA patients.

Conclusion (proposition de traduction) : La gravité progressive de la bronchopneumopathie chronique obstructive est associée à une augmentation de la prédominance des rythmes non choquables chez les patients en arrêt cardiaque exytrahospitalier.

Coronary lesions in refractory out of hospital cardiac arrest (OHCA) treated by extra corporeal pulmonary resuscitation (ECPR).
Lamhaut L, Tea V, Raphalen JH, An K, Dagron C, Jouffroy R, Jouven X, Cariou A, Baud F, Spaulding C, Hagege A, Danchin N, Carli P, Hutin A, Puymirat E. | Resuscitation. 2018 May;126:154-159
DOI: https://doi.org/10.1016/j.resuscitation.2017.12.017
Keywords: Coronary artery disease; Extracorporeal cardiopulmonary resuscitation; Refractory cardiac arrest

Clinical papers

Introduction : Extracorporeal cardiopulmonary resuscitation (ECPR) is a second line treatment for refractory cardiac arrest (R-OHCA). Timing of ECPR before performing coronary angiography (CAG) is still debated. The aim of the study was to describe the clinical and angiographic characteristics of the largest cohort of out-of-hospital cardiac arrest (OHCA) patients undergoing ECPR.

Méthode : All refractory OHCA patients with ECPR managed by the prehospital mobile intensive care unit (MoICU of the SAMU) in Paris (France) were prospectively included from October 2014 to December 2016.

Résultats : Among 74 patients included over the period, 54 patients had coronary artery disease (CAD). There is a trend toward the CAD patients being older but it did not meet statistical significance (55.3 ± 11.8 vs. 50.6 ± 12.8, p = 0,14). Patients were more frequently men and smokers (p = 0.03 for both). The proportion of initial shockable rhythm tended to be higher in patients with CAD (71% vs. 55%). The rate of 1-, 2-, and 3-vessel disease were 43%, 35% and 22% respectively. The Syntax Score was 18 ± 9 and the lesions in each epicardial vessel were mainly proximal. Percutaneous coronary intervention was performed ad hoc in 49 patients (91%). Complete revascularization was performed in 64%. Inhospital death was numerically lower (65% vs. 75%) in patients with CAD, especially in patients with initial shockable rhythm.

Conclusion : In 74 refractory OHCA patients treated with ECPR implanted by a prehospital mobile intensive care unit, the rate of CAD was high (54/74) especially in patients with shockable rhythm. The majority of patients presented with double or triple vessel disease and proximal lesions. The severity and extension of CAD may explain the refractory nature of the cardiac arrest.

Conclusion (proposition de traduction) : Chez 74 patients en arrêt cardiaque extrahospitalier réfractaire traités par ECPR, implantés par une unité de soins intensifs préhospitaliers, le taux de coronaropathie était élevé (54/74), en particulier chez les patients à rythme choquable. La majorité des patients présentaient une maladie à double ou triple vaisseau atteint et des lésions proximales. La sévérité et l'extension de la coronaropathie peuvent expliquer la nature réfractaire de l'arrêt cardiaque.

Coronary angiographic findings and outcomes in patients with sudden cardiac arrest without ST-elevation myocardial infarction: A SWEDEHEART study.
Wester A, Mohammad MA, Andell P, Rylance R, Dankiewicz J, Friberg H, James S, Omerovic E, Erlinge D, Koul S. | Resuscitation. 2018 May;126:172-178
DOI: https://doi.org/10.1016/j.resuscitation.2018.01.044
Keywords: Coronary angiography; PCI; SWEDEHEART; Sudden cardiac arrest; Sudden cardiac arrest without STEMI

Clinical papers

Introduction : Sudden cardiac arrest (SCA) has a substantial mortality rate and the acute coronary syndrome constitutes the major cause. Post-resuscitation electrocardiogram ST-elevation SCA (STE-SCA) is a strong indication for emergency coronary angiography, but the role of early angiography and PCI in patients without ST-elevation (NSTE-SCA) remains to be established. This paper aimed to describe this patient group and evaluate the prognostic effect of early PCI in a large nationwide cohort of NSTE-SCA patients undergoing coronary angiography.

Méthode : Data from SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) on 4308 SCA patients in Sweden between 2005 and 2016 were descriptively analyzed and related to mortality within 30-days in both unadjusted and adjusted analyses using Cox proportional hazard models.

Résultats : NSTE-SCA patients had more often serious comorbidities than STE-SCA patients. Among NSTE-SCA patients, 36.4% had no significant coronary artery stenosis while severe coronary stenosis (≥90%) was present in 43.9% (1271/2896). In NSTE-SCA patients with significant stenosis (≥90%), PCI was performed in 59.2% (753/1271) with an increased unadjusted 30-day mortality (40.9% vs. 32.7%; p = .011). However, after adjustments for confounders, no difference in mortality was observed (hazard ratio 1.07; 95% CI 0.84-1.36; p = .57).

Conclusion : In resuscitated SCA patients without ST-elevation who underwent coronary angiography, this large retrospective study found severe coronary artery stenosis in 43.9% but found no clear benefit of early PCI. Prospective randomized controlled trials are needed to accurately define the role of coronary angiography and PCI in post-resuscitation care.

Conclusion (proposition de traduction) : Chez les patients réanimés victimes d'arrêt cardiaque inopinés sans élévation du segment ST qui ont bénéficié d'une angiographie coronaire, cette grande étude rétrospective a trouvé une sténose de l'artère coronaire sévère dans 43,9 %, mais n'a trouvé aucun bénéfice clair de l'intervention coronarienne percutanée de précoce.
Des études contrôlées randomisées prospectives sont nécessaires pour définir exactement la place de l'angiographie coronaire et de l'intervention coronarienne percutanée dans les soins après réanimation.

Self-learning basic life support: A randomised controlled trial on learning conditions.
Pedersen TH, Kasper N, Roman H, Egloff M, Marx D, Abegglen S, Greif R. | Resuscitation. 2018 May;126:147-153
DOI: https://doi.org/10.1016/j.resuscitation.2018.02.031
Keywords: Automatic external defibrillator; Basic life support; Cardiac arrest; Cardio pulmonary resuscitation; Education; Facilitator_led learning; Learning; Learning methods; Self-learning; Video

Clinical papers

Introduction : To investigate whether pure self-learning without instructor support, resulted in the same BLS-competencies as facilitator-led learning, when using the same commercially available video BLS teaching kit.

Méthode : First-year medical students were randomised to either BLS self-learning without supervision or facilitator-led BLS-teaching. Both groups used the MiniAnne kit (Laerdal Medical, Stavanger, Norway) in the students' local language. Directly after the teaching and three months later, all participants were tested on their BLS-competencies in a simulated scenario, using the Resusci Anne SkillReporter™ (Laerdal Medical, Stavanger, Norway). The primary outcome was percentage of correct cardiac compressions three months after the teaching. Secondary outcomes were all other BLS parameters recorded by the SkillReporter and parameters from a BLS-competence rating form.

Résultats : 240 students were assessed at baseline and 152 students participated in the 3-month follow-up. For our primary outcome, the percentage of correct compressions, we found a median of 48% (interquartile range (IQR) 10-83) for facilitator-led learning vs. 42% (IQR 14-81) for self-learning (p = 0.770) directly after the teaching. In the 3-month follow-up, the rate of correct compressions dropped to 28% (IQR 6-59) for facilitator-led learning (p = 0.043) and did not change significantly in the self-learning group (47% (IQR 12-78), p = 0.729).

Conclusion : Self-learning is not inferior to facilitator-led learning in the short term. Self-learning resulted in a better retention of BLS-skills three months after training compared to facilitator-led training.

Conclusion (proposition de traduction) : L'auto-apprentissage n'est pas inférieure à l'apprentissage menée par les animateur-formateurs, à court terme. L'auto-apprentissage avait pour résultat une meilleure rétention des connaissances des gestes élémentaires de survie (GES) trois mois après l'entraînement de manière comparable à l'entraînement mené par les animateur-formateurs.

Primary Results of the Multicenter ARISE II Study (Analysis of Revascularization in Ischemic Stroke With EmboTrap).
Zaidat OO, Bozorgchami H, Ribó M, Saver JL, Mattle HP, Chapot R, Narata AP, Francois O, Jadhav AP, Grossberg JA, Riedel CH, Tomasello A, Clark WM, Nordmeyer H, Lin E, Nogueira RG, Yoo AJ, Jovin TG, Siddiqui AH, Bernard T, Claffey M, Andersson T.. | Stroke. 2018 May;49(5):1107-1115
DOI: https://doi.org/10.1161/STROKEAHA.117.020125  | Télécharger l'article au format  
Keywords: goals; humans; reperfusion; stroke; thrombectomy

Major Clinical Trial

Introduction : EmboTrap is a novel stent retriever designed to achieve rapid and substantial flow restoration in acute ischemic stroke secondary to large-vessel occlusions. Here, we evaluated EmboTrap's safety and efficacy compared with established stent retrievers.

Méthode : ARISE II (Analysis of Revascularization in Ischemic Stroke With EmboTrap) was a single-arm, prospective, multicenter study, comparing the EmboTrap device to a composite performance goal criterion derived using a Bayesian meta-analysis from the pivotal SWIFT (Solitaire device) and TREVO 2 (Trevo device) trials. Patients at 11 US and 8 European sites were eligible for inclusion if they had large-vessel occlusions and moderate-to-severe neurological deficits within 8 hours of symptom onset. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b within 3 EmboTrap passes as adjudicated by the core laboratory. The primary safety end point was a composite of symptomatic intracerebral hemorrhage and serious adverse device effects. Secondary end points included functional independence (modified Rankin Scale, 0-2) and all-cause mortality at 90 days.

Résultats : Between October 2015 and February 2017, 227 patients were enrolled and treated with the EmboTrap device. The primary efficacy end point (mTICI ≥2b within 3 passes) was achieved in 80.2% (95% confidence interval, 74%-85% versus 56% performance goal criterion; P value, <0.0001), and mTICI 2c/3 was 65%. After all interventions, mTICI 2c/3 was achieved in 76%, and mTICI ≥2b was 92.5%. The rate of first pass (mTICI ≥2b following a single pass) was 51.5%. The primary safety end point composite rate of symptomatic intracerebral hemorrhage or serious adverse device effects was 5.3%. Functional independence and all-cause mortality at 90 days were 67% and 9%, respectively.

Conclusion : The EmboTrap stent-retriever mechanical thrombectomy device demonstrated high rates of substantial reperfusion and functional independence in patients with acute ischemic stroke secondary to large-vessel occlusions.

Conclusion (proposition de traduction) : Le dispositif de thrombectomie mécanique EmboTrap Retriever a montré des taux élevés de reperfusion substantielle et d’indépendance fonctionnelle chez les patients ayant subi un AVC ischémique aigu secondaire à une occlusion d'un gros vaisseaux.

Impact of Smoking on Clinical Outcome and Recanalization After Intravenous Thrombolysis for Stroke: Multicenter Cohort Study.
Kurmann R, Engelter ST, Michel P, Luft AR, Wegener S, Branscheidt M, Eskioglou E, Sirimarco G, Lyrer PA, Gensicke H, Horvath T, Fischer U, Arnold M, Sarikaya H. | Stroke. 2018 May;49(5):1170-1175
DOI: https://doi.org/10.1161/STROKEAHA.117.017976  | Télécharger l'article au format  
Keywords: atrial fibrillation; hypertension; middle cerebral artery; prognosis; smokers

Original contributions

Introduction : The impact of smoking on prognosis after stroke is controversial. We aimed to assess the relationship between smoking status and stroke outcome after intravenous thrombolysis in a large cohort study by adjusting for potential confounders and incorporating recanalization rates.

Méthode : In a prospective observational multicenter study, we analyzed baseline and outcome data of consecutive patients with acute ischemic stroke treated with intravenous thrombolysis. Using uni- and multivariable modeling, we assessed whether smoking was associated with favorable outcome (modified Rankin Scale score of 0-1) and mortality. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage and recanalization of middle cerebral artery. Patients reporting active cigarette use were classified as smokers.

Résultats : Of 1865 patients, 19.8% were smokers (n=369). They were younger (mean 63.5 versus 71.3 years), less often women (56% versus 72.1%), and suffered less often from hypertension (61.3% versus 70.1%) and atrial fibrillation (22.7% versus 35.6%) when compared with nonsmokers. Favorable outcome and 3-month mortality were in favor of smokers in unadjusted analyses (45.8% versus 39.5% and 9.3% versus 15.8%, respectively), whereas symptomatic intracranial hemorrhage was comparable in both cohorts. Smoking was not associated with clinical outcome and mortality after adjusting for confounders (odds ratio, 1.20; 95% confidence interval, 0.91-1.61; P=0.197 and odds ratio, 1.08; 95% confidence interval, 0.68-1.71; P=0.755, respectively). However, smoking still independently predicted recanalization of middle cerebral artery in multivariable analyses (odds ratio, 2.68; 95% confidence interval, 1.11-6.43; P=0.028).

Conclusion : Our study suggests that good outcome in smokers is mainly related to differences in baseline characteristics and not to biological effects of smoking. The higher recanalization rates in smokers, however, call for further studies.

Conclusion (proposition de traduction) : Notre étude suggère que les bons résultats chez les fumeurs sont principalement liés aux différences de caractéristiques de base et non aux effets biologiques du tabagisme. Les taux de revascularisation plus élevés chez les fumeurs nécessitent toutefois des études supplémentaires.

Commentaire : Consulter sur le sujet, l'article de von Martial R and al. PLoS One. 2018 May 2;13(5):e0194652  . « Impact of smoking on stroke outcome after endovascular treatment » qui conclu que «: le tabagisme chez les patients ayant subi un AVC peut être un facteur prédictif d'un excellent résultat clinique après un traitement endovasculaire. Cependant, ces données ne doivent pas être interprétées comme des effets bénéfiques du tabagisme en raison de la conception de l’étude par observation. Compte tenu des effets délétères du tabagisme sur la santé cardiovasculaire, il convient de continuer à recommander de cesser de fumer pour prévenir les AVC ».

Modified Thrombolysis in Cerebral Infarction 2C/Thrombolysis in Cerebral Infarction 3 Reperfusion Should Be the Aim of Mechanical Thrombectomy. Insights From the ASTER Trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization.
Dargazanli C, and al. | Stroke. 2018 May;49:1189–1196
DOI: https://doi.org/10.1161/STROKEAHA.118.020700  | Télécharger l'article au format  
Keywords: aspiration; cerebral infarction; reperfusion; stent retriever; stroke; thrombectomy

Original contributions

Introduction : Although successful reperfusion is usually defined as a modified Thrombolysis in Cerebral Infarction (mTICI) 2B or 3 at the end of the procedure, studies have shown that mTICI 2B patients had poorer functional outcomes than TICI 3 patients. An mTICI 2C category has been recently introduced for patients with near-complete perfusion except for slow flow in a few distal cortical vessels or presence of small distal cortical emboli after mechanical thrombectomy. The purpose of this study was to evaluate the difference in functional outcome between patients achieving successful reperfusion (ie, mTICI 2B, mTICI 2C, and TICI 3 scores).

Méthode : Ancillary study from the ASTER (Contact Aspiration Versus Stent Retriever for Successful Revascularization) prospective multicenter blinded end point trial. Reperfusion results are reported as the mTICI score, including the mTICI 2C grade. Primary outcome was the percentage of patients with favorable outcome defined as a 90-day modified Rankin Scale score of 0 to 2.

Résultats : Two hundred ninety patients with successful reperfusion (mTICI ≥2B), harboring ischemic stroke secondary to occlusion of the anterior circulation within 6 hours of onset of symptoms, undergoing mechanical thrombectomy by contact aspiration or stent retriever were included. Favorable outcome (pre-specified as primary outcome of this ancillary study) did not differ significantly between the 3 reperfusion grades, with a similar positive effect of 2C (odds ratio, 1.71; 95% confidence interval, 0.98–3.00) and 3 (odds ratio, 1.73; 95% confidence interval, 0.88–3.41) grades compared with 2B grade. After combining grades 2C and 3, patients had a significantly higher rate of favorable outcome than patients with 2B (odds ratio, 1.72; 95% confidence interval, 1.01–2.90; P=0.043). Favorable outcome rate decreased with increasing onset-to-reperfusion time, with no significant interaction between mTICI 2C/3 grade and onset-to-reperfusion time on favorable outcome.

Conclusion : Combining mTICI 2C and TICI 3 grades helps to determine a subgroup of patients achieving better functional outcomes than mTICI 2B patients. Achieving mTICI 2C/3 reperfusion should be the new aim of mechanical thrombectomy for anterior circulation LVO.

Conclusion (proposition de traduction) : La combinaison des grades mTICI 2C et TICI 3 permet de déterminer un sous-groupe de patients obtenant de meilleurs résultats fonctionnels que les patients mTICI 2B. Atteindre la reperfusion mTICI 2C/3 devrait être le nouvel objectif de la thrombectomie mécanique pour l’occlusion des grands vaisseaux dans la circulation antérieure.

Smoking and Risk of Ischemic Stroke in Young Men.
Markidan J, Cole JW, Cronin CA, Merino JG, Phipps MS, Wozniak MA, Kittner SJ. | Stroke. 2018 May;49:1276–1278
DOI: https://doi.org/10.1161/STROKEAHA.117.018859  | Télécharger l'article au format  
Keywords: risk factors; smoke; smoking; stroke; tobacco products

Brief Reports

Introduction : There is a strong dose–response relationship between smoking and risk of ischemic stroke in young women, but there are few data examining this association in young men. We examined the dose–response relationship between the quantity of cigarettes smoked and the odds of developing an ischemic stroke in men under age 50 years.

Méthode : The Stroke Prevention in Young Men Study is a population-based case–control study of risk factors for ischemic stroke in men ages 15 to 49 years. The χ2 test was used to test categorical comparisons. Logistic regression models were used to calculate the odds ratio for ischemic stroke occurrence comparing current and former smokers to never smokers. In the first model, we adjusted solely for age. In the second model, we adjusted for potential confounding factors, including age, race, education, hypertension, myocardial infarction, angina, diabetes mellitus, and body mass index.

Résultats : The study population consisted of 615 cases and 530 controls. The odds ratio for the current smoking group compared with never smokers was 1.88. Furthermore, when the current smoking group was stratified by number of cigarettes smoked, there was a dose–response relationship for the odds ratio, ranging from 1.46 for those smoking <11 cigarettes per day to 5.66 for those smoking 40+ cigarettes per day.

Conclusion : We found a strong dose–response relationship between the number of cigarettes smoked daily and ischemic stroke among young men. Although complete smoking cessation is the goal, even smoking fewer cigarettes may reduce the risk of ischemic stroke in young men.

Conclusion (proposition de traduction) : Nous avons constaté une forte relation dose-réponse entre le nombre de cigarettes fumées quotidiennement et les accidents vasculaires cérébraux ischémiques chez les hommes jeunes. Bien que le renoncement au tabac soit l'objectif principal, même fumer moins de cigarettes peut réduire le risque d'AVC ischémique chez les hommes jeunes.

Blood Pressure-Attained Analysis of ATACH 2 Trial.
Adnan I. Qureshi, and al. | Stroke. 2018 May;49:1412-1418
DOI: https://doi.org/10.1161/STROKEAHA.117.019845  | Télécharger l'article au format  
Keywords: acute hypertensive response; blood pressure; cerebral hemorrhage; clinical trial; humans

Original contributions

Introduction : We compared the rates of death or disability, defined by modified Rankin Scale score of 4 to 6, at 3 months in patients with intracerebral hemorrhage according to post-treatment systolic blood pressure (SBP)–attained status.

Méthode : We divided 1000 subjects with SBP ≥180 mm Hg who were randomized within 4.5 hours of symptom onset as follows: SBP <140 mm Hg achieved or not achieved within 2 hours; subjects in whom SBP <140 mm Hg was achieved within 2 hours were further divided: SBP <140 mmHg for 21 to 22 hours (reduced and maintained) or SBP was ≥140 mm Hg for at least 2 hours during the period between 2 and 24 hours (reduced but not maintained).

Résultats : Compared with subjects without reduction of SBP <140 mmHg within 2 hours, subjects with reduction and maintenance of SBP <140 mmHg within 2 hours had a similar rate of death or disability (relative risk of 0.98; 95% confidence interval, 0.74–1.29). The rates of neurological deterioration within 24 hours were significantly higher in reduced and maintained group (10.4%; relative risk, 1.98; 95% confidence interval, 1.08–3.62) and in reduced but not maintained group (11.5%; relative risk, 2.08; 95% confidence interval, 1.15–3.75) compared with reference group. The rates of cardiac-related adverse events within 7 days were higher among subjects with reduction and maintenance of SBP <140 mmHg compared to subjects without reduction (11.2% versus 6.4%).

Conclusion : No decline in death or disability but higher rates of neurological deterioration and cardiac-related adverse events were observed among intracerebral hemorrhage subjects with reduction with and without maintenance of intensive SBP goals.

Conclusion (proposition de traduction) : Aucune diminution de la mortalité ou de l'incapacité, mais des taux plus élevés de détérioration neurologique et d'événements indésirables liés à la maladie cardiaque ont été observés chez les sujets atteints d'hémorragie intracérébrale, avec une réduction avec et sans maintien des objectifs intensifs de pression artérielle systolique.

The relationship between fibrinogen and in-hospital mortality in patients with type A acute aortic dissection.
Liu J, Sun LL, Wang J, Ji G. | Am J Emerg Med. 2018 May;36(5):741-744
DOI: https://doi.org/10.1016/j.ajem.2017.10.001
Keywords: Aortic dissection; Fibrinogen; In-hospital death

Original Contribution

Introduction : Fibrinogen plays an important role in hemostasis and thrombosis and is proven to have prognostic significance in patients with cardiovascular disease. We examined the utility of fibrinogen as a prognostic indicator for patients with type A acute aortic dissection (AAD).

Méthode : This study was performed in consecutive patients with type A AAD admitted to our hospital within 24 hours after onset of symptoms. Fibrinogen levels were measured on admission. Baseline clinical characteristics and laboratory test results were collected. The endpoint was in-hospital mortality.

Résultats : A total of 143 patients with type A AAD were enrolled. Compared with the survivors, the nonsurvivors had significant lower fibrinogen levels (1.95(1.37, 2.38) vs. 2.37(1.85, 3.15) g/L, p=0.001). The cutoff level of fibrinogen determined by ROC curve analysis was 2.17 g/L, with a sensitivity, specificity of 71.9%, 60.4% respectively, and the area under the ROC curve was 0.686 (95% CI, 0.585-0.768; p=0.001). After controlling for potentially relevant confounding variables, we found an admission fibrinogen level less than 2.17g/L was associated with an increased risk of in-hospital mortality (odds ratio, 5.527; 95% CI, 1.660-18.401; p=0.005) compared with those with fibrinogen greater than 2.17g/L.

Conclusion : Low fibrinogen level on admission is an independent predictor of in-hospital mortality in patients with type A AAD.

Conclusion (proposition de traduction) : Un faible taux de fibrinogène à l'admission est un prédicteur indépendant de la mortalité hospitalière chez les patients présentant une dissection aortique aiguë de type A.

Clinical value of triage lactate in risk stratifying trauma patients using interval likelihood ratios.
Baron BJ, Nguyen A, Stefanov D, Shetty A, Zehtabchi S. | Am J Emerg Med. 2018 May;36(5):784-788
DOI: https://doi.org/10.1016/j.ajem.2017.10.015
Keywords: Lactate; Lactic acid; Risk stratification; Trauma; Wounds and injuries

Original Contribution

Introduction : Emergency physicians face the challenge of rapidly identifying high-risk trauma patients. Lactate (LAC) is widely used as a surrogate of tissue hypoperfusion. However, clinically important values for LAC as a predictor of mortality are not well defined.
OBJECTIVES: 1. To assess the value of triage LAC in predicting mortality after trauma. 2. To compute interval likelihood ratios (LR) for LAC.

Méthode : Retrospective chart review of trauma patients with a significant injury mechanism that warranted labs at an urban trauma center.
OUTCOME: In-hospital mortality. Data are presented as median and quartiles or percentages with 95% confidence intervals. Groups (lived vs. died) were compared with Man-Whitney-U or Fisher's-exact test. Multivariate analysis was used to measure the association of the independent variables and mortality. The interval likelihood ratios were calculated for all LAC observed values.

Résultats : 10,575 patients; median age: 38 [25-57]; 69% male; 76% blunt; 1.1% [n=119] mortality. LAC was statistically different between groups in univariate (2.3 [1.6,3.0] vs 2.8 [1.6,4.8], p=0.008) and multivariate analyses (odds ratio: 1.14 [1.08-1.21], p=0.0001). Interval ratios for LR- ranged from 0.6-1.0. Increasing LAC increased LR+. However, LR+ for LAC reached 5 with LAC>9mmol/L and passed 10 (moderate and conclusive increase in disease probability, respectively) with LAC>18mmol/L.

Conclusion : In a cohort of trauma patients with a wide spectrum of characteristics triage LAC was statistically able to identify patients at high risk of mortality. However, clinically meaningful contribution to decision-making occurred only at LAC>9. LAC was not useful at excluding those with a low risk of mortality.

Conclusion (proposition de traduction) : Dans une cohorte de patients traumatisés présentant un large éventail de caractéristiques, le dosage des lactates a été en mesure d'identifier statistiquement les patients à risque élevé de mortalité. Cependant, une contribution cliniquement significative à la prise de décision ne s'est produite que pour des taux de lactate > 9. Les lactates n'étaient pas utile pour exclure les personnes présentant un faible risque de mortalité.

A prospective study of ketamine as primary therapy for prehospital profound agitation.
Cole JB, Klein LR, Nystrom PC, Moore JC, Driver BE, Fryza BJ, Harrington J, Ho JD. | Am J Emerg Med. 2018 May;36(5):789-796
DOI: https://doi.org/10.1016/j.ajem.2017.10.022
Keywords: Agitation; EMS; Excited delirium syndrome; Intubation; Ketamine; Sedation

Original contribution

Introduction : We investigated the effectiveness of ketamine as a primary therapy for prehospital profound agitation.

Méthode : This was a prospective observational study of patients receiving 5mg/kg of intramuscular ketamine for profound agitation, defined as a score of +4 on the Altered Mental Status Scale (AMSS), a validated ordinal scale of agitation from -4 (unresponsive) to +4 (most agitated). The primary outcome was time to adequate sedation (AMSS<+1). Secondary outcomes included need for additional sedatives, intubation frequency, complications associated with ketamine, and mortality.

Résultats : Forty-nine patients were enrolled. Median age was 29years (range 18-66); 76% (37/49) were male. Median time to adequate sedation was 4.2min (95% CI: 2.5-5.9, range 1-25min) and 90% (44/49) had adequate sedation prehospital. Seven patients (14%) received a second sedative prehospital. Intubation occurred in 57% (28/49) of patients. Mechanical ventilation lasted <24h in 82% (23/28) of patients, and <48h in 96% (27/28) of patients. A single physician intubated 36% (10/28) of the patients. Complications related to ketamine included hypersalivation (n=9, 18%), vomiting (n=3, 6%), and emergence reaction (n=2, 4%). One patient died from complications of septic shock on hospital day 29, likely unrelated to ketamine.

Conclusion : In patients with prehospital profound agitation, ketamine provides rapid effective sedation when used as a primary therapy. Intubation was common but accompanied by a short duration of mechanical ventilation and appears to have been subject to individual physician practice variation.

Conclusion (proposition de traduction) : Chez les patients souffrant d'agitation sévère avant l'hospitalisation, la kétamine procure une sédation rapide et efficace lorsqu'elle est utilisée comme traitement de première intention. L'intubation était courante, mais s'accompagnait d'une courte durée de ventilation mécanique et semble avoir fait l'objet de variations dans la pratique individuelle des médecins.

Blood sugar changes and hospital mortality in multiple trauma.
Torabi M, Mazidi Sharaf Abadi F, Baneshi MR. | Am J Emerg Med. 2018 May;36(5):816-819
DOI: https://doi.org/10.1016/j.ajem.2017.10.029
Keywords: Blood sugar monitoring; Coagulopathy; Hyperglycemia; Multiple trauma

Original contribution

Introduction : Hyperglycemia with unknown mechanism plays a predictive role in determining the prognosis of multiple trauma patients. The exact time of blood sugar measurement and the role of blood sugar changes in the monitoring of these patients have not been well established.

Méthode : This follow-up study was done on multiple trauma patients (>18years) with an Injury Severity Scores (ISS)>16. These patients didn't have any history of diabetes, underlying disease, or drug or alcohol use. Data collection was done by the questionnaire (checklist), and the patients were followed by the medical records. Cox regression was used to measure the effect of independent variables on the patients' hospital mortality.

Résultats : Of a total of 963 patients, 280 patients were enrolled. Of those, 202 were male (72.1%) and 78 were female (27.9%). Hospital mortality was 18 (6.4%). Cox regression analysis suggested that those who had high blood sugar 3h after admission had higher hospital mortality (P=0.04). Changes in blood sugar, ΔBS (BS 3h after admission - BS on admission), in these patients was also significantly correlated with hospital mortality (P<0.001). The multivariate model using the backward conditional method showed that ΔBS (P<0.001), international normalized ration (INR) (P<0.001), and heart rate (P=0.036) were significantly correlated with hospital mortality.

Conclusion : In multiple trauma patients, blood sugar changes in the early hours of admission to the emergency department may help predict hospital mortality, but further studies are needed. Blood sugar monitoring in these patients during this time frame may be helpful in predicting these patients' outcomes. In addition, coagulopathy and tachycardia were significantly associated with hospital mortality.

Conclusion (proposition de traduction) : Chez les patients ayant subi de multiples traumatismes, l'évolution du taux de glycémie dans les premières heures d'admission aux urgences peuvent aider à prédire la mortalité hospitalière, mais d'autres études sont nécessaires. La surveillance de la glycémie chez ces patients pendant cette période peut être utile pour prédire les résultats de ces patients. De plus, la coagulopathie et la tachycardie étaient associées de façon significative à la mortalité hospitalière.

Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores.
Jouffroy R, Saade A, Ellouze S, Carpentier A, Michaloux M, Carli P, Vivien B. | Am J Emerg Med. 2018 May;36(5):820-824
DOI: https://doi.org/10.1016/j.ajem.2017.10.030
Keywords: Aucun

Original contribution

Introduction : A couple of scoring systems have been developed for risk stratification of septic patients. Their performance in the management of out-of-hospital initial care delivery is not documented. This study try to evaluate the predictive ability of Quick Sequential Organ Failure Assessment (qSOFA), Robson Screening Tool (RST), Modified Early Warning Score (MEWS) and Prehospital Early Sepsis Detection (PRESEP) scores on out of-hospital triage of septic patients, to predict intensive care unit (ICU) admission.

Méthode : A retrospective study using call records received by the SAMU 15 regulation call centre including all patients with presumed septic shock was performed. The primary outcome was the admission to the ICU.

Résultats : Among the 47 000 reports received, 37 patients with presumed septic shock were included. Twenty-two patients (59%) were admitted to ICU. AUCs of qSOFA, RST, MEWS and PRESEP scores were respectively 0.40 [0.22-0.59], 0.60 [0.43-0.78], 0.66 [0.47-0.85] and 0.67 [0.51-0.84]. RST outperformed PRESEP, MEWS and qSOFA for sensitivity (1, 0.92, 0.85 and 0.62 respectively). MEWS showed better specificity than PRESEP, MRST and qSOFA (0.33, 0.29, 0.16 and 0.16). MEWS showed comparable positive predictive value than PRESEP and outperformed MRST and qSOFA (0.41, 0.41, 0.39 and 0.29 respectively). Negative predictive value of MRST outperformed PRESEP, MEWS and qSOFA (1, 0.88, 0.80 and 0.44 respectively).

Conclusion : Our findings suggest that screening patients at SAMU 15 regulation call centre using qSOFA, MRST, MEWS and PRESEP scores to predict ICU admission is irrelevant. Development of a specific scoring system for out-of-hospital triage of septic patients is needed.

Conclusion (proposition de traduction) : Nos résultats suggèrent que le dépistage des patients par le centre d'appels et de régulation du SAMU (Centre 15) utilisant les scores qSOFA, MRST, MEWS et PRESEP pour prédire l'admission à l'USI n'est pas pertinent. Il est nécessaire de mettre au point un système de notation spécifique pour le triage des patients atteints d'une septicémie à l'extérieur de l'hôpital.

Resuscitation quality of rotating chest compression providers at one-minute vs. two-minute intervals: A mannequin study.
Kılıç D, Göksu E, Kılıç T, Buyurgan CS. | Am J Emerg Med. 2018 May;36(5):829-833
DOI: https://doi.org/10.1016/j.ajem.2017.10.035
Keywords: Aucun

Original contribution

Introduction : The aim of this randomized cross-over study was to compare one-minute and two-minute continuous chest compressions in terms of chest compression only CPR quality metrics on a mannequin model in the ED.

Méthode : Thirty-six emergency medicine residents participated in this study. In the 1-minute group, there was no statistically significant difference in the mean compression rate (p=0.83), mean compression depth (p=0.61), good compressions (p=0.31), the percentage of complete release (p=0.07), adequate compression depth (p=0.11) or the percentage of good rate (p=51) over the four-minute time period. Only flow time was statistically significant among the 1-minute intervals (p<0.001). In the 2-minute group, the mean compression depth (p=0.19), good compression (p=0.92), the percentage of complete release (p=0.28), adequate compression depth (p=0.96), and the percentage of good rate (p=0.09) were not statistically significant over time. In this group, the number of compressions (248±31 vs 253±33, p=0.01) and mean compression rates (123±15 vs 126±17, p=0.01) and flow time (p=0.001) were statistically significant along the two-minute intervals. There was no statistically significant difference in the mean number of chest compressions per minute, mean chest compression depth, the percentage of good compressions, complete release, adequate chest compression depth and percentage of good compression between the 1-minute and 2-minute groups.

Conclusion : There was no statistically significant difference in the quality metrics of chest compressions between 1- and 2-minute chest compression only groups.

Conclusion (proposition de traduction) : Il n'y avait pas de différence statistiquement significative dans les paramètres de qualité des compressions thoraciques entre les groupes de compression thoracique d'une à deux minutes seulement.

Misplacing V1 and V2 can have clinical consequences.
Walsh B | Am J Emerg Med. 2018 May;36(5):865-870
DOI: https://doi.org/10.1016/j.ajem.2018.02.006
Keywords: Diagnostic errors; ECG; EKG; Electrocardiography/standards; Electrodes

Diagnostics

Editorial : The precordial electrocardiogram (ECG) leads V1 and V2 are often misplaced. Such misplacement usually involves placing these leads too high on the chest. The resulting ECG may generate erroneous ECG patterns: e.g. incomplete right bundle branch block, anterior T wave inversion, septal Q waves, ST-segment elevation. These features may falsely suggest acute or old cardiac ischemia, pulmonary embolism, or a type-2 Brugada pattern. On rare occasion, conversely, high placement of V1 and V2 may reveal a true type-1 Brugada pattern. The emergency clinician needs to be aware of the possibility of lead misplacement, and should know how to suspect it based on unusual P wave morphology in V1 and V2.

Conclusion : The leads V1 and V2 are frequently misplaced, but the electrocardiographic manifestations of this error may not be recognized. The cases here illustrate how these erroneous ECG patterns can affect patient management. Patients may be inappropriately investigated for cardiopulmonary conditions, receive unneeded testing, and incur expense and anxiety. Only in one circumstance did misplaced leads likely facilitate investigation for a serious (but rare) condition. Clinicians should be aware of the common “mimics” that lead misplacement can generate, and also the features of the ECG, such as P wave morphology, that can suggest misplacement.

Conclusion (proposition de traduction) : Les dérivations V1 et V2 sont souvent mal placées, mais les manifestations électrocardiographiques de cette erreur peuvent ne pas être identifiées. Les cas présentés ici illustrent comment ces modèles d'ECG erronés peuvent affecter la prise en charge du patient. Les patients peuvent faire l'objet d'une enquête inappropriée pour des affections cardiopulmonaires, subir des examens inutiles et engager des dépenses et générer de l'anxiété.
Il est pourtant une circonstance où le mauvais placement des électrodes a probablement facilité l'enquête étiologique pour une affection grave (mais rare). Les cliniciens doivent être conscients des « mimiques » communes que le mauvais positionnement peut générer, ainsi que des caractéristiques de l'ECG, telles que la morphologie des ondes P, qui peuvent suggérer un mauvais positionnement.

Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department.
Glober N, Tainter CR, Brennan J, Darocki M, Klingfus M, Choi M, Derksen B, Rudolf F, Wardi G, Castillo E, Chan T. | J Emerg Med. 2018 May;54(5):585-592
DOI: https://doi.org/10.1016/j.jemermed.2018.01.032
Keywords: PERC; d-dimer; emergency department; pulmonary embolism

Original Contributions

Introduction : Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging.
OBJECTIVE: Our objective was to examine the test characteristics of the high-sensitivity d-dimer for the diagnosis of PE at our institution and evaluate use of the d-dimer and factors associated with a falsely elevated d-dimer.

Méthode : We retrospectively collected data on adult patients evaluated with a d-dimer and computed tomography (CT) pulmonary angiogram or ventilation perfusion scan at two EDs between June 4, 2012 and March 30, 2016. We collected symptoms (dyspnea, unilateral leg swelling, hemoptysis), vital signs, and medical and social history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, chronic obstructive pulmonary disease, smoking). We calculated test characteristics, including sensitivity, specificity, and likelihood ratios for the assay using conventional threshold and with age adjustment, and performed a univariate analysis.

Résultats : We found 3523 unique visits with d-dimer and imaging, detecting 198 PE. Imaging was pursued on 1270 patients with negative d-dimers, revealing 9 false negatives, and d-dimer was sent on 596 patients for whom negative Pulmonary Embolism Rule-Out Criteria (PERC) were documented with 2% subsequent radiographic detection of PE. The d-dimer showed a sensitivity of 95.7% (95% confidence interval [CI] 91-98%), specificity of 40.0% (95% CI 38-42%), negative likelihood ratio of 0.11 (95% CI 0.06-0.21), and positive likelihood ratio of 1.59 (95% CI 1.53-1.66) for the radiographic detection of PE. With age adjustment, 347 of the 2253 CT scans that were pursued in patients older than 50 years with an elevated d-dimer could have been avoided without missing any additional PE. Many risk factors, such as age, history of PE, recent surgery, shortness of breath, tachycardia and hypoxia, elevated the d-dimer, regardless of the presence of PE.

Conclusion : Many patients with negative d-dimer and PERC still received imaging. Our data support the use of age adjustment, and perhaps adjustment for other factors seen in patients evaluated for PE.

Conclusion (proposition de traduction) : Beaucoup de patients ayant des D-dimères négatif et de Critères d'exclusion de l'Embolie Pulmonaire (Pulmonary Embolism Rule-Out Criteria - PERC) ont tout de même eu une imagerie médicale. Nos données confirment l'utilisation de l'ajustement des D-dimères en fonction de l'âge, et peut-être l'ajustement pour d'autres facteurs observés chez des patients avec une suspicion d'embolie pulmonaire.

Comparison of the Accuracy of Emergency Department-Performed Point-of-Care-Ultrasound (POCUS) in the Diagnosis of Lower-Extremity Deep Vein Thrombosis.
Pedraza García J, Valle Alonso J, Ceballos García P, Rico Rodríguez F, Aguayo López MÁ, Muñoz-Villanueva MDC. | J Emerg Med. 2018 May;54(5):656-664
DOI: https://doi.org/10.1016/j.jemermed.2017.12.020
Keywords: DVT; diagnosis; emergency department management; imaging; thromboembolic disease; ultrasound

Ultrasound in Emergency Medicine

Introduction : Compression ultrasonography is the most effective diagnostic tool in the emergency department (ED) for the diagnosis of deep vein thrombosis (DVT). It has been demonstrated to be highly accurate and cost-effective.
OBJECTIVE: The objective of this study was to determine the accuracy of emergency physicians who performed three-point compression ultrasound (US) for suspected above-knee DVT within the context of using Wells score and D-dimer.

Méthode : This was a prospective diagnostic test assessment of three-point ultrasound conducted in a district general hospital of patients who presented to the ED with suspected DVT of the lower limb. The accuracy of three-point ultrasound carried out by the emergency physicians was assessed by comparison of the Doppler ultrasound carried out by the Radiology Department as reference standard. The study incorporated ultrasound alongside the Wells score and D-dimer.

Résultats : A total of 109 patients (66.1%) had a three-point compression point-of-care ultrasound in the ED and a second ultrasound performed by the Radiology Department. Bedside three-point compression ultrasound of the lower extremity performed by physicians in the ED had a sensitivity of 93.2% (95% confidence interval [CI] 83.8-97.3%) and a specificity of 90.0% (95% CI 78.6-95.7%), with an accuracy of 91.7% (95% CI 85-95.6%).

Conclusion : Emergency physicians can obtain a level of competence equivalent to that of radiologists, but it requires substantial training and practice to achieve and maintain this performance. Providers should be aware of their limitations and maintain regular training with ultrasound applications.

Conclusion (proposition de traduction) : Les médecins urgentistes peuvent obtenir un niveau de compétence équivalent à celui des radiologues, mais il faut une formation et une pratique importantes pour atteindre et maintenir ce niveau. Les urgentistes doivent être conscients de leurs limites et maintenir une formation régulière sur les examens d'échographie.

Effect of door-to-angioembolization time on mortality in pelvic fracture: Every hour of delay counts.
Matsushima K, Piccinini A, Schellenberg M, Cheng V, Heindel P, Strumwasser A, Benjamin E, Inaba K, Demetriades D. | J Trauma Acute Care Surg. 2018 May;84(5):685-692
DOI: https://doi.org/10.1097/TA.0000000000001803
Keywords: Aucun

AAST 2017 Podium Paper

Introduction : Angioembolization (AE) is widely used for hemorrhagic control in patients with pelvic fracture. The latest version of the Resources for Optimal Care of the Injured Patient issued by the American College of Surgeons Committee on Trauma requires interventional radiologists to be available within 30 minutes to perform an emergency AE. However, the impact of time-to-AE on patient outcomes remains unknown. We hypothesized that a longer time-to-AE would be significantly associated with increased mortality in patients with pelvic fracture.

Méthode : This is a 2-year retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2014. We included adult patients (age ≥ 18 years) with blunt pelvic fracture who underwent pelvic AE within 4 hours of hospital admission. Patients who required any hemorrhage control surgery for associated injuries within 4 hours were excluded. Hierarchical logistic regression was performed to evaluate the impact of time-to-AE on in-hospital and 24-hour mortality.

Résultats : A total of 181 patients were included for analysis. The median age was 54 years (interquartile range, 38-68) and 69.6% were male. The median injury severity score was 34 (interquartile range, 27-43). Overall in-hospital mortality rate was 21.0%. The median packed red blood cell transfusions within 4 and 24 hours after admission were 4 and 6 units, respectively. After adjusting for other covariates in a hierarchical logistic regression model, a longer time-to-pelvic AE was significantly associated with increased in-hospital mortality (odds ratio, 1.79 for each hour; 95% confidence interval, 1.11-2.91; p = 0.018).

Conclusion : The current study showed an increased risk of in-hospital mortality related to a prolonged time-to-AE for hemorrhagic control following pelvic fractures. Our results suggest that all trauma centers should allocate resources to minimize delays in performing pelvic AE.

Conclusion (proposition de traduction) : La présente étude a montré un risque accru de mortalité à l'hôpital lié à une angioembolisation prolongée pour le contrôle hémorragique après une fracture du bassin. Nos résultats suggèrent que tous les centres de traumatologie devraient allouer des ressources pour minimiser les retards dans l'exécution de l'angioembolisation pelvienne.

Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST).
Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. | J Trauma Acute Care Surg. 2018 May;84(5):736-744
DOI: https://doi.org/10.1097/TA.0000000000001764
Keywords: Aucun

2017 EAST Podium Paper

Introduction : Spine immobilization in trauma has remained an integral part of most emergency medical services protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a practice management guideline.

Méthode : We conducted a Cochrane style systematic review and meta-analysis and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit.

Résultats : A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with risk ratio [RR], 2.4 (confidence interval [CI], 1.07-5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR, 4.16 (CI, 0.56-30.89), and RR, 1.19 (CI, 0.83-1.70), although the point estimates favored no immobilization.

Conclusion : Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma.

Conclusion (proposition de traduction) : L'immobilisation de la colonne vertébrale dans les traumatismes pénétrants est associée à une mortalité accrue et il n'a pas été démontré qu'elle avait un effet bénéfique sur l'atténuation des déficits neurologiques, même les déficits neurologiques potentiellement réversibles.
Nous recommandons que l’immobilisation de la colonne vertébrale ne soit pas utilisée systématiquement chez les patients adultes présentant un traumatisme pénétrant.

Use of French lyophilized plasma transfusion in severe trauma patients is associated with an early plasma transfusion and early transfusion ratio improvement.
Nguyen C, Bordes J, Cungi PJ, Esnault P, Cardinale M, Mathais Q, Cotte J, Beaume S, Sailliol A, Prunet B, Meaudre E. | J Trauma Acute Care Surg. 2018 May;84(5):780-785
DOI: https://doi.org/10.1097/TA.0000000000001801
Keywords: Aucun

Original articles

Introduction : Early transfusion of high ratio of fresh frozen plasma (FFP) and red blood cells (RBC) is associated with mortality reduction. However, time to reach high ratio is limited by the need to thaw the FFP. French lyophilized plasma (FLYP) used by French army and available in military teaching hospital does not need to be thawed and is immediately available. We hypothesize that the use of FLYP may reduce time to reach a plasma/RBC ratio of 1:1.

Méthode : A retrospective study performed in a Level 1 trauma center between January 2012 and December 2015. Severe trauma patients who received 2 U of RBC in the emergency room were included and assigned to two groups according to first plasma transfused: FLYP group and FFP group.

Résultats : Forty-three severe trauma patients in the FLYP group and 29 in the FFP group were included. The time until first plasma transfusion was shorter in the FLYP group than in the FFP group, respectively 15 min (10-25) versus 95 min (70-145) (p < 0.0001). Time until a 1:1 ratio was shorter in the FLYP group than in the FFP group. There were significantly fewer cases of massive transfusion in the FLYP group than in the FFP group with respectively 7% vs. 45% (p < 0.0001).

Conclusion : The use of FLYP provided significantly faster plasma transfusions than the use of FFP as well as a plasma and RBC ratio superior to 1:2 that was reached more rapidly in severe trauma patients. These results may explain the less frequent need for massive transfusion in the patients who received FLYP. These positive results should be confirmed by a prospective and randomized evaluation.

Conclusion (proposition de traduction) : L'utilisation de plasma lyophilisé français a permis des transfusions plasmatiques significativement plus rapides que l'utilisation de plasma frais congelé ainsi qu'un rapport plasma/globules rouges supérieur à 1:2, plus rapide chez les patients traumatisés sévères. Ces résultats pourraient expliquer le besoin moins fréquent de transfusion massive chez les patients ayant reçu du plasma lyophilisé français. Ces résultats positifs doivent être confirmés par une évaluation prospective et randomisée.

Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials.
Tran A, Yates J, Lau A, Lampron J, Matar M. | J Trauma Acute Care Surg. 2018 May;84(5):802-808
DOI: https://doi.org/10.1097/TA.0000000000001816
Keywords: Aucun

Systematic Reviews

Introduction : Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia. Animal studies suggest that permissive hypotension maintains appropriate organ perfusion, reduces bleeding and improves mortality. This review assesses the efficacy and safety of permissive hypotension in adult trauma patients with hemorrhagic shock.

Méthode : We searched the MEDLINE and EMBASE databases from inception to May 2017 for randomized controlled trials comparing permissive hypotension vs. conventional resuscitation following traumatic injury. We included preoperative and intraoperative resuscitation strategies. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood product utilization, estimated blood loss and in-hospital complications. Pooling was performed with a random-effects model.

Résultats : We screened 722 abstracts, from which five randomized trials evaluating 1,158 patients were included. Blood pressure targets in the intervention arms varied from systolic BP 50 mm Hg to 70 mm Hg or mean arterial pressure of 50 mm Hg or higher as compared to systolic BP 65 mm Hg to 100 mm Hg or mean arterial pressure of 65 or higher in the control arms. Two studies evaluated only patients with penetrating injury while the remaining three additionally included blunt injuries. Four trials suggested a survival benefit for 30-day or in-hospital mortality with hypotensive resuscitation, although three studies were insufficiently powered to find statistical significance. Studies were of poor to moderate quality due to poor protocol reporting and lack of blinding. The pooled odds ratio was 0.70 (95% confidence interval, 0.53-0.92), suggesting a survival benefit for permissive hypotension. Those patients received fewer blood products and had lesser estimated blood loss.

Conclusion : Permissive hypotension may offer a survival benefit over conventional resuscitation for patients with hemorrhagic injury. It may additionally reduce blood loss and blood product utilization. However, the majority of studies were underpowered, thus reflecting a need for high quality, adequately powered trials.

Conclusion (proposition de traduction) : L'hypotension permissive peut offrir un avantage de survie par rapport à la réanimation conventionnelle chez les patients présentant une lésion hémorragique. Il peut également réduire la perte de sang et l'utilisation des produits sanguins.
Cependant, la majorité des études étaient sous-performantes, reflétant ainsi un besoin d'essais de haute qualité et suffisamment puissants.

Systematic review of prehospital tourniquet use in civilian limb trauma.
Kauvar DS, Dubick MA, Walters TJ, Kragh JF Jr. | J Trauma Acute Care Surg. 2018 May;84(5):819-825
DOI: https://doi.org/10.1097/TA.0000000000001826
Keywords: Aucun

Systematic Reviews

Introduction : Military enthusiasm for limb tourniquet use in combat casualty care has resulted in acceptance by the trauma community for use in the prehospital care of civilian limb injuries. To date, there has been no report synthesizing the published data on civilian tourniquet use. The objective of this systematic review was to compile and analyze the content and quality of published data on the civilian use of tourniquets in limb trauma.

Méthode : The MEDLINE database was searched for studies on civilian limb tourniquet use in adults published between 2001 and 2017. Search terms were tourniquet, trauma, and injury. Military reports and case series lacking systematic data collection were excluded. Counts and percentages were aggregated and weighted for analysis.

Résultats : Reports were included from six regional trauma centers and one interregional collaboration (total of 572 cases). One national prehospital database report was included but analyzed separately (2,048 cases). All were retrospective cohort studies without prospective data collection. Three reports defined a primary outcome, two had a nontourniquet control group, and no two articles reported the same variables. Limb injury severity and characteristics were inconsistently and incompletely described across reports, as were tourniquet indications and effectiveness. Arterial injury was reported in two studies and was infrequent among cases of tourniquet use. Mortality was low, and limb-specific complications were infrequent but variably reported.

Conclusion : The rapid increase in the civilian use of tourniquets for limb hemorrhage control has occurred without a large amount or high quality of data. Adoption of a multicenter registry with standardized data collection specific to limb trauma and tourniquet use can serve to improve the trauma community's understanding of the safety and effectiveness of tourniquet use in civilian trauma settings.

Conclusion (proposition de traduction) : L'augmentation rapide du recours en pratique civile des garrots pour le contrôle de l'hémorragie des membres s'est produite sans grande quantité ni qualité élevée de données. L'adoption d'un registre multicentrique avec une collecte de données normalisée spécifique au traumatisme des membres et à l'utilisation du garrot peut permettre d'améliorer la compréhension de la communauté des orthopédistes sur la sécurité et l'efficacité de l'utilisation du garrot dans des contextes de traumatologie civile.

Systematic review of prehospital tourniquet use in civilian limb trauma.
Kauvar DS, Dubick MA, Walters TJ, Kragh JF Jr. | J Trauma Acute Care Surg. 2018 May;84(5):819-825
DOI: https://doi.org/10.1097/TA.0000000000001826
Keywords: Aucun

Systematic Reviews

Introduction : Military enthusiasm for limb tourniquet use in combat casualty care has resulted in acceptance by the trauma community for use in the prehospital care of civilian limb injuries. To date, there has been no report synthesizing the published data on civilian tourniquet use. The objective of this systematic review was to compile and analyze the content and quality of published data on the civilian use of tourniquets in limb trauma.

Méthode : The MEDLINE database was searched for studies on civilian limb tourniquet use in adults published between 2001 and 2017. Search terms were tourniquet, trauma, and injury. Military reports and case series lacking systematic data collection were excluded. Counts and percentages were aggregated and weighted for analysis.

Résultats : Reports were included from six regional trauma centers and one interregional collaboration (total of 572 cases). One national prehospital database report was included but analyzed separately (2,048 cases). All were retrospective cohort studies without prospective data collection. Three reports defined a primary outcome, two had a nontourniquet control group, and no two articles reported the same variables. Limb injury severity and characteristics were inconsistently and incompletely described across reports, as were tourniquet indications and effectiveness. Arterial injury was reported in two studies and was infrequent among cases of tourniquet use. Mortality was low, and limb-specific complications were infrequent but variably reported.

Conclusion : The rapid increase in the civilian use of tourniquets for limb hemorrhage control has occurred without a large amount or high quality of data. Adoption of a multicenter registry with standardized data collection specific to limb trauma and tourniquet use can serve to improve the trauma community's understanding of the safety and effectiveness of tourniquet use in civilian trauma settings.

Conclusion (proposition de traduction) : L'augmentation rapide de l'utilisation civile des garrots pour le contrôle des hémorragies des membres s'est produite sans une grande quantité ou qualité des données.
L'adoption d'un registre multicentrique avec collecte de données normalisées, spécifiques aux traumatismes des membres et à l'utilisation du garrot tourniquet, pourrait permettre à la communauté qui prend en charge des traumatisés, d'améliorer la compréhension sur la sécurité et l'efficacité de l'utilisation du garrot dans les situations de la traumatologie civile.