Bibliographie de Médecine d'Urgence

Mois de juin 2018


Academic Emergency Medicine

Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation.
DeMeester S, Hess RA, Hubbard B, LeClerc K, Ferraro J, Albright JJ. | Acad Emerg Med. 2018 Jun;25(6):641-649
DOI: https://doi.org/10.1111/acem.13383  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : Atrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate-controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life-threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm.

Méthode : Study design is a retrospective cohort analysis pre- and postimplementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3- and 30-day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013-February 2014) and after (March 2015-February 2016) implementation. Chi-square tests and logistic regressions were run to test for significant changes in the three outcome variables.

Résultats : A total of 1,108 individuals met inclusion criteria with 586 patients in the preimplementation group and 522 in the postimplementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs. 67.4% post, adjusted odds ratio [OR] = 3.4, p < 0.001). Despite this difference there was no change in ED return rates within 3 or 30 days (adjusted ORs = 0.93 and 0.89, p = 0.91 and 0.73, respectively).

Conclusion : Implementation of a novel algorithm to identify and treat low-risk patients with AFib can significantly decrease the rate of hospital admissions without increased ED returns. This simple algorithm could be adopted by other community hospitals and help lower costs.

Conclusion (proposition de traduction) : La mise en œuvre d'un nouvel algorithme permettant d'identifier et de traiter les patients à faible risque atteints de fibrillation auriculaire peut réduire de manière significative le taux d'admissions à l'hôpital sans augmenter les reconsultations aux urgences.
Cet algorithme simple pourrait être adopté par d'autres hôpitaux communautaires et aider à réduire les coûts.

Hot Off the Press: Peripheral Intravenous Cannula Insertion and Use in the Emergency Department.
Rangarajan S, Morgenstern J, Milne WK, Heitz C. | Acad Emerg Med. 2018 Jun;25(6):668-671
DOI: https://doi.org/10.1111/acem.13390
Keywords: Aucun

Original contributions

Editorial : This is a prospective before-after study comparing peripheral intravenous cannulation (PIVC) placement and usage rates following a 10-week-long multimodal intervention provided to medical and nursing staff working in a tertiary emergency department (ED). The intervention focused on improving appropriate use of PIVCs in an emergency setting by emphasizing to clinicians that a PIVC should only be placed if it was believed there was more than an 80% chance that it would be used. Patients were eligible for the study if they presented to the ED and were >18 years of age. Patients were excluded from the study if they were triage category 1, already had a PIVC placed in an ambulance, or were transferred from another hospital. Among the 4,172 patients included in the analysis, there was a 9.8% reduction in the number of PIVCs inserted (95% confidence interval [CI] = 6.8-12.87) and a 12% increase in PIVC usage (95% CI = 8.7%-17.0%) in the postintervention cohort.

Conclusion : This study provides evidence that a 10-week multi-modal intervention can reduce PIVC insertion and increase PIVC usage rates. The longevity of such an intervention, its potential harms, and the true patient oriented benefits are not clear. Implementation of this simple multi-modal intervention would likely prevent unnecessary patient discomfort and anxiety, optimize the clinical staff’s time in ED, and save physical hospital resources. Patients should ask their care provider if a PIVC is necessary while in the ED.

Conclusion (proposition de traduction) : Cette étude démontre qu'une intervention multimodale de 10 semaines peut réduire le nombre de voie veineuses périphériques et augmenter les taux d'utilisation de celles mises en place. La longévité d'une telle intervention, ses inconvénients potentiels et les véritables avantages pour les patients ne sont pas clairs. La mise en œuvre de cette intervention multimodale simple permettrait probablement de prévenir l'inconfort et l'anxiété inutiles des patients, d'optimiser le temps du personnel clinique aux urgences et d'économiser les ressources physiques de l'hôpital. Les patients devraient demander à leur intervenant si une voie veineuses périphériques est nécessaire pendant qu'ils sont aux urgences.

The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis.
Wong C, Teitge B, Ross M, Young P, Robertson HL, Lang E. | Acad Emerg Med. 2018 Jun;25(6):684-698
DOI: https://doi.org/10.1111/acem.13388
Keywords: Aucun

EVIDENCE‐BASED DIAGNOSTICS

Introduction : Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis and 2) to assess its prognostic value in the management of renal colic.

Méthode : The review protocol was registered to the PROSPERO database (CRD42016035331). An electronic database search of MEDLINE, Embase, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were computed tomography evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by consensus with a third reviewer. Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary objective of prognostic value was reported as a narrative summary.

Résultats : The electronic search yielded 627 unique titles. After relevance screening, 26 papers underwent full-text review, and nine articles met all inclusion criteria. Of these, five high-quality studies (N = 1,773) were included in the meta-analysis for diagnostic accuracy and the remaining yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% confidence interval [CI] = 67.1%-73.2%) and 75.4% (95% CI = 72.5%-78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect. Two of the studies in the meta-analysis found that the finding of moderate or greater hydronephrosis yielded a specificity of 94.4% (95% CI = 92.7%-95.8%). Four studies examining prognostic value noted a higher likelihood of a large stone when positive POCUS findings were present. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation.

Conclusion : Point-of-care ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The finding of moderate or severe hydronephrosis is highly specific for the presence of any stone, and the presence of any hydronephrosis is suggestive of a larger (>5 mm) stone in those presenting with renal colic.

Conclusion (proposition de traduction) : L'échographie au point de service (POCUS) a une précision diagnostique modeste pour le diagnostic de la colique néphrétique.
La découverte d'une hydronéphrose modérée ou sévère est hautement spécifique de la présence d'une lithiase, et la présence de toute hydronéphrose suggère une plus grosse lithiase (> 5 mm) chez les patients se présentant pour une colique néphrétique.

Anaesthesia Critical Care & Pain Medicine

Changes in the availability of bedside ultrasound practice in emergency rooms and prehospital settings in France.
Bobbia X, Abou-Badra M, Hansel N, Pes P, Petrovic T, Claret PG, Lefrant JY, de La Coussaye JE; Winfocus France Group. | Anaesth Crit Care Pain Med. 2018 Jun;37(3):201-205
DOI: https://doi.org/10.1016/j.accpm.2017.06.008
Keywords: Aucun

Original articles

Introduction : Ensuring the availability of ultrasound devices is the initial step in implementing clinical ultrasound (CUS) in emergency services. In France in 2011, 52% of emergency departments (EDs) and only 9% of mobile intensive care stations (MICS) were equipped with ultrasound devices. The main goal of this study was to determine the movement of these rates since 2011.

Méthode : We conducted a cross-sectional, descriptive, multicentre study in the form of a questionnaire. To estimate the numbers of EDs and MICS equipped with at least one ultrasound system with a confidence level of 95% and margin of error of 5%, 170 responding EDs and 145 MICS were required. Each service was solicited three times by secure online questionnaire and then by phone.

Résultats : Three hundred and twenty-eight (84%) services responded to the questionnaire: 179 (86%) EDs and 149 (82%) MICS. At least one ultrasound machine was available in 127 (71%, 95% CI [64; 78]) EDs vs. 52% in 2011 (P<0.01). 42 (28%, 95% CI [21; 35]) MICS were equipped vs. 9% in 2011 (P<0.01). In 97 (76%) EDs and 24 (55%) MICS, less than a half of physicians were trained. CUS was used at least three times a day in 52 (41%) EDs and in 8 (19%) MICS.

Conclusion : Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Conclusion (proposition de traduction) : Our study demonstrates improved access to ultrasound devices in French EDs and MICS. Almost three-quarters of EDs and nearly one-third of MICS are now equipped with at least one ultrasound device. However, the rate of physicians trained per service remains insufficient.

Anesthesiology

Biologic Impact of Mechanical Power at High and Low Tidal Volumes in Experimental Mild Acute Respiratory Distress Syndrome.
Santos RS, Maia LA, Oliveira MV, Santos CL, Moraes L, Pinto EF, Samary CDS, Machado JA, Carvalho AC, Fernandes MVS, Martins V, Capelozzi VL, Morales MM, Koch T, Gama de Abreu M, Pelosi P, Silva PL, Rocco PRM. | Anesthesiology. 2018 Jun;128(6):1193-1206
DOI: https://doi.org/10.1097/ALN.0000000000002143
Keywords: Aucun

Critical Care Medicine Basic Science

Introduction : The authors hypothesized that low tidal volume (VT) would minimize ventilator-induced lung injury regardless of the degree of mechanical power. The authors investigated the impact of power, obtained by different combinations of VT and respiratory rate (RR), on ventilator-induced lung injury in experimental mild acute respiratory distress syndrome (ARDS).

Méthode : Forty Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 h, 32 rats were randomly assigned to be mechanically ventilated (2 h) with a combination of different VT (6 ml/kg and 11 ml/kg) and RR that resulted in low and high power. Power was calculated as energy (ΔP,L/E,L) × RR (ΔP,L = transpulmonary driving pressure; E,L = lung elastance), and was threefold higher in high than in low power groups. Eight rats were not mechanically ventilated and used for molecular biology analysis.

Résultats : Diffuse alveolar damage score, which represents the severity of edema, atelectasis, and overdistension, was increased in high VT compared to low VT, in both low (low VT: 11 [9 to 14], high VT: 18 [15 to 20]) and high (low VT: 19 [16 to 25], high VT: 29 [27 to 30]) power groups. At high VT, interleukin-6 and amphiregulin expressions were higher in high-power than in low-power groups. At high power, amphiregulin and club cell protein 16 expressions were higher in high VT than in low VT. Mechanical energy and power correlated well with diffuse alveolar damage score and interleukin-6, amphiregulin, and club cell protein 16 expression.

Conclusion : In experimental mild ARDS, even at low VT, high mechanical power promoted ventilator-induced lung injury. To minimize ventilator-induced lung injury, low VT should be combined with low power.

Conclusion (proposition de traduction) : Dans le SDRA expérimental léger, même à faible volume courant, une puissance mécanique élevée a favorisé des lésions pulmonaires induites par le respirateur. Pour réduire au minimum les lésions pulmonaires causées par le respirateur, un faible volume courant devrait être combiné à une faible puissance.

Annals of Emergency Medicine

Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain.
Tsze DS, von Baeyer CL, Pahalyants V, Dayan PS. | Ann Emerg Med. 2018 Jun;71(6):691-702.e3
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.009
Keywords: Aucun

Pediatrics

Introduction : The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity. It is unclear how the validity and reliability of the scale scores vary across children's ages. We aimed to determine the validity and reliability of the scale for children presenting to the emergency department across a comprehensive spectrum of age.

Méthode : This was a cross-sectional study of children aged 4 to 17 years. Children self-reported their pain intensity, using the Verbal Numerical Rating Scale and Faces Pain Scale-Revised at 2 serial assessments. We evaluated convergent validity (strong validity defined as correlation coefficient ≥0.60), agreement (difference between concurrent Verbal Numerical Rating Scale and Faces Pain Scale-Revised scores), known-groups validity (difference in score between children with painful versus nonpainful conditions), responsivity (decrease in score after analgesic administration), and reliability (test-retest at 2 serial assessments) in the total sample and subgroups based on age.

Résultats : We enrolled 760 children; 27 did not understand the Verbal Numerical Rating Scale and were removed. Of the remainder, Pearson correlations were strong to very strong (0.62 to 0.96) in all years of age except 4 and 5 years, and agreement was strong for children aged 8 and older. Known-groups validity and responsivity were strong in all years of age. Reliability was strong in all age subgroups, including each year of age from 4 to 7 years.

Conclusion : Convergent validity, known-groups validity, responsivity, and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years. Convergent validity was not strong for children aged 4 and 5 years. Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older, but not for those aged 4 and 5 years.

Conclusion (proposition de traduction) : La validité convergente, la validité des groupes connus, la sensibilité et la fiabilité de l'échelle d'évaluation numérique verbale étaient fortes pour les enfants âgés de 6 à 17 ans. La validité convergente n'était pas forte pour les enfants de 4 et 5 ans.
Nos constatations confirment l'utilisation de l'échelle d'évaluation numérique verbale pour la plupart des enfants de 6 ans et plus, mais pas pour ceux de 4 et 5 ans.

How Older Adults Experience an Emergency Department Visit: Development and Validation of Measures.
McCusker J, Cetin-Sahin D, Cossette S, Ducharme F, Vadeboncoeur A, Vu TTM, Veillette N, Ciampi A, Belzile E, Berthelot S, Lachance PA, Mah R. | Ann Emerg Med.  2018 Jun;71(6):755-766.e4
DOI: https://doi.org/10.1016/j.annemergmed.2018.01.009
Keywords: Aucun

Geriatrics

Introduction : This study aims to develop and validate measures of experiences of an emergency department (ED) visit suitable for use by older adults or their family members.

Méthode : A cohort of patients aged 75 years and older who were discharged home was recruited at 4 EDs. At 1 week after the visit, patients or family members were interviewed by telephone to assess problems experienced at the visit. Twenty-six questions based on 6 domains of care found in the literature were developed: 16 questions were administered to all patients; 10 questions were administered to bed patients only. Scales were developed with multiple correspondence analysis. Regression analyses were used to validate the scales, using 2 validation criteria: perceived overall quality of care and willingness to return to the same ED.

Résultats : Four hundred twelve patients completed the 1-week interview, 197 ambulatory and 215 bed patients; family members responded for 75 patients. Two scales were developed, assessing personal care and communication (8 questions; α=.63) and waiting times (2 questions; α=.79). Both scales were significantly independently associated with perceived overall quality of care and willingness to return to the same ED.

Conclusion : Two scales assessing important aspects of ED care experienced by older adults are ready for further evaluation in other settings.

Conclusion (proposition de traduction) : Deux échelles d'évaluation des aspects importants des soins d'urgence prodigués aux personnes âgées sont prêtes à faire l'objet d'une évaluation plus approfondie dans d'autres contextes.

Annals of Intensive Care

Impact of fluid challenge increase in cardiac output on the relationship between systemic and cerebral hemodynamics in severe sepsis compared to brain injury and controls.
Le Dorze M, Huché F, Coelembier C, Rabuel C, Payen D. | Ann Intensive Care. 2018 Jun 28;8(1):74
DOI: https://doi.org/10.1186/s13613-018-0419-1  | Télécharger l'article au format  
Keywords: Brain perfusion; Fluid challenge; Sepsis; Systemic inflammation; Transcranial Doppler

Research

Introduction : Cognitive dysfunction and delirium after ICU are frequent and may partially result from brain ischemia episodes. We hypothesized that systemic inflammation (severe sepsis or septic shock) modifies the control of brain circulation and the relation between systemic and cerebral hemodynamic after a positive response to fluid challenge (FC).

Méthode : Three groups of patients were studied if they increased stroke volume (SV) > 10% after 250 or 500 ml of crystalloids: control group: patients free of comorbidity anesthetized for orthopedic surgery; sepsis group: patients with severe sepsis or septic shock (classic definition); brain injury (BI) group: trauma brain jury or hemorrhagic stroke with no detectable systemic inflammation. The measurements before and after FC were mean arterial blood pressure (MAP) (radial catheter); SV and cardiac output (CO; transesophageal Doppler); bilateral middle cerebral artery (MCAv) velocity with peak systolic (PSV) and end diastolic (EDV) values (transcranial Doppler); end-tidal CO2. The role of MAP increase was investigated by an arbitrarily threshold increase of 5%, called responder in CO and MAP (RR). The remaining patients were call responders in CO and non-responders in MAP (RnR). Nonparametric tests were used for statistical analysis.

Résultats : Among the 86 screened patients, 66 have completed the protocol: 17 in control group; 38 in sepsis group; and 11 in BI group. All patients increased SV > 10% after FC. Only the sepsis group increased MAP [+ 12 (2-25%), p < 0.05] with a significant increase in PSV and EDV [(17 (3-30)% and 17 (12-42)%, respectively (p < 0.05)], which did not change in the two other groups. The septic RR or RnR had similar variations in MCAv after FC. The baseline MAP < or > baseline median MAP had similar MCAv.

Conclusion : After a FC-induced increase in SV, MCAv (PSV and EDV) increased only in septic group, mostly independently from MAP increase and from baseline MAP level. Cerebral perfusion becomes passively dependent on systemic blood flow, suggesting a modification of the control of cerebrovascular tone in sepsis-induced systemic inflammation. This information has been considered in the clinical management of septic patients.

Conclusion (proposition de traduction) : Après une augmentation du volume systolique induite par le test de provocation, la vélocité de l'artère cérébrale moyenne (pic systolique et diastolique) n'a augmenté que dans le groupe septique, principalement indépendamment de l'augmentation moyenne de la tension artérielle et du niveau artériel moyen. La perfusion cérébrale devient passivement dépendante du flux sanguin systémique, ce qui suggère une modification du contrôle du tonus cérébrovasculaire dans l'inflammation systémique induite par la septicémie. Cette information a été prise en compte dans la prise en charge clinique des patients septiques.

Estimating mean circulatory filling pressure in clinical practice: a systematic review comparing three bedside methods in the critically ill.
Wijnberge M, Sindhunata DP, Pinsky MR, Vlaar AP, Ouweneel E, Jansen JR, Veelo DP, Geerts BF. | Ann Intensive Care. 2018 Jun 20;8(1):73
DOI: https://doi.org/10.1186/s13613-018-0418-2  | Télécharger l'article au format  
Keywords: Blood pressure; Blood volume; Critical care; Hemodynamics; Intensive care; Venous pressure

Review

Introduction : The bedside hemodynamic assessment of the critically ill remains challenging since blood volume, arterial-venous interaction and compliance are not measured directly. Mean circulatory filling pressure (Pmcf) is the blood pressure throughout the vascular system at zero flow. Animal studies have shown Pmcf provides information on vascular compliance, volume responsiveness and enables the calculation of stressed volume. It is now possible to measure Pmcf at the bedside.

Méthode : e performed a systematic review of the current Pmcf measurement techniques and compared their clinical applicability, precision, accuracy and limitations. A comprehensive search strategy was performed in PubMed, Embase and the Cochrane databases. Studies measuring Pmcf in heart-beating patients at the bedside were included. Data were extracted from the articles into predefined forms. Quality assessment was based on the Newcastle-Ottawa Scale for cohort studies.

Résultats : A total of 17 prospective cohort studies were included. Three techniques were described: Pmcf hold, based on inspiratory hold-derived venous return curves, Pmcf arm, based on arterial and venous pressure equilibration in the arm as a model for the entire circulation, and Pmcf analogue, based on a Guytonian mathematical model of the circulation. The included studies show Pmcf to accurately follow intravascular fluid administration and vascular compliance following drug-induced hemodynamic changes.

Conclusion : Bedside Pmcf measures allow for more direct assessment of circulating blood volume, venous return and compliance. However, studies are needed to determine normative Pmcf values and their expected changes to therapies if they are to be used to guide clinical practice.

Conclusion (proposition de traduction) : Les mesures de pression de remplissage circulatoire moyennes au lit du malade permettent une évaluation plus directe du volume sanguin circulant, du retour veineux et de la compliance. Cependant, des études sont nécessaires pour déterminer les valeurs normatives des mesures de la pression circulatoire moyenne de remplissage et les changements attendus dans les thérapies si elles doivent être utilisées pour guider la pratique clinique.

Effectiveness of antimicrobial-coated central venous catheters for preventing catheter-related blood-stream infections with the implementation of bundles: a systematic review and network meta-analysis.
Wang H, Tong H, Liu H, Wang Y, Wang R, Gao H, Yu P, Lv Y, Chen S, Wang G, Liu M, Li Y, Yu K, Wang C. | Ann Intensive Care. 2018 Jun 15;8(1):71
DOI: https://doi.org/10.1186/s13613-018-0416-4  | Télécharger l'article au format  
Keywords: Bundles; Catheter colonization; Catheter-related blood-stream infections; Central venous catheter; Meta-analysis

Review

Introduction : Catheter-related blood-stream infections (CRBSIs) are the most common complication when using central venous catheters (CVCs). Whether coating CVCs under bundles could further reduce the incidence of CRBSIs is unclear. We aimed to assess the effectiveness of implementing the use of bundles with antimicrobial-coated CVCs for preventing catheter-related blood-stream infections.

Méthode : In this systematic review and network meta-analyses, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library in addition to the EMBASE, MEDLINE, CINAHL, and Web of Science databases for studies published before July 2017. The primary outcome was the rate of CRBSIs per 1000 catheter-days, and the secondary outcome was the incidence of catheter colonization.

Résultats : Twenty-three studies revealed significant differences in the rate of CRBSIs per 1000 catheter-days between antimicrobial-impregnated and standard CVCs (RR 0.70, 95% CI 0.53-0.91, p = 0.008). Thirty-three trials were included containing 10,464 patients who received one of four types of CVCs. Compared with a standard catheter, chlorhexidine/silver sulfadiazine- and antibiotic-coated catheters were associated with lower numbers of CRBSIs per 1000 catheter-days (ORs and 95% CrIs: 0.64 (0.40-0.955) and 0.53 (0.25-0.95), respectively) and a lower incidence of catheter colonization (ORs and 95% CrIs: 0.44 (0.34-0.56) and 0.30 (0.20-0.46), respectively).

Conclusion : Outcomes are superior for catheters impregnated with chlorhexidine/silver sulfadiazine or other antibiotics than for standard catheters in preventing CRBSIs and catheter colonization under bundles. Compared with silver ion-impregnated CVCs, chlorhexidine/silver sulfadiazine antiseptic catheters resulted in fewer cases of microbial colonization of the catheter but did not reduce CRBSIs.

Conclusion (proposition de traduction) : Les résultats sont supérieurs pour les cathéters imprégnés de chlorhexidine/sulfadiazine d'argent ou d'autres antibiotiques que pour les cathéters standards dans la prévention des septicémies liées au cathéter et la colonisation des cathéters en packages.
Par rapport aux cathéters veineux centraux imprégnés d'ions d'argent, les cathéters antiseptiques chlorhexidine/sulfadiazine d'argent ont entraîné moins de cas de colonisation microbienne du cathéter, mais n'ont pas réduit les septicémies liées au cathéter.

Adherence to a procalcitonin-guided antibiotic treatment protocol in patients with severe sepsis and septic shock.
Hohn A, Balfer N, Heising B, Hertel S, Wiemer JC, Hochreiter M, Schröder S. | Ann Intensive Care. 2018 Jun 4;8(1):68
DOI: https://doi.org/10.1186/s13613-018-0415-5  | Télécharger l'article au format  
Keywords: Antibiotic consumption; Procalcitonin; Protocol adherence; Sepsis

Research

Introduction : In randomised controlled trials, procalcitonin (PCT)-guided antibiotic treatment has been proven to significantly reduce length of antibiotic therapy in intensive care unit (ICU) patients. However, concern was raised on low protocol adherence and high rates of overruling, and thus the value of PCT-guided treatment in real clinical life outside study conditions remains unclear. In this study, adherence to a PCT protocol to guide antibiotic treatment in patients with severe sepsis and septic shock was analysed.

Méthode : From 2012 to 2014, surgical ICU patients with severe sepsis or septic shock were retrospectively screened for PCT measurement series appropriate to make treatment decisions on antibiotic therapy. We compared (1) patients with appropriate PCT measurement series to patients without appropriate series; (2) patients who reached the antibiotic stopping advice threshold (PCT < 0.5 ng/mL and/or decrease to 10% of peak level) to patients who did not reach a stopping advice threshold; and (3) patients who were treated adherently to the PCT protocol to non-adherently treated patients. The groups were compared in terms of antibiotic treatment duration, PCT kinetics, and other clinical outcomes.

Résultats : Of 81 patients with severe sepsis or septic shock, 14 were excluded due to treatment restriction or short course in the ICU. The final analysis was performed on 67 patients. Forty-two patients (62.7%) had appropriate PCT measurement series. In patients with appropriate PCT series, median initial PCT (p = 0.001) and peak PCT levels (p < 0.001) were significantly higher compared to those with non-appropriate series. In 26 patients with appropriate series, PCT levels reached an antibiotic stopping advice. In 8 of 26 patients with stopping advice, antibiotics were discontinued adherently to the PCT protocol (30.8%). Patients with adherently discontinued antibiotics had a shorter antibiotic treatment (7d [IQR 6-9] vs. 12d [IQR 9-16]; p = 0.002). No differences were seen in terms of other clinical outcomes.

Conclusion : In patients with severe sepsis and septic shock, procalcitonin testing was irregular and adherence to a local PCT protocol was low in real clinical life. However, adherently treated patients had a shorter duration of antibiotic treatment without negative clinical outcomes. Procalcitonin peak values and kinetics had a clear impact on the regularity of PCT testing.

Conclusion (proposition de traduction) : Chez les patients atteints de sepsis sévère et de choc septique, le taux de procalcitonine était irrégulier et l'adhésion à un protocole local PCT était faible dans la vie clinique réelle. Cependant, les patients traités par adhésion au protocole avaient une durée de traitement antibiotique plus courte sans résultats cliniques négatifs. Les valeurs de pointe et la cinétique de la procalcitonine ont eu un impact évident sur la régularité des dosages de PCT.

BMC Emergency Medicine

Titration of oxygen therapy in critically ill emergency department patients: a feasibility study.
Dobbe ASM, Stolmeijer R, Ter Maaten JC, Ligtenberg JJM. | BMC Emerg Med. 2018 Jun 26;18(1):17
DOI: https://doi.org/10.1186/s12873-018-0169-2  | Télécharger l'article au format  
Keywords: Critically ill patients; Emergency department; Emergency medicine; Hyperoxia; Hypoxia; Normoxia; Oxygen; Oxygen inhalation therapy; Prospective studies; Pulmonary disease, chronic obstructive; Titration of oxygen therapy

Research article

Introduction : Liberal use of oxygen in an emergency situation is common. Today, most health care professionals do not adjust the amount of oxygen given when a saturation of 100% or a PaO2 which exceeds the normal range is reached- which may result in hyperoxia. There is increasing evidence for the toxic effects of hyperoxia. Therefore, it seems justified to aim for normoxia when giving oxygen. This study evaluates whether it is feasible to aim for normoxia when giving oxygen therapy to patients at the emergency department (ED).

Méthode : A prospective cohort study was performed at the ED of the University Medical Center Groningen (UMCG). A protocol was developed, aiming for normoxia. During a 14 week period all patients > 18 years arriving at the ED between 8 a.m. and 23 p.m. requiring oxygen therapy registered for cardiology, internal medicine, emergency medicine and pulmonology were included. Statistical analysis was performed using student independent t-test, Mann-Whitney U-test, Fisher's exact test or a Pearson's chi-squared test.

Résultats : During the study period the study protocol was followed and normoxia was obtained after 1 h at the ED in 86,4% of the patients. Patients with COPD were more at risk for not being titrated to normal oxygen levels.

Conclusion : We showed that it is feasible to titrate oxygen therapy to normoxia at the ED. The study results will be used for further research assessing the potential beneficial effects of normoxia compared to hyper- or hypoxia in ED patients and for the development of guidelines.

Conclusion (proposition de traduction) : Nous avons montré qu'il est possible de titrer l'oxygénothérapie en normoxie aux urgences. Les résultats de l'étude seront utilisés pour d'autres recherches visant à évaluer les effets bénéfiques potentiels de la normoxie par rapport à l'hyper ou à l'hypoxie chez les patients des services d'urgence et pour l'élaboration de recommandations.

BMJ Emergency Medicine Journal

Sepsis-3 and simple rules.
Foëx BA | Emerg Med J. 2018 Jun;35(6):343-344
DOI: https://doi.org/10.1136/emermed-2018-207668  | Télécharger l'article au format  
Keywords: emergency department; infectious diseases, bacterial; intensive care

Commentary

Editorial : Sepsis is a complex syndrome, where complexity is defined as having multiple interdependent parts. It has been a challenge to define it, and, as our understanding has evolved, so its definition has changed from the first iteration in 1991,1 to the second in 20012 and now a third in 2016.3 At its most basic sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.3 Singer et al have suggested that this organ dysfunction can be identified using an acute change in the Sequential Organ Failure Assessment (SOFA) score ≥2 points as a result of the infection.3 The problem with the SOFA score is that it does rely on some laboratory data, which makes it difficult to use outside hospital or at the ‘front door’. Singer et al then developed what they described as a ‘parsimonious clinical model’, which they termed the qSOFA (quick SOFA)3 based only on RR, systolic BP and altered mental state. One point is scored for (1) a RR ≥22 breaths per minute, (2) a systolic BP of ≤100 mm Hg and (3) altered mental state (GCS<15). A score of ≥2 in a patient with infection was associated with an increased risk of death.3 The new definition of sepsis and the role of qSOFA has aroused controversy (eg, refs.4–7). Two papers in this issue of the journal join in the controversy.

Conclusion : qSOFA should not replace more complex ‘track and trigger’ systems but should complement them, particularly in (relatively) resource-poor settings, such as primary care, and for research.

Conclusion (proposition de traduction) : Le qSOFA ne devrait pas remplacer des systèmes plus complexes de « diagnostic et prise en charge », mais devrait les compléter, en particulier dans des contextes (relativement) pauvres en ressources, tels que les soins primaires, et pour la recherche.

qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis.
Goulden R, Hoyle MC, Monis J, Railton D, Riley V, Martin P, Martina R, Nsutebu E. | Emerg Med J. 2018 Jun;35(6):345-349
DOI: https://doi.org/10.1136/emermed-2017-207120  | Télécharger l'article au format  
Keywords: clinical assessment; diagnosis; infection; infectious diseases

Original article

Introduction : The third international consensus definition for sepsis recommended use of a new prognostic tool, the quick Sequential Organ Failure Assessment (qSOFA), based on its ability to predict inhospital mortality and prolonged intensive care unit (ICU) stay in patients with suspected infection. While several studies have compared the prognostic accuracy of qSOFA to the Systemic Inflammatory Response Syndrome (SIRS) criteria in suspected sepsis, few have compared qSOFA and SIRS to the widely used National Early Warning Score (NEWS).

Méthode : This was a retrospective cohort study carried out in a UK tertiary centre. The study population comprised emergency admissions in whom sepsis was suspected and treated. The accuracy for predicting inhospital mortality and ICU admission was calculated and compared for qSOFA, SIRS and NEWS.

Résultats : Among 1818 patients, 53 were admitted to ICU (3%) and 265 died in hospital (15%). For predicting inhospital mortality, the area under the receiver operating characteristics curve for NEWS (0.65, 95% CI 0.61 to 0.68) was similar to qSOFA (0.62, 95% CI 0.59 to 0.66) (test for difference, P=0.18) and superior to SIRS (P<0.001), which was not predictive. The sensitivity of NEWS≥5 (74%, 95% CI 68% to 79%) was similar to SIRS≥2 (80%, 95% CI 74% to 84%) and higher than qSOFA≥2 (37%, 95% CI 31% to 43%). The specificity of NEWS≥5 (43%, 95% CI 41% to 46%) was higher than SIRS≥2 (21%, 95% CI 19% to 23%) and lower than qSOFA≥2 (79%, 95% CI 77% to 81%). The negative predictive value was 88% (86%-90%) for qSOFA, 86% (82%-89%) for SIRS and 91% (88%-93%) for NEWS. Results were similar for the secondary outcome of ICU admission.

Conclusion : NEWS has equivalent or superior value for most test characteristics relative to SIRS and qSOFA, calling into question the rationale of adopting qSOFA in institutions where NEWS is already in use.

Conclusion (proposition de traduction) : NEWS a une valeur équivalente ou supérieure pour la plupart des caractéristiques du test par rapport au SIRS et au qSOFA, ce qui remet en question la logique de l'adoption de qSOFA dans les institutions où NEWS est déjà utilisé.

Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness.
Rodriguez RM, Greenwood JC, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Speich KG, Valencia J, Kilgannon JH, Fernandez D, Baumann BM. | Emerg Med J. 2018 Jun;35(6):350-356
DOI: https://doi.org/10.1136/emermed-2017-207383  | Télécharger l'article au format  
Keywords: Screening; critical illness; emergency department; qSOFA; sepsis; severe sepsis

Original article

Introduction : We sought to compare the quick sequential organ failure assessment (qSOFA) to systemic inflammatory response syndrome (SIRS), severe sepsis criteria and lactate levels for their ability to identify ED patients with sepsis with critical illness.

Méthode : We conducted this multicenter retrospective cohort study at five US hospitals, enrolling all adult patients admitted to these hospitals from their EDs with infectious disease-related illnesses from 1 January 2016 to 30 April 2016. We abstracted clinical variables for SIRS, severe sepsis and qSOFA scores, using values in the first 6 hours of ED stay. Our primary outcome was critical illness, defined as one or more of the composite outcomes of death, vasopressor use or intensive care unit (ICU) admission within 72 hours of presentation. We determined diagnostic test characteristics for qSOFA scores, SIRS, severe sepsis criteria and lactate level thresholds.

Résultats : Of 3743 enrolled patients, 512 (13.7%) had the primary composite outcome. The qSOFA scores were ≥1, >2 and 3 in 1839 (49.1%), 626 (16.7%) and 146 (3.9%) patients, respectively; 2202 (58.8%) met SIRS criteria and 1085 (29.0%) met severe sepsis criteria. qSOFA ≥1 and SIRS had similarly high sensitivity [86.1% (95% CI 82.8% to 89.0%) vs 86.7% (95% CI 83.5% to 89.5%)], but qSOFA ≥1 had higher specificity [56.7% (95% CI 55.0% to 58.5%) vs 45.6% (43.9% to 47.3%); mean difference 11.1% (95% CI 8.7% to 13.6%)]. qSOFA ≥2 had higher specificity than severe sepsis criteria [89.1% (88.0% to 90.2%) vs 77.5% (76.0% to 78.9%); mean difference 11.6% (9.8% to 13.4%)]. qSOFA ≥1 had greater sensitivity than a lactate level ≥2 (mean difference 24.6% (19.2% to 29.9%)).

Conclusion : For patients admitted from the ED with infectious disease diagnoses, qSOFA criteria performed as well or better than SIRS criteria, severe sepsis criteria and lactate levels in predicting critical illness.

Conclusion (proposition de traduction) : Pour les patients admis aux urgences avec un diagnostic de maladie infectieuse, les critères qSOFA ont été aussi bons ou meilleurs que les critères SIRS, les critères de septicémie sévère et les niveaux de lactate dans la prédiction d'une atteinte grave.

Marauding terrorist attack (MTA): prehospital considerations.
Chauhan R, Conti BM2, Keene D. | Emerg Med J. 2018 Jun;35(6):389-395
DOI: https://doi.org/10.1136/emermed-2017-206959
Keywords: communications; disaster planning and response; emergency ambulance systems; gunshot; major incident, planning

Review

Editorial : Terrorist attacks are increasing each year as are the number of deaths associated with them. Recent incidents have seen a shift in tactics with the use of multiple terrorists across multiple locations with firearms or knives, referred to as the marauding terrorist attack. These methods are becoming more prevalent alongside the use of vehicles deliberately aimed at pedestrians. Management of these incidents can be challenging. Not only it involves a large number of casualties but also the management of a dynamic scene in terms of both location and threat from attack. In order to improve response, and potentially outcomes, a system or response needs to have preplanned and practised procedures in place. This article reviews major incident management for those unfamiliar with current prehospital practice and details some of the findings from recent marauding terrorist firearm attacks, in particular the evolution of newer scene management tools such as 3 Echo and THREAT.

Conclusion : It highlights the importance of haemorrhage control and the public initiatives focusing on actions during a terrorist incident.

Conclusion (proposition de traduction) : Cette revue souligne l'importance du contrôle des hémorragies et des initiatives publiques axées sur les actions lors d'un incident terroriste.

Critical Care

Antiepileptic drugs in critically ill patients.
Farrokh S, Tahsili-Fahadan P, Ritzl EK, Lewin JJ, Mirski MA. | Crit Care. 2018 Jun 7;22(1):153
DOI: https://doi.org/10.1186/s13054-018-2066-1  | Télécharger l'article au format  
Keywords: Antiepileptic drugs; Critical care; Drug-drug Interaction; Pharmacodynamics; Pharmacokinetics; Seizure

Review

Introduction : The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited.

Méthode : This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included.

Conclusion : Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place.

Conclusion (proposition de traduction) : La gestion optimale des antiépileptiques dans l'unité de soins intensifs est un défi étant donné la modification de la physiologie, la polypharmacie et les interventions non pharmacologiques, et exige une approche multidisciplinaire lorsque des plans d'évaluation, de diagnostic, de traitement et de surveillance appropriés et opportuns sont en place.

Longing for better ultrasound-guided subclavian/axillary venous cannulation.
Shrestha GS | Crit Care. 2018 Jun 5;22(1):148
DOI: https://doi.org/10.1186/s13054-018-2075-0  | Télécharger l'article au format  
Keywords: Aucun

Letter

Editorial : Ultrasound guidance for central venous catheter (CVC) placement reduces complications, increases safety and enhances the quality of the procedure. Existing guidelines suggest a higher level of evidence for ultrasound-guided internal jugular venous cannulation compared with the subclavian/axillary route. Meta-analysis of trials studying the use of ultrasound guidance for subclavian venous cannulation, when compared with the landmark technique, showed decreased incidence of arterial puncture and hematoma formation, but there was no overall difference in complications and success rates.

Conclusion : Smaller studies have shown that patient positioning during cannulation of the subclavian vein (e.g., turning the head to the contralateral side, shoulder-pulled-downward position, and abducted position of arm) can alter the relationship between the subclavian vein and the internal jugular vein and can also alter the cross-sectional area of the vein, thus potentially affecting the safety and success of cannulation. Further well designed studies should try to explore the influence of these various patient positions on ultrasound-guided subclavian venous cannulation.

Conclusion (proposition de traduction) : De plus petites études ont montré que le positionnement du patient pendant la canulation de la veine sous-clavière (par exemple, tourner la tête vers le côté controlatéral, la position de l'épaule vers le bas et la position du bras en abduction) peut modifier la relation entre la veine sous-clavière et la veine jugulaire interne et peut également modifier la section transversale de la veine, ce qui peut affecter la sécurité et le succès de la canulation. D'autres études bien conçues devraient essayer d'explorer l'influence de ces différentes positions du patient sur la canulation veineuse sous-clavière guidée par échographie.

Critical Care Medicine

The Surviving Sepsis Campaign Bundle: 2018 Update.
Levy MM, Evans LE, Rhodes A. | Crit Care Med. 2018 Jun;46(6):997-1000
DOI: https://doi.org/10.1097/CCM.0000000000003119
Keywords: Aucun

Special Article

Editorial : The “sepsis bundle” has been central to the implementation of the Surviving Sepsis Campaign (SSC) from the first publication of its evidence-based guidelines in 2004 through subsequent editions. Developed separately from the guidelines pub- lication by the SSC, the bundles have been the cornerstone of sepsis quality improvement since 2005. As noted when they were introduced, the bundle elements were designed to be updated as indicated by new evidence and have evolved accordingly. In response to the publication of “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016”, a revised “hour-1 bundle” has been developed and is presented below.

Conclusion : Previous iterations of the sepsis bundle were introduced as a means of providing education and improvement related to sepsis management. The literature supports the use of sepsis bundles for improving outcomes in patients with sepsis and septic shock. This new sepsis “hour-1 bundle,” based on the 2016 guidelines, should be introduced to emergency department, floor, and ICU staff as the next iteration of ever-improv- ing tools in the care of patients with sepsis and septic shock as we all work to lessen the global burden of sepsis.

Conclusion (proposition de traduction) : Les itérations précédentes des processus de soins des septicémies ont été introduites comme moyen d'éducation et d'amélioration de la prise en charge des septicémies. La littérature appuie l'utilisation de processus de soins pour améliorer les résultats chez les patients atteints de septicémie et de choc septique.
Ce nouveau processus de soins de la septicémie à une heure, basé sur les lignes directrices de 2016, devrait être présenté au personnel des services d'urgence, des étages et des soins intensifs comme la prochaine itération d'outils toujours améliorés dans les soins aux patients atteints de septicémie et de choc septique, alors que nous travaillons tous à réduire l'incidence globale de la septicémie.

Current Opinion in Critical Care

To intubate or not to intubate?.
Gough CJR, Nolan JP. | Curr Opin Crit Care. 2018 Jun;24(3):131-137
DOI: https://doi.org/10.1097/MCC.0000000000000497
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Editorial : Cardiac arrest mortality remains high, and the impact on outcome of most advanced life support interventions is unclear. The optimal method for managing the airway during cardiac arrest remains unknown. This review will summarize and critique recently published evidence comparing basic airway management with the use of more advanced airway interventions [insertion of supraglottic airway (SGA) devices and tracheal intubation].

Discussion : Systematic reviews generally document an association between advanced airway management and worse neurological outcome but they are subject to considerable bias. A recent observational study of tracheal intubation for in-hospital cardiac arrest that used time-dependent propensity matching showed an association between tracheal intubation during the first 15 min of cardiac arrest and a worse a neurological outcome compared with no intubation in the first 15 min. In a recent randomized clinical trial, tracheal intubation was compared with bag-mask ventilation (with intubation only after return of spontaneous circulation) in 2043 patients with out-of-hospital cardiac arrest. There was no difference in favorable neurological outcome at 28 days.

Conclusion : Most of the available evidence about airway management during cardiac arrest comes from observational studies. The best option for airway management is likely to be different for different rescuers, and at different time points of the resuscitation process. Thus, it is common for a single patient to receive multiple 'stepwise' airway interventions. The only reliable way to determine the optimal airway management strategy is to undertake properly designed, prospective, randomized trials. One randomized clinical trial has been published recently and two others have completed enrollment but have yet to be published.

Conclusion (proposition de traduction) : La plupart des données disponibles sur la prise en charge des voies respiratoires au cours d'un arrêt cardiaque proviennent d'études observationnelles. La meilleure option pour la gestion des voies aériennes est susceptible d'être différente pour différents sauveteurs, et à différents moments du processus de réanimation. Ainsi, il est courant qu'un seul patient reçoive plusieurs interventions « par étapes » sur les voies respiratoires. La seule façon fiable de déterminer la stratégie de gestion optimale des voies respiratoires consiste à entreprendre des essais prospectifs, randomisés et bien conçus. Un essai clinique randomisé a été publié récemment et deux autres ont terminé le recrutement mais n'ont pas encore été publiés.

Antiarrhythmic drug therapy during cardiopulmonary resuscitation: should we use it?.
Soar J | Curr Opin Crit Care. 2018 Jun;24(3):138-142
DOI: https://doi.org/10.1097/MCC.0000000000000498
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION

Editorial : The optimal antiarrhythmic drug therapy (amiodarone or lidocaine) in the treatment of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) cardiac arrest that is refractory to defibrillation is uncertain. This article reviews the evidence for and against these drugs, alternatives treatments for refractory VF/pVT and aims to define the role of antiarrhythmic drugs during cardiopulmonary resuscitation (CPR).

Discussion : A large randomized controlled trial that compared amiodarone, lidocaine and saline 0.9% sodium chloride for the treatment of refractory VF/pVT out-of-hospital cardiac arrest reported no difference in survival to hospital discharge or neurological outcome. In patients with witnessed arrest, survival was improved with antiarrhythmic drugs compared to saline.

Conclusion : The benefit of antiarrhythmic drugs appears to be for those patients in whom initial early CPR and defibrillation attempts fail and the antiarrhythmic drug is given early. There does not appear to be any clear survival benefit for any one particular drug and other factors such as availability and cost should be considered when deciding which drug to use. Furthermore, other interventions (e.g. percutaneous coronary intervention and extra-corporeal CPR) may provide additional survival benefit when defibrillation attempts and antiarrhythmic drugs are not effective.

Conclusion (proposition de traduction) : Le bénéfice des médicaments antiarythmiques semble être pour les patients chez qui les premières tentatives de RCP et de défibrillation initiales échouent et à qui l'antiarythmique est administré tôt. Il ne semble pas y avoir de bénéfice de survie clair pour un médicament en particulier et d'autres facteurs tels que la disponibilité et le coût doivent être pris en compte lors du choix du médicament à utiliser. En outre, d'autres interventions (par exemple une intervention coronarienne percutanée et une RCP extracorporelle) peuvent apporter un bénéfice de survie supplémentaire lorsque les tentatives de défibrillation et les médicaments antiarythmiques ne sont pas efficaces.

Understanding the carbon dioxide gaps.
Scheeren TWL, Wicke JN, Teboul JL. | Curr Opin Crit Care. 2018 Jun;24(3):181-189
DOI: https://doi.org/10.1097/MCC.0000000000000493
Keywords: Aucun

CARDIOPULMONARY MONITORING

Editorial : The current review attempts to demonstrate the value of several forms of carbon dioxide (CO2) gaps in resuscitation of the critically ill patient as monitor for the adequacy of the circulation, as target for fluid resuscitation and also as predictor for outcome.

Discussion : Fluid resuscitation is one of the key treatments in many intensive care patients. It remains a challenge in daily practice as both a shortage and an overload in intravascular volume are potentially harmful. Many different approaches have been developed for use as target of fluid resuscitation. CO2 gaps can be used as surrogate for the adequacy of cardiac output (CO) and as marker for tissue perfusion and are therefore a potential target for resuscitation. CO2 gaps are easily measured via point-of-care analysers. We shed light on its potential use as nowadays it is not widely used in clinical practice despite its potential. Many studies were conducted on partial CO2 pressure differences or CO2 content (cCO2) differences either alone, or in combination with other markers for outcome or resuscitation adequacy. Furthermore, some studies deal with CO2 gap to O2 gap ratios as target for goal-directed fluid therapy or as marker for outcome.

Conclusion : CO2 gap is a sensitive marker of tissue hypoperfusion, with added value over traditional markers of tissue hypoxia in situations in which an oxygen diffusion barrier exists such as in tissue oedema and impaired microcirculation. Venous-to-arterial cCO2 or partial pressure gaps can be used to evaluate whether attempts to increase CO should be made. Considering the potential of the several forms of CO2 measurements and its ease of use via point-of-care analysers, it is recommendable to implement CO2 gaps in standard clinical practice.

Conclusion (proposition de traduction) : Le tau de CO2 est un marqueur sensible de l'hypoperfusion tissulaire, avec une valeur ajoutée par rapport aux marqueurs traditionnels de l'hypoxie tissulaire dans les situations où une barrière à la diffusion d'oxygène existe, comme dans l'œdème tissulaire et la microcirculation altérée. Des taux de cO2 veineuses ou des pressions partielles peuvent être utilisés pour évaluer si des tentatives d'augmentation du CO devraient être tentées.
Compte tenu du potentiel des différentes formes de mesure du CO2 et de sa facilité d'utilisation par l'intermédiaire d'analyseurs au lit du malade, il est recommandé de mettre d'utiliser les taux de CO2 dans la pratique clinique standard.

Assessment of fluid responsiveness: recent advances.
Monnet X, Teboul JL. | Curr Opin Crit Care. 2018 Jun;24(3):190-195
DOI: https://doi.org/10.1097/MCC.0000000000000501
Keywords: Aucun

CARDIOPULMONARY MONITORING

Editorial : In the field of prediction of fluid responsiveness, the most recent studies have focused on validating new tests, on clarifying the limitations of older ones, and better defining their modalities.

Discussion : The limitations of pulse pressure/stroke volume variations are numerous, but recent efforts have been made to overcome these limitations, like in case of low tidal volume ventilation. Following pulse pressure/stroke volume variations, new tests have emerged which assess preload responsiveness by challenging cardiac preload through heart-lung interactions, like during recruitment manoeuvres and end-expiratory/inspiratory occlusions. Given the risk of fluid overload that is inherent to the 'classical' fluid challenge, a 'mini' fluid challenge, made of 100 ml of fluid only, has been developed and investigated in recent studies. The reliability of the passive leg raising test is now well established and the newest publications have mainly aimed at defining several noninvasive estimates of cardiac output that can be monitored to assess its effects.

Conclusion : Research in this field is still very active, such that several indices and tests of fluid responsiveness are now available. They may contribute to reduce excessive fluid balance by avoiding unnecessary fluid administration and, also, by ensuring safe fluid removal.

Conclusion (proposition de traduction) : La recherche dans ce domaine est encore très active, de sorte que plusieurs indices et tests de réponse au remplissage sont maintenant disponibles. Ils peuvent contribuer à réduire l'équilibre hydrique excessif en évitant une administration de liquides de remplissage inutile et, également, en assurant une élimination sûre des de liquides de remplissage.

European Journal of Clinical Microbiology & Infectious Diseases

Increased overall survival after introduction of structured bedside consultation in Staphylococcus aureus bacteraemi.
Ariaans MBPA, Roovers EA, Claassen MAA, Hassing RJ, Swanink CMA, Gisolf EH. | Eur J Clin Microbiol Infect Dis. 2018 Jun;37(6):1187-1193
DOI: https://doi.org/10.1007/s10096-018-3239-1
Keywords: 365-day overall survival; PET scan; Staphylococcus aureus bacteraemia; Structured bedside consultation; Transoesophageal echocardiography

Original Article

Introduction : Staphylococcus aureus bacteraemia (SAB) is a common and severe disease. In 2012, a structured bedside consultation (SBC) was introduced at Rijnstate Hospital.

Méthode : We analysed the effect of this SBC on the overall survival of patients with SAB and the effect on the diagnostic workup. We performed a retrospective cohort study, including all patients over 18 years with SAB from 2009 until 2017. The cases preceding versus those after implementation of SBC in 2012 were compared.

Résultats : In total, 613 episodes of SAB were analysed: 234 cases before and 379 cases since SBC. In 484 patients at risk for a complicated course, there was no significant difference in the 30-day survival (77 versus 82%, p = 0.18); however, an increase in 365-day survival was seen (56 versus 64%, p = 0.05). Overall, more patients received adequate therapy, both in the first 2 weeks (67.8 versus 86.7%, p < 0.001), as in complicated SAB (70.5 versus 93.2%, p < 0.001). In 21% of patients with transoesophageal echocardiogram (TEE) following a negative or inconclusive TTE, endocarditis was diagnosed. In patients at risk for complicated SAB, the PET scan revealed a metastatic infection which was not clinically suspected in 65% of positive PET scans.

Conclusion : Structured bedside consultation is associated with a better 365-day survival in patients at risk for complicated SAB. Moreover, the additional value of TEE and the PET scan was shown. We strongly advise compliance to SBC in all patients at risk for complicated SAB and the use of both TEE and PET scans in these patients. Even in uncomplicated SAB, TEE or PET scan can reveal metastatic infections.

Conclusion (proposition de traduction) : La consultation structurée au lit du patient est associée à une meilleure survie à 365 jours chez les patients à risque de bactériémie compliquée à Staphylococcus aureus. En outre, la valeur supplémentaire de l'échocardiogramme transœsophagien et le PET scan ont été montrés. Nous recommandons fortement la mise en place d'une consultation structurée au lit de tous les patients à risque de bactériémie compliquée à Staphylococcus aureus et l'utilisation de l'échocardiographie transœsophagienne et de du PET scan chez ces patients. Même en cas de bactériémie Staphylococcus aureus non compliquée, l'échocardiographie transœsophagienne ou la PET scan peuvent révéler des infections métastatiques.

Commentaire : Dr Philippe Lesprit sur Info-ATBVAC : Ce travail confirme les résultats de plusieurs études ayant montré l’utilité d’un avis infectiologique systématique dans les bactériémies à S. aureus, permettant une meilleure prise en charge des patients : meilleure adéquation de l’antibiothérapie, amélioration du pronostic vital et diminution des rechutes. Un avis infectiologique semble d’autant plus nécessaire chez les patients à risque de complication.
Il a également comme intérêt de rappeler l’intérêt de l’ETO pour éliminer ou confirmer une endocardite, et apporte des arguments pour réaliser un PET scan systématique dans ce groupe de patients.

European Journal of Emergency Medicine

Impact of a general practitioners’ strike and of terrorist attacks on a call centre.
Reuter PG, Orsini C, Grave M, Linval F, Akodad H, Goix L, Adnet F, Lapostolle F. | Eur J Emerg Med. 2018 Jun;25(3):199-203
DOI: https://doi.org/10.1097/MEJ.0000000000000436
Keywords: Aucun

Original article

Introduction : We aimed to evaluate the impact of the same-day GPs' strike and terrorist attacks on a call centre's activity.

Méthode : We compared the number of calls received, the number of patient's medical files (PMFs) created and the number of mobile ICU (MICU) dispatched per hour on Friday, 13 November, to the repository established on the five previous Fridays. As previously published, the variation criterion was set to an activity variation above 20% for more than 2 h.

Résultats : On Friday, 13 November, 1745 calls were received compared with 1455 calls, on average, for the five previous Fridays. The number of calls received increased after the terrorist attacks (≤90%) and remained above the threshold for 3 h. The number of PMFs exceeded the threshold from 10:00 a.m. to 05:00 p.m., but was not affected by the attacks. The number of MICUs dispatched exceeded the threshold (>500%) in the first hour after the attacks.

Conclusion : The GPs' strike and the terrorist attacks did not impact our call centre's activity in the same manner. The strike increased the number of PMFs without increasing the number of calls received. The attacks increased the number of calls received and MICU dispatched without increasing the number of PMFs. Many markers are at the disposal of call centres to evaluate the impact of healthcare events.

Conclusion (proposition de traduction) : La grève des médecins généralistes et les attaques terroristes n'ont pas eu d'impact sur l'activité de notre centre d'appels de la même manière. La grève a augmenté le nombre de dossiers médicaux patients sans augmenter le nombre d'appels reçus. Les attaques ont augmenté le nombre d'appels reçus et de SMUR envoyés sans augmenter le nombre de dossiers médicaux patients.
De nombreux marqueurs sont à la disposition des centres d'appels pour évaluer l'impact des soins de santé.

European Journal of Trauma and Emergency Surgery

Fall from heights: does height really matter?.
Alizo G, Sciarretta JD, Gibson S, Muertos K, Romano A, Davis J, Pepe A. | Eur J Trauma Emerg Surg. 2018 Jun;44(3):411-416
DOI: https://doi.org/10.1007/s00068-017-0799-1
Keywords: Fall from heights; High-level fall; Trauma

Original Article

Introduction : Fall from heights is high energy injuries and constitutes a fraction of all fall-related trauma evaluations while bearing an increase in morbidity and mortality. We hypothesize that despite advancements in trauma care, the overall survivability has not improved in this subset of trauma patients.

Méthode : All adult trauma patients treated after sustaining a fall from heights during a 40-month period were retrospectively reviewed. Admission demographics, clinical data, fall height (ft), injury patterns, ISS, GCS, length of stay, and mortality were reviewed.

Résultats : 116 patients sustained a fall from heights, 90.4% accidental. A mean age of 37± 14.7 years, 86% male, and a fall height of 19 ± 10 ft were encountered. Admission GCS was 13 ± 2 with ISS 10 ± 11. Overall LOS was 6.6 ± 14.9 days and an ICU LOS of 2.8 ± 8.9 days. Falls ≥ 25 ft.(16%) had lower GCS 10.4 ± 5.8, increased ISS 22.6 ± 13.8, a fall height 37.9 ± 13.1 ft and associated increased mortality (p < 0.001). Mortality was 5.2%, a mean distance fallen of 39 ± 22 ft. and an ISS of 31.5 ±16.5. Brain injury was the leading cause of death, 50% with open skull fractures.

Conclusion : Level of height fallen is a good predictor of overall outcome and survival. Despite advances in trauma care, death rates remain unchanged. Safety awareness and injury prevention programs are needed to reduce the risk of high-level falls.

Conclusion (proposition de traduction) : La hauteur de chute est un bon prédicteur du résultat global et de la survie. Malgré les progrès réalisés dans le domaine des soins de traumatologie, les taux de mortalité demeurent inchangés. Des programmes de sensibilisation à la sécurité et de prévention des blessures sont nécessaires pour réduire le risque de chutes de haut niveau.

Commentaire : Etude rétrospective sur 40 mois ayant inclus 116 patients.
Un âge moyen de 37 ± 14,7 ans, 86 % d'hommes, et une hauteur moyenne de chute de 5,8 ± 3 mètres ont été colligés.
Les lésions cérébrales étaient la principale cause de décès, 50 % d'entre elles ayant une fracture ouverte du crâne.

Gériatrie et Psychologie Neuropsychiatrie du Vieillissement

Huguel B, Vaugrenard T, Saby L, Benhamou L, Arméro S, Camilleri E, Langar A, Alitta Q, Grino M, Retornaz F. | Geriatr Psychol Neuropsychiatr Vieil. 2018 June,16(2):145-54
DOI: https://doi.org/10.1684/pnv.2018.0730
Keywords: insuffisance cardiaque aiguë, bio-impédancemètre portable, faisabilité, acceptabilité

Articles originaux

Introduction : L’insuffisance cardiaque chronique (ICC) constitue un enjeu de santé publique majeure. C’est une pathologie invalidante (fréquentes poussées d’insuffisance cardiaque aiguë (ICA)) et très coûteuse pour le système de santé. La bioimpédancemétrie du corps entier (BIA) semble être une nouvelle technique pour la détection de l’état des liquides. L’objectif de notre étude est de tester la faisabilité et l’acceptabilité de l’automesure avec un BIA portable bluetooth, dans l’ICC.

Méthode : Cette étude prospective monocentrique a inclus des patients hospitalisés en ICA. Trois automesures avec le BIA portable ont été comparées avec les critères clinico-biologiques et échocardiographiques des patients. Un questionnaire évaluant l’acceptabilité du BIA a été recueilli.

Résultats : Plus de 80 % des 23 patients inclus ont réalisé les 3 mesures de façon autonome. L’acceptabilité du BIA s’est avérée excellente (90 %). Une corrélation statistiquement significative a été retrouvée entre les variations d’eau totale et de poids (p = 0,001).

Conclusion (proposition de traduction) : L’excellente faisabilité et acceptabilité de l’automesure avec BIA portable, chez le patient en ICA, ouvre des perspectives intéressantes dans l’autosurveillance et la gestion à domicile de ces patients. L’intérêt de cet outil connecté dans la prévention des hospitalisations nécessite maintenant d’être démontré.

Dussaule C, Bouilleret V. | Geriatr Psychol Neuropsychiatr Vieil. 2018 June;16(2):181-8
DOI: https://doi.org/10.1684/pnv.2018.0733
Keywords: épilepsie, psychiatrie, effets des traitements, antiépileptiques

Articles original

Editorial : Pathologie psychiatrique et maladie épileptique sont intriquées : les comorbidités psychiatriques telles que les troubles anxieux et dépressifs sont fréquentes chez les patients épileptiques, et les patients ayant une maladie psychiatrique sont à risque de développer une épilepsie. Sur le plan thérapeutique, certains médicaments antiépileptiques (MAE) présentent des effets psychiatriques indésirables ; inversement des MAE sont utilisés pour traiter des pathologies psychiatriques. L’objectif de cet article est de déterminer quels sont les effets psychiatriques provoqués par les MAE les plus fréquemment prescrits chez l’adulte épileptique, en s’appuyant sur les données actuelles de la littérature. Ainsi, on distingue globalement les MAE ayant des effets positifs thymorégulateurs et antidépresseurs, notamment le valproate, les benzodiazépines et les bloqueurs des canaux sodiques (en particulier la carbamazépine et la lamotrigine), des MAE entraînant des effets indésirables comme le lévétiracétam, le perampanel, le topiramate, le zonisamide et les barbituriques.

Conclusion (proposition de traduction) : Le principal facteur de risque de présenter ce type d’effets indésirables est un antécédent personnel de pathologie psychiatrique. Ainsi le dépistage de la survenue d’effets indésirables psychiatriques est essentiel, surtout lors de l’utilisation des MAE les plus à risques et/ou en cas d’antécédent psychiatrique (où il est préférable d’utiliser les MAE ayant des effets psychiatriques positifs).

Intensive Care Medicine

Management of cardiogenic shock complicating myocardial infarction.
Mebazaa A, Mebazaa A, Combes A, van Diepen S, Hollinger A, Katz JN, Landoni G, Hajjar LA, Lassus J, Lebreton G, Montalescot G, Park JJ, Price S, Sionis A, Yannopolos D, Harjola VP, Levy B, Thiele H. | Intensive Care Med. 2018 Juin 16;44(6):760 - 773
DOI: https://doi.org/10.1007/s00134-018-5214-9
Keywords: Acute myocardial infarction, Cardiogenic shock, Catecholamines, Mechanical circulatory support

Review

Editorial : Up to 10% of acute coronary syndromes are complicated by cardiogenic shock (CS) with contemporary mortality rates of 40–50%. The extent of ischemic myocardium has a profound impact on the initial, in‐hospital, and post‐dis‐ charge management and prognosis in this patient population. Individualized patient risk assessment plays an impor‐ tant role in determining appropriate revascularization, drug treatment with inotropes and vasopressors, mechanical circulatory support, intensive care support of other organ systems, hospital level of care triage, and allocation of clini‐ cal resources. This review will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of CS complicating acute coronary syndromes with a focus on (a) potential therapeutic issues from the perspective an interventional cardiologist, an emergency physician, and an intensive care physician, (b) the type of revascularization, and (c) new therapeutic advancements in pharmacologic and mechanical percutaneous circulatory support.

Conclusion : Despite early revascularization the mortality of patients with CS is still high. In cases where CS has developed, we advocate for multidisciplinary care in a specialized center. Patients who are treated according to clinical practice guidelines, with early reperfusion for all patients and an optimal supportive intensive care treatment, have a mortality rate of approximately 40%, as shown in recent randomized trials.

Conclusion (proposition de traduction) : Malgré une revascularisation précoce, le taux de mortalité des patients présentant un choc cardiogénique reste élevé. Dans les cas où un choc cardiogénique s'est développé, nous préconisons des soins multidisciplinaires dans un centre spécialisé. Les patients traités selon les recommandations de pratique clinique, avec une reperfusion précoce pour tous les patients et un traitement de soutien intensif optimal, ont un taux de mortalité d'environ 40 %, comme le montrent de récents essais randomisés.

Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper.
Vieillard-Baron A, Naeije R3, Haddad F, Bogaard HJ, Bull TM, Fletcher N, Lahm T, Magder S, Orde S, Schmidt G, Pinsky MR. | Intensive Care Med. 2018 June;44(6):774 - 790
DOI: https://doi.org/10.1007/s00134-018-5172-2
Keywords: Critically ill patients; Echocardiography; Pulmonary hypertension; Right ventricle failure; Sho

Review

Introduction : This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors.

Résultats : The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion

Conclusion : RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.

Conclusion (proposition de traduction) : L'évaluation de la fonction ventriculaire droite est essentielle chez les patients en phase critique pour la prise en charge hémodynamique, comme l'optimisation du remplissage, la stratégie vasopresseur et l'assistance respiratoire. L'insuffisance ventriculaire droite peut être diagnostiquée par l'association de différents dispositifs et paramètres, tandis que l'échocardiographie est cruciale.

Expert statement for the management of hypovolemia in sepsis.
Perner A, Cecconi M, Cronhjort M, Darmon M, Jakob SM, Pettilä V, van der Horst ICC. | Intensive Care Med. 2018 June;44(6):791-798
DOI: https://doi.org/10.1007/s00134-018-5177-x
Keywords: Critical care; Fluid therapy; Hemodynamics; Hypovolemia; Sepsis; Shock

Review

Editorial : Hypovolemia is frequent in patients with sepsis and may contribute to worse outcome. The management of these patients is impeded by the low quality of the evidence for many of the specific components of the care. In this paper, we discuss recent advances and controversies in this field and give expert statements for the management of hypovolemia in patients with sepsis including triggers and targets for fluid therapy and volumes and types of fluid to be given. Finally, we point to unanswered questions and suggest a roadmap for future research.

Conclusion : Trial groups from around the world have embarked on trial programs to answer several of the questions above. The ongoing large trial programs on different volumes, types (PLUS and BASICS trials), and rates of infusion (BASICS trial) are run by collaborative, academic groups from Brazil, Europe, Australasia, and North America. The growing collaboration between the trial groups will facilitate joint analyses of large data sets of patients randomized to different fluid management strategies. These efforts will directly improve the fluid therapy of patients with sepsis and will form new hypoth- eses to be tested in future trials.

Conclusion (proposition de traduction) : Des groupes d'essais cliniques du monde entier se sont lancés dans des programmes d'essais cliniques pour répondre à plusieurs des questions ci-dessus. Les programmes d'essais clinique de grande envergure en cours sur différents volumes, types (essais PLUS et BASICS) et taux de perfusion (essai BASICS) sont dirigés par des groupes universitaires du Brésil, d'Europe, d'Australasie et d'Amérique du Nord. La collaboration croissante entre les groupes d'essai clinique facilitera l'analyse conjointe de vastes ensembles de données de patients randomisés selon différentes stratégies de gestion des liquides de remplissage. Ces efforts amélioreront directement la thérapeutique du remplissage des patients présentant une septicémie et formeront de nouvelles hypothypothèses qui seront testées lors d'essais futurs.

The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities.
Nolan JP, Nolan JP, Berg RA, Callaway CW5, Morrison LJ, Nadkarni V, Perkins GD, Sandroni C, Skrifvars MB, Soar J, Sunde K, Cariou A. | Intensive Care Med. 2018 Jun;44(6):823-832
DOI: https://doi.org/10.1007/s00134-018-5230-9
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Post-resuscitation care; Prognostication

Review

Introduction : The purpose of this review is to describe the epidemiology of out-of-hospital cardiac arrest (OHCA), disparities in organisation and outcome, recent advances in treatment and ongoing controversies. We also outline the standard of care that should be provided by the critical care specialist and propose future directions for cardiac arrest research.

Méthode : Narrative review with contributions from international resuscitation experts.

Résultats : Although it is recognised that survival rates from OHCA are increasing there is considerable scope for improvement and many countries have implemented national strategies in an attempt to achieve this goal. More resources are required to enable high-quality randomised trials in resuscitation.

Conclusion : Increasing international collaboration should facilitate resuscitation research and knowledge translation. The International Liaison Committee on Resuscitation (ILCOR) has adopted a continuous evidence review process, which facilitate the implementation of resuscitation interventions proven to improve patient outcomes.

Conclusion (proposition de traduction) : L'intensification de la collaboration internationale devrait faciliter la recherche en réanimation et l'application des connaissances. Le Comité international de liaison pour la réanimation (ILCOR) a adopté un processus d'examen continu des données probantes, qui facilite la mise en œuvre d'interventions de réanimation éprouvées pour améliorer les résultats pour les patients.

A global perspective on vasoactive agents in shock.
Annane D, Ouanes-Besbes L, de Backer D, Du B, Gordon AC, Hernández G, Olsen KM, Osborn TM, Peake S, Russell JA, Cavazzoni SZ. | Intensive Care Med. 2018 Jun;44(6):833-846
DOI: https://doi.org/10.1007/s00134-018-5242-5
Keywords: Adrenergic agonists; Cardiovascular system; Clinical trials; Practice guidelines; Shock

Review

Introduction : We set out to summarize the current knowledge on vasoactive drugs and their use in the management of shock to inform physicians' practices.

Méthode : This is a narrative review by a multidisciplinary, multinational-from six continents-panel of experts including physicians, a pharmacist, trialists, and scientists.

Résultats : Vasoactive drugs are an essential part of shock management. Catecholamines are the most commonly used vasoactive agents in the intensive care unit, and among them norepinephrine is the first-line therapy in most clinical conditions. Inotropes are indicated when myocardial function is depressed and dobutamine remains the first-line therapy.

Conclusion : Vasoactive drugs have a narrow therapeutic spectrum and expose the patients to potentially lethal complications. Thus, these agents require precise therapeutic targets, close monitoring with titration to the minimal efficacious dose and should be weaned as promptly as possible. Moreover, the use of vasoactive drugs in shock requires an individualized approach. Vasopressin and possibly angiotensin II may be useful owing to their norepinephrine-sparing effects.

Conclusion (proposition de traduction) : Les médicaments vasoactifs ont un spectre thérapeutique étroit et exposent les patients à des complications potentiellement mortelles. Ainsi, ces agents nécessitent des cibles thérapeutiques précises, une surveillance étroite avec un titrage à la dose efficace minimale et doivent être sevrés aussi rapidement que possible. De plus, l'utilisation de médicaments vasoactifs en état de choc nécessite une approche individualisée. La vasopressine et éventuellement l'angiotensine II peuvent être utiles en raison de leurs effets d'épargne de la norépinéphrine.

Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients.
Léopold V, Léopold V, Gayat E, Pirracchio R, Spinar J, Parenica J, Tarvasmäki T, Lassus J, Harjola VP, Champion S, Zannad F, Valente S, Urban P, Chua HR, Bellomo R, Popovic B, Ouweneel DM, Henriques JPS, Simonis G, Lévy B, Kimmoun A19, Gaudard P, Basir MB, Markota A, Adler C, Reuter H, Mebazaa A, Chouihed T. | Intensive Care Med. 2018 Jun;44(6):847-856
DOI: https://doi.org/10.1007/s00134-018-5222-9
Keywords: Cardiogenic shock; Epinephrine; Meta-analysis; Prognosis

Systematic Review

Introduction : Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients.

Méthode : We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality.

Résultats : Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17-76%) and short-term mortality rate was 49% (21-69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8-3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4-6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0-6.0]).

Conclusion : In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.

Conclusion (proposition de traduction) : Dans cette très grande cohorte, l'utilisation de l'épinéphrine pour la prise en charge hémodynamique des patients choc septique est associée à une augmentation par trois du risque de décès.

Internal and Emergency Medicine

Timing of INR reversal using fresh-frozen plasma in warfarin-associated intracerebral hemorrhage.
Akhter M, Morotti A, Cohen AS, Chang Y, Ayres AM, Schwab K, Viswanathan A, Gurol ME, Anderson CD, Greenberg SM, Rosand J, Goldstein JN. | Intern Emerg Med. 2018 Jun;13(4):557-565
DOI: https://doi.org/10.1007/s11739-017-1680-2
Keywords: Anticoagulants; Cerebral hemorrhage; Intracerebral hemorrhage; Stroke; Warfarin

EM - ORIGINAL

Introduction : Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome.

Méthode : We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis.

Résultats : 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3-3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5-14) h vs. 10 (IQR 7-16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6-14) h vs. 12 (8-19) h, p = 0.064).

Conclusion : We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.

Conclusion (proposition de traduction) : Nous ne trouvons aucune preuve d'une association entre une réversion plus rapide de l'INR et une réduction de l'hématome ou un meilleur résultat.

Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism.
Nazerian P, Volpicelli G, Gigli C, Lamorte A, Grifoni S, Vanni S. | Intern Emerg Med. 2018 Jun;13(4):567-574
DOI: https://doi.org/10.1007/s11739-017-1681-1  | Télécharger l'article au format  
Keywords: Diagnostic accuracy; Echocardiography; Pulmonary embolism; Right ventricular dysfunction; Shock; Ultrasound; Venous compression ultrasonography

EM - ORIGINAL

Introduction : Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE).

Méthode : Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy.

Résultats : Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80-97%) and 87% (95% CI 80-91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45-60%) but higher specificity (95%, 95% CI 88-99%) than cardiac US (both p < 0.05). When cardiac and venous US were both positive (22 out of 105 patients, 21%) the specificity increased to 100% (p < 0.01 vs cardiac US), whereas when at least one was positive (54 out of 105 patients, 51%) the sensitivity increased to 95% (p = 0.06 vs cardiac US).

Conclusion : Focused cardiac US showed good but not optimal sensitivity and specificity for the diagnosis of PE in patients presenting with shock. Venous US significantly increased specificity of cardiac US, and the diagnosis of PE can be certain when both tests are positive or reasonably excluded when negative.

Conclusion (proposition de traduction) : L'échographie cardiaque ciblée a montré une sensibilité et une spécificité bonne mais non optimale pour le diagnostic de l'embolie pulmonaire chez les patients présentant un état de choc. L'échographie veineux a significativement augmenté la spécificité de l'échographie cardiaque, et le diagnostic d'embolie pulmonaire peut être certain lorsque les deux examens sont positifs ou raisonnablement exclus lorsqu'ils sont négatifs.

Is proton pump inhibitors' prophylaxis indicated for patients on antiplatelet therapy?.
Porta L, Baorda F, Fusco A; Gruppo di Autoformazione Metodologica (GrAM).. | Intern Emerg Med. 2018 Jun;13(4):585-587
DOI: https://doi.org/10.1007/s11739-018-1827-9
Keywords: Aucun

THE CUTTING EDGE: RESEARCH UPDATE

Editorial : In USA and Europe, more than 50% of adults aged 75 years old or older are taking a lifelong antiplatelet treatment, of which half are for secondary prevention of vascular diseases [1]. The major side effect of the aforementioned therapy is the risk of major bleeding, particularly from the upper gas- trointestinal tract. However, clinical guidelines on second- ary prevention of vascular events do not recommend proton pump inhibitors (PPIs), which could reduce the incidence of bleeding by 70–90%. This is probably due to the adverse effects of the PPIs, as stated in a recent Mayo Clinic’s review [2], and because in aspirin trials, the gastrointestinal bleeds have a low mortality and permanent disability rates. However, most of the populations of the aspirin trials were younger than 75 years of age, and thus, up to now, the age- specific risk of bleeding in patients on long-term antiplate- let treatment after vascular events has not been sufficiently studied.

Conclusion : While this study should raise concern in every physician about the necessity of a detailed evaluation of the benefits and risks of the prescription of an antiplatelet agent, espe- cially in old patients (> 85 years old), we do not think that neither the study design nor the data support the systematic use of PPIs.

Conclusion (proposition de traduction) : Bien que cette étude doive inquiéter chaque médecin quant à la nécessité d'une évaluation détaillée des bénéfices et des risques de la prescription d'un antiagrégant plaquettaire, en particulier chez les patients âgés (> 85 ans), nous ne pensons pas que le design de 'étude ou les données ne soutiennent pas l'utilisation systématique des IPP.

Outcomes in syncope research: a systematic review and critical appraisal.
Solbiati M, Bozzano V, Barbic F, Casazza G, Dipaola F, Quinn JV, Reed MJ, Sheldon RS, Shen WK, Sun BC, Thiruganasambandamoorthy V, Furlan R, Costantino G. | Intern Emerg Med. 2018 Jun;13(4):593-601
DOI: https://doi.org/10.1007/s11739-018-1788-z  | Télécharger l'article au format  
Keywords: Consensus; Emergency Department; Outcomes; Risk stratification; Syncope; Systematic review

CE - SYSTEMATIC REVIEW

Introduction : Syncope is the common clinical manifestation of different diseases, and this makes it difficult to define what outcomes should be considered in prognostic studies. The aim of this study is to critically analyze the outcomes considered in syncope studies through systematic review and expert consensus.

Méthode : We performed a systematic review of the literature to identify prospective studies enrolling consecutive patients presenting to the Emergency Department with syncope, with data on the characteristics and incidence of short-term outcomes. Then, the strengths and weaknesses of each outcome were discussed by international syncope experts to provide practical advice to improve future selection and assessment.

Résultats : 31 studies met our inclusion criteria. There is a high heterogeneity in both outcome choice and incidence between the included studies. The most commonly considered 7-day outcomes are mortality, dysrhythmias, myocardial infarction, stroke, and rehospitalisation. The most commonly considered 30-day outcomes are mortality, haemorrhage requiring blood transfusion, dysrhythmias, myocardial infarction, pacemaker or implantable defibrillator implantation, stroke, pulmonary embolism, and syncope relapse.

Conclusion : We present a critical analysis of the pros and cons of the commonly considered outcomes, and provide possible solutions to improve their choice in ED syncope studies. We also support global initiatives to promote the standardization of patient management and data collection.

Conclusion (proposition de traduction) : Nous présentons une analyse critique des avantages et des inconvénients des résultats couramment considérés, et nous proposons des solutions possibles pour améliorer leur choix dans les études sur la syncope aux urgences. Nous soutenons également les initiatives mondiales visant à promouvoir la normalisation de la gestion des patients et de la collecte de données.

JAMA

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.
Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. | JAMA. 2018 Jun 5;319(21):2179-2189
DOI: https://doi.org/10.1001/jama.2018.6496  | Télécharger l'article au format  
Keywords: Aucun

Introduction : Importance : The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. Objectifs : To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. Patients et méthode : The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection.

Méthode : Interventions : Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). Evolution et mesures : The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia.

Résultats : Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.

Conclusion : In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings.

Conclusion (proposition de traduction) : Dans ce service d'urgence, l'utilisation d'une bougie par rapport à un tube endotrachéal et d'un stylet a permis d'obtenir un succès d'intubation à la première tentative significativement plus élevé chez les patients bénéficiant d'une intubation trachéale d'urgence. Cependant, ces résultats doivent être considérés comme provisoires jusqu'à ce que la généralisabilité soit évaluée dans d'autres institutions et environnements.

Commentaire : Voir l'analyse de l'article sur de la SRLF : Intubation aux urgences : Y voit-on plus clair avec la bougie ?  . Rédigé par le Dr Dr Christophe GUITTON le 11/07/2019.

Journal Européen des Urgences et de Réanimation

Myocardial infarction: What's new in ESC 2017 Guidelines?.
Braik N, Ecollan P, Montalescot G. | JEUR. 2018 June 4 - In Press
DOI: https://doi.org/10.1016/j.jeurea.2018.05.004
Keywords: Myocardial infarction; Reperfusion; Antithrombotic agent; Primary angioplasty

Recommandations

Editorial : Mortality of myocardial infarction is constantly decreasing; the wide use of more effective anti-thrombotic agents, the generalization of the radial access and the use of latest generations of drug eluting stents significantly improves outcomes. Reperfusion, in particular, primary angioplasty, remains the cornerstone of STEMI management, the refinement of revascularization strategies for multi-vessel disease, changes in the recommendation levels of anticoagulants and the no more recommanded systematic thrombo-aspiration are expected to improve the prognosis of patients. The establishment and monitoring of quality of care indicators also aims to improve practices.

Conclusion (proposition de traduction) : La mortalité de l’infarctus du myocarde est en diminution constante. L’utilisation large de traitements antithrombotiques plus efficaces, la généralisation de la voie radiale et des dernières générations de stents actifs améliorent de façon significative la prise en charge. La reperfusion, en particulier, l’angioplastie primaire reste la pierre angulaire du traitement du STEMI, l’affinement des stratégies de revascularisation des patients multitronculaires, l’évolution des niveaux de recommandation des anticoagulants et la disparition de la thrombo-aspiration systématique permettront d’améliorer le pronostic des patients. La mise en place et la surveillance d’indicateurs de la qualité des soins ont également pour objectif l’amélioration des pratiques.

Journal of Anesthesia

New-onset atrial fibrillation: an update.
Omae T, Inada E. | J Anesth. 2018 Jun;32(3):414-424
DOI: https://doi.org/10.1007/s00540-018-2478-8
Keywords: Anticoagulant therapy; Hemodynamic management; Perioperative atrial fibrillation; Rate control; Rhythm control

Review Article

Editorial : New-onset atrial fibrillation (NOAF) is the most common perioperative complication of heart surgery, typically occurring in the perioperative period. NOAF commonly occurs in patients who are elderly, or have left atrial enlargement, or left ventricular hypertrophy. Various factors have been identified as being involved in the development of NOAF, and numerous approaches have been proposed for its prevention and treatment. Risk factors include diabetes, obesity, and metabolic syndrome. For prevention of NOAF, β-blockers and amiodarone are particularly effective and are recommended by guidelines. NOAF can be treated by rhythm/rate control, and antithrombotic therapy. Treatment is required in patients with decreased cardiac function, a heart rate exceeding 130 beats/min, or persistent NOAF lasting for ≥ 48 h. It is anticipated that anticoagulant therapies, as well as hemodynamic management, will also play a major role in the management of NOAF. When using warfarin as an anticoagulant, its dose should be adjusted based on PT-INR. PT-INR should be controlled between 2.0 and 3.0 in patients aged < 70 years and between 1.6 and 2.6 in those aged ≥ 70 years. Rate control combined with antithrombotic therapies for NOAF is expected to contribute to further advances in treatment and improvement of survival.

Conclusion : Following the publication of evidence regarding the impact of NOAF on patient survival, various findings on postopera- tive AF have been obtained and applied to the development of prevention and treatment strategies for NOAF. While it has been believed that the development of NOAF itself affects patient survival, recent evidence suggests that better survival can be achieved not by prophylaxis protocols, but by treatment of NOAF, including rhythm and rate control therapies, in particular. These treatments, combined with antithrombotic therapies, another major treatment approach for NOAF, are expected to contribute to further advances in treatment and improvement of survival.

Conclusion (proposition de traduction) : Suite à la publication de données probantes concernant l'impact de fibrillation atriale paroxystique sur la survie des patients, diverses conclusions sur la FA postopératoire ont été obtenues et appliquées à l'élaboration de stratégies de prévention et de traitement pour les fibrillation atriale paroxystique. Bien que l'on pense que le développement de la fibrillation atriale paroxystique affecte la survie des patients, des données récentes suggèrent qu'une meilleure survie peut être obtenue non pas par des protocoles de prophylaxie, mais par le traitement des fibrillations atriales paroxystiques, en particulier des thérapies de contrôle du rythme et de la fréquence. Ces traitements, combinés à des thérapies antithrombotiques, une autre approche de traitement majeure pour la fibrillation atriale paroxystique, devraient contribuer à de nouvelles avancées dans le traitement et l'amélioration de la survie.

Journal of Critical Care

Early glycemia and mortality in critically ill septic patients: Interaction with insulin-treated diabetes.
Magee F, Bailey M, Pilcher DV, Mårtensson J, Bellomo R. | J Crit Care. 2018 Jun;45:170-177
DOI: https://doi.org/10.1016/j.jcrc.2018.03.012
Keywords: Blood glucose; Diabetes; Dysglycemia; Glycemic variability; Hyperglycemia; Hypoglycemia; Sepsis

Original research article

Introduction : To investigate the relationship between dysglycemia and hospital mortality in patients with and without a preadmission diagnosis of insulin treated diabetes mellitus (ITDM).

Méthode : An observational multicentre cohort study using the ANZICS-APD database on adult patients admitted to ICU with sepsis between January 1st 2006 and December 31st 2015. Four domains of dysglycemia were investigated (highest, mean and lowest blood glucose levels and glycemic variability: the absolute difference between the highest and lowest level). The association between a preadmission diagnosis of ITDM and hospital mortality in each domain was analysed.

Résultats : We studied 90,644 septic patients including 5127 patients with ITDM. We found that septic ICU patients with ITDM have lower adjusted hospital mortality with higher peak blood glucose levels in the first 24 h while non-ITDM patients have increased mortality (interaction p 0.012). We found that this significant difference was replicated when assessing glycemic variability (interaction p 0.048).

Conclusion : Septic patients with a pre-existing diagnosis of ITDM show a different relationship between hospital mortality and highest glucose levels and glycemic variability in the first 24 h than those without ITDM. These findings provide a rationale for an ITDM-specific approach to the management of dysglycemia.

Conclusion (proposition de traduction) : Les patients septiques avec un diagnostic préexistant de diabète sucré traité à l'insuline montrent une relation différente entre la mortalité hospitalière et les taux de glucose les plus élevés et la variabilité glycémique dans les 24 h que ceux qui n'ont pas de diabète sucré traité à l'insuline.
Ces résultats justifient l'adoption d'une approche spécifique au traitement du diabète sucré par l'insuline pour la prise en charge de la dysglycémie.

Hyperchloraemia is associated with acute kidney injury and mortality in the critically ill: A retrospective observational study in a multidisciplinary intensive care unit.
de Vasconcellos K, Skinner DL. | J Crit Care. 2018 Jun;45:45-51
DOI: https://doi.org/10.1016/j.jcrc.2018.01.019
Keywords: Acute kidney injury; Chloride; Critical care; Hyperchloremia; Mortality

Original research article

Introduction : The aim of this study was to determine whether serum chloride and changes in serum chloride over time were associated with acute kidney injury (AKI) or intensive care unit (ICU) mortality in a heterogenous critically ill population.

Méthode : The study was a retrospective observational study of 250 adult patients admitted to a multidisciplinary academic ICU. Serum chloride within 48 h of admission, changes in chloride, and other biochemical and clinical parameters were evaluated as predictors of AKI and mortality.

Résultats : Hyperchloraemia occurred in 143 (57.2%) patients within 48 h of ICU admission. Hyperchloraemia at 48 h was significantly associated with AKI, OR = 6.44 (95% CI 2.95-14.10) and mortality, OR = 2.46 (95% CI 1.22-4.94) on univariate analysis, with this association persisting on multivariable analysis. An increase in serum chloride was also associated with a significantly increased risk of AKI and mortality on univariate analysis. Hyperchloraemia on admission was, however, not associated with AKI or death. Of the 150 patients with AKI, 147 (98.0%) had developed AKI by 48 h.

Conclusion : Hyperchloraemia and increasing serum chloride are associated with adverse outcomes in critically ill patients. There is equipoise as to whether this represents an association, an epiphenomenon or causation.

Conclusion (proposition de traduction) : L'hyperchlorémie et l'augmentation du chlorure sérique sont associées à des effets indésirables chez les patients gravement malades. Il existe une incertitude quant à savoir s'il s'agit d'une association, d'un épiphénomène ou d'un lien de causalité.

Predicting central line-associated bloodstream infections and mortality using supervised machine learning.
Parreco JP, Hidalgo AE, Badilla AD, Ilyas O, Rattan R. | J Crit Care. 2018 Jun;45:156-162
DOI: https://doi.org/10.1016/j.jcrc.2018.02.010
Keywords: Artificial intelligence; Central line-associated bloodstream infection; Hospital-acquired infections; Machine learning; Quality improvement; Severity of illness score

Original research article

Introduction : The purpose of this study was to compare machine learning techniques for predicting central line-associated bloodstream infection (CLABSI).

Méthode : The Multiparameter Intelligent Monitoring in Intensive Care III database was queried for all ICU admissions. The variables included six different severities of illness scores calculated on the first day of ICU admission with their components and comorbidities. The outcomes of interest were in-hospital mortality, central line placement, and CLABSI. Predictive models were created for these outcomes using classifiers with different algorithms: logistic regression, gradient boosted trees, and deep learning.

Résultats : There were 57,786 total hospital admissions and the mortality rate was 10.1%. There were 38.4% patients with a central line and the rate of CLABSI was 1.5%. The classifiers using deep learning performed with the highest AUC for mortality, 0.885±0.010 (p<0.01) and central line placement, 0.816±0.006 (p<0.01). The classifier using logistic regression for predicting CLABSI performed with an AUC of 0.722±0.048 (p<0.01).

Conclusion : This study demonstrates models for identifying patients who will develop CLABSI. Early identification of these patients has implications for quality, cost, and outcome improvements.

Conclusion (proposition de traduction) : Cette étude démontre des modèles pour identifier les patients qui développeront une septicémie associée aux cathéters centraux. L'identification précoce de ces patients a des répercussions sur la qualité, le coût et l'amélioration des résultats.

Current practices and safety of medication use during rapid sequence intubation.
Groth CM, Acquisto NM, Khadem T. | J Crit Care. 2018 Jun;45:65-70
DOI: https://doi.org/10.1016/j.jcrc.2018.01.017
Keywords: Adverse effects; Emergency department; Intensive Care Unit (ICU); Medications; Rapid sequence intubation (RSI)

Original research article

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

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

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

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

Conclusion (proposition de traduction) : Les pratiques de traitement pendant les l'intubations en séquence rapide varient d'un prestataire à l'autre et les médicaments sont souvent utilisés de façon inappropriée. Il est possible d'optimiser l'utilisation des médicaments pendant l'intubation en séquence rapide.

Journal of Intensive Care Medicine

Survey on the Current State of Endotracheal Intubation Among the Critically Ill: HEMAIR Investigators.
Seisa MO, Gondhi V, Demirci O, Diedrich DA, Kashyap R, Smischney NJ. | J Intensive Care Med. 2018 Jun;33(6):354-360
DOI: https://doi.org/10.1177/0885066616654452
Keywords: airway management; endotracheal intubation; hemodynamic management; intensive care unit; survey

Review of a Large Clinical Series

Introduction : In the last decade, the practice of intubation in the intensive care unit (ICU) has evolved. To further examine the current intubation practice in the ICU, we administered a survey to critical care physicians.

Méthode : Cross-sectional survey study design.
SETTING: Thirty-two academic/nonacademic centers nationally and internationally.

Résultats : The survey was developed among a core group of physicians with the assistance of the Survey Research Center at Mayo Clinic, Rochester, Minnesota. The survey was pilot tested for functionality and reliability. The response rate was 82 (51%) of 160 among the 32 centers. Although propofol was the induction drug of choice, there was a significant difference with actual ketamine use and those who indicated a preference for it (ketamine: 52% vs 61%; P < .001). The most common airway device used for intubation was direct laryngoscopy (Miller laryngoscope blade) at 56 (68%) followed by video laryngoscopy at 26 (32%). Most (>90%) indicated that they have a difficult airway cart, but only 55 (67%) indicated they have a documented plan to handle a difficult airway with even lower results for documented review of adverse events (49%).

Conclusion : Although propofol was the induction drug of choice, ketamine was a medication that many preferred to use, possibly relating to the fact that the most common complication postintubation is hypotension. Direct laryngoscopy remains the primary airway device for endotracheal intubation. Finally, although the majority stated they had a difficult airway cart available, most did not have a documented plan in place when encountering a difficult airway or a documented process to review adverse events surrounding intubation.

Conclusion (proposition de traduction) : Bien que le propofol soit le médicament de choix, la kétamine était un médicament que beaucoup préféraient utiliser, peut-être en raison du fait que l’hypotension était la complication la plus fréquente après l’intubation. La laryngoscopie directe reste la méthode principale de contrôle des voies respiratoires pour l'intubation orotrachéale. Enfin, même si la majorité des répondants ont déclaré qu’un chariot d'intubation difficile était disponible, la plupart n’avaient pas de procédure documenté pour faire face à une intubation difficile ou à un processus documenté pour examiner les événements indésirables entourant l’intubation.

Le Praticien en Anesthésie Réanimation

Marjanovic N, Drugeona B, Moya M,Guénézan J. | Prat Anesth Reanim. 2018 June;22(3):129-133
DOI: https://doi.org/10.1016/j.pratan.2018.04.010
Keywords: Analgesia/pain control; Emergency department; Prehospital care; Acute pain; Methoxyflurane

Mise au point

Editorial : In Emergency departments, 60% of patients experience pain regardless of the reason for admission. In these patients, pain is insufficiently evaluated and/or treated. Since methoxyflurane has a rapid and prolonged action, it has been launched on the market for treatment of moderate to severe acute traumatic pain. Methoxyflurane is an inhaled anesthetic agent with a rapid analgesic effect at low concentrations. Side effects are frequent and mostly neurological (vertigo, headache, drowsiness). Serious adverse reactions associated with anesthetic doses (renal and hepatic toxicity) contraindicate its use in patients with a medical history of renal failure, diabetes mellitus or hepatocellular insufficiency, even when administered at analgesic doses.

Conclusion : The lack of studies with a good level of evidence and/or comparison of methoxyflurane with other analgesics used in the same indication does not allow it to be positioned in emergency room pain management algorithms or recommended for large-scale use.

Conclusion (proposition de traduction) : Le Methoxyflurane est un médicament anesthésique et analgésique par voie inhalée qui semble avoir une efficacité dans la prise en charge de la douleur d’origine traumatique chez l’adulte et chez l’enfant (hors AMM) et au cours des interventions préhospitalières. Son délai d’action rapide et son utilisation simple, ne nécessitant pas d’un accès vasculaire, rendent cette molécule intéressante en phase initiale de la prise en charge de la douleur notamment traumatique. Cepen- dant, la fréquence des effets indésirables même à faible dose, notamment neurologiques, nécessite une surveillance stricte des patients traités et limite son utilisation à une population ciblée. De plus, l’absence d’étude prospective et/ou de bon niveau de preuve, comparant le Methoxyflurane à d’autres antalgiques ne permet pas d’en évaluer les avantages et de le positionner par rapport aux autres antalgiques dans les algorithmes de prise en charge de la douleur modérée à sévère aux urgences.

Commentaire : Le méthoxyflurane est commercialisé sous le nom de PENTHROX, liquide pour inhalation par vapeur, en France depuis le 06 février 2017. L’indication dans le cadre de son autorisation de mise sur le marché concerne le soulagement d’urgence des douleurs modérées à sévères associées à un traumatisme chez des patients adultes (plus de 18 ans) conscients. Le méthoxyflurane est un halogéné, ancien agent anesthésique utilisé à doses plus élevées (40 à 60 ml) jusqu’en 1974 en France. Son abandon était dû à une néphrotoxicité grave à doses élevées. Il est à nouveau commercialisé comme antalgique sous le nom de Penthrox®. Il se présente sous la forme d’un flacon de 3 ml de méthoxyflurane à vaporiser dans un inhalateur manuel. A la fin de la dose de 3 ml, une autre dose de 3 ml peut être délivrée, sans dépasser 6 ml par administration.
Pour plus d'information consulter l'article de Blair HA and al. Methoxyflurane: A Review in Trauma Pain. Clin Drug Investig. 2016 Dec;36(12):1067-1073  .

Harkouk H, Ichou L, Kassoul A, Fletche D. | Prat Anesth Reanim. 2018 June;22(3):164-167
DOI: https://doi.org/10.1016/j.pratan.2018.04.001
Keywords: Tramadol; Opioids; Postoperative analgesia

Opinion

Editorial : Le tramadol est un analgésique opioïde qui possède également un effet d’inhibition du recapture de la sérotonine. Sont métabolisme hépatique produit du O-demethyl-tramadol qui est un agoniste opioïde puissant. Ce métabolisme connaît des variations génétiques importantes. Le tramadol provoque des effets secondaires comme la sédation et les nausées vomissements. Son association aux autres opioïdes n’a aucun intérêt mais les analgésiques non opioïdes comme les AINS augmentent l’effet analgésique.

Conclusion (proposition de traduction) : Le tramadol n’est donc ni un ami ni un ennemi mais un antalgique intéressant qui s’utilise au mieux en association avec les antalgiques non morphiniques (paracétamol et/ou kétoprofène). Il faut connaître la possibilité de variabilité génétique impactant son efficacité et sa tolérance. Son association avec la morphine n’a pas d’intérêt. Le tramadol peut exposer à des interactions avec l’ondansétron et les antidépresseurs avec risque d’inefficacité partielle. Enfin, comme tous les opioïdes, le tramadol en prescription chronique peut conduire à une utilisation inadaptée qu’il faut savoir détecter et prévenir.

Médecine et Armées

Caubère A, Gonzalez JF, Thomas J, Balandraud P, Rigal S, Boileau P et le groupe de travail attentat du service chirurgie orthopédique et traumatologie. | Médecine et Armées. 2018 juin;46(3):305-10
DOI:  | Télécharger l'article au format  
Keywords: Attentat. Afflux massif. Damage control orthopédique. Écrasement. Nice. Tuerie de masse.

Soignants en situation de crise

Editorial : Le 14 juillet 2016, un attentat sur la promenade des Anglais à Nice a provoqué 84 morts et plus de 300 blessés. Le nombre important de traumatisés graves reçus a imposé une organisation spécifique basée sur les principes du triage et du damage control, issus de la chirurgie de guerre. L’objectif de ce travail était d’analyser les spécificités de l’adaptation de ces principes en milieu civil. Matériel et méthodes : il s’agit d’une analyse rétrospective de la réponse hospitalière mise en place par l’équipe de chirurgie orthopédique, ainsi qu’un recensement du type de lésions ostéo-articulaires rencontrées lors de cet attentat. Résultats : au total, 182 patients ont été reçus, dont 47 en moins d’une heure. Trente-deux patients hospitalisés présentaient des lésions ostéo-articulaires : 13 étaient des traumatisés graves et 19 des polyfracturés. Ces patients avaient essentiellement des lésions par écrasement. Le concept tactique de triage chirurgical était appliqué et 15 patients ont été opérés selon une procédure de damage control orthopédique. Discussion : la plupart des lésions ostéo-articulaires présentées par les victimes des attentats de Nice étaient semblables à celles rencontrées quotidiennement par le chirurgien orthopédiste en accidentologie routière avec une grande place pour les traumatismes du bassin. Dans le cadre d’un afflux massif de traumatisés graves, une prise en charge pour le plus grand nombre nécessite une organisation particulière, rapide et efficace afin de prévenir un maximum de décès et limiter la morbidité.

Conclusion (proposition de traduction) : Les principes fondamentaux que représentent « organisation anticipée, triage et Damage Control » ont permis de prendre en charge rapidement ces victimes. L’actualisation des plans blancs devrait s’orienter sur l’organisation du triage et de la cellule administrative. L’information la plus claire possible paraît être la clef dans la gestion d’un afflux massif. L’expérience de spécialistes militaires opérationnelles habitués à la gestion d’afflux massif en opérations extérieurs pourrait être profitable aux structures civiles dans ces cas extrêmes.

Pediatric Emergency Care

First-Attempt Success, Longevity, and Complication Rates of Ultrasound-Guided Peripheral Intravenous Catheters in Children.
Vinograd AM, Zorc JJ, Dean AJ, Abbadessa MKF, Chen AE. | Pediatr Emerg Care. 2018 Jun;34(6):376-380
DOI: https://doi.org/10.1097/PEC.0000000000001063
Keywords: Aucun

Original articles

Introduction : The aim of this study was to examine the success rates, longevity, and complications of ultrasound-guided peripheral intravenous lines (USgPIVs) placed in a pediatric emergency department.

Méthode : The study analyzed 300 USgPIV attempts in an urban tertiary-care pediatric emergency department. Data regarding USgPIV placement were collected from a 1-page form completed by the clinician placing the USgPIV. The time and reason for USgPIV removal were extracted from the medical record for patients with USgPIVs admitted to the hospital. A Kaplan-Meier survival analysis was performed.

Résultats : This study demonstrated a success rate of 68% and 87% for the first and second attempts with USgPIV. Fifty-five percent of patients had 1 or more prior traditional intravenous access attempt. Most USgPIVs placed on patients admitted to the hospital were removed because they were no longer needed (101/160). We calculated a Kaplan-Meier median survival of 143 hours (6 days; interquartile range, 68-246 hours). The failure rate at 48 hours was 25%.

Conclusion : Ultrasound-guided intravenous access is a feasible alternative to traditional peripheral intravenous access in the pediatric emergency setting. We observed a high first-stick success rate even in patients who had failed traditional peripheral intravenous access attempts, few complications, and a long intravenous survival time.

Conclusion (proposition de traduction) : L'accès veineux écho-guidé est une solution de rechange possible à l'accès veineux périphérique traditionnel dans le contexte d'une urgence pédiatrique. Nous avons observé un taux de réussite élevé même chez les patients chez qui on n'avait pas réussi à obtenir un accès intraveineux périphérique traditionnel, peu de complications et une longue période de maintien de la voie veineuse.

How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department.
Abbas PI, Zamora IJ, Elder SC, Brandt ML, Lopez ME, Orth RC1, Bisset GS1, Cruz AT. | Pediatr Emerg Care. 2018 Jun;34(6):381-384
DOI: https://doi.org/10.1097/PEC.0000000000000720
Keywords: Aucun

Original articles

Introduction : Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score).

Méthode : In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range.

Résultats : A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39).

Conclusion : The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.

Conclusion (proposition de traduction) : L'élaboration d'un score radiographique de l'appendicite, bien que permettant une méthode de déclaration standardisée, n'a pas modifié de façon significative le déroulement du processus d'évaluation de l'appendicite aux urgences. Cela reflète la complexité de la fréquentation des urgences et révèle la nécessité d'autres facteurs de changement pour améliorer le flux des patients.

Commentaire : Voir l'article de 2016 : Abbas PI and al. How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department.Pediatr Emerg Care. 2016 Mar 3. 
  

Intravenous and Nebulized Magnesium Sulfate for Treating Acute Asthma in Children: A Systematic Review and Meta-Analysis.
Su Z, Li R, Gai Z. | Pediatr Emerg Care. 2018 Jun;34(6):390-395
DOI: https://doi.org/10.1097/PEC.0000000000000909
Keywords: Aucun

Original articles

Introduction : This study aimed to evaluate the efficacy of intravenous (IV) and nebulized magnesium sulfate in acute asthma in children.

Méthode : The PubMed, Cochrane Library, and EMBASE databases were searched. Randomized controlled trials and quasi-randomized controlled trials of IV and nebulized magnesium sulfate in pediatric acute asthma were included. The outcomes subject to meta-analysis were pulmonary function, hospitalization, and further treatment. If statistical heterogeneity was significant, random-effects models were used for meta-analysis, otherwise, fixed-effects models were applied.

Résultats : Ten randomized and quasi-randomized trials (6 IV, 4 nebulized) were identified. Intravenous magnesium sulfate treatment is associated with significant effects on respiratory function (standardized mean difference, 1.94; 95% confidence interval [CI], 0.80-3.08; P = 0.0008) and hospital admission (risk ratio, 0.55; 95% CI, 0.31-0.95; P = 0.03). But nebulized magnesium sulfate treatment shows no significant effect on respiratory function (standardized mean difference, 0.19; 95% CI, -0.01-0.40; P = 0.07) or hospital admission (risk ratio, 1.11; 95% CI, 0.86-1.44; P = 0.42).

Conclusion : The meta-analysis revealed that IV magnesium sulfate is an effective treatment in children, with the pulmonary function significantly improved and hospitalization and further treatment decreased. But nebulized magnesium sulfate treatment showed no significant effect on respiratory function or hospital admission and further treatment.

Conclusion (proposition de traduction) : La méta-analyse a révélé que le sulfate de magnésium IV est un traitement efficace chez les enfants, avec une amélioration significative de la fonction pulmonaire et une diminution de l'hospitalisation et des traitements ultérieurs. Mais le traitement par le sulfate de magnésium nébulisé n'a montré aucun effet significatif sur la fonction respiratoire ou l'admission à l'hôpital et le traitement ultérieur.

Radiology Callbacks to a Pediatric Emergency Department and Their Clinical Impact.
Arora R, Kannikeswaran N. | Pediatr Emerg Care. 2018 Jun;34(6):422-425
DOI: https://doi.org/10.1097/PEC.0000000000001510
Keywords: Aucun

Original articles

Introduction : Clinical impact of radiology callbacks (missed initial radiologic diagnosis) remains largely unknown in the pediatric emergency department (PED).
OBJECTIVE: The aim of this study was to describe the incidence, nature of radiology callbacks, and the impact on clinical care during the return visit (RV).

Méthode : We performed a retrospective chart review of quality assurance database of RVs for radiology callbacks to our PED over a 1-year period.

Résultats : Return visit rate to our PED was 3% (2765/92,000) of which 1.9% (55/2765) was for radiology callbacks. Radiology misses involved mostly x-ray interpretations (92.7%), occurred after-hours (83.6%), with fractures being the most common missed finding. Majority of patients (94.5%) required 1 or more interventions during the RV; 34.5% of radiology callbacks had a major impact on clinical management; 27.2% of radiology callbacks were false-positive.

Conclusion : Although RVs secondary to radiology callback remain low, one third of them resulted in major changes in diagnosis, treatment, or disposition and impacted patient outcome.

Conclusion (proposition de traduction) : Bien que les consultations de reconvocation par le service de radiologie des urgences pédiatriques demeurent faibles, un tiers d'entre elles ont entraîné des changements majeurs au niveau du diagnostic, du traitement ou du devenir et ont eu un impact sur l'évolution du patient.

Analysis of Complications After Button Battery Ingestion in Children.
Varga Á, Kovács T, Saxena AK. | Pediatr Emerg Care. 2018 Jun;34(6):443-446
DOI: https://doi.org/10.1097/PEC.0000000000001413
Keywords: Aucun

Review Article

Introduction : Button battery ingestion (BBI) in children may cause severe complications. This analysis is a literature review of complications after pediatric BBI.

Méthode : Literature was searched on PubMed (1995-2015) using the terms "button battery," "ingestion," and "children." End points were age, type and diameter of battery, complications, affected organ, and fatality.

Résultats : A total of 31 publications were analyzed. Patients from 4 months to 19 years old were included (n = 136,191, with n = 102,143 or 75% aged <6 y). In 6262, the diameter of the battery was documented. Batteries of 20 mm or greater in size were more prone to complications (n = 226). With regard to the anatomy, BBI caused complications mainly in the esophagus (n = 88, 38.94%). Sixty-one fatal outcomes were reported.

Conclusion : Children younger than 6 years are the most prone to BBI, with lithium batteries of 20 mm or greater in size associated with complications. Complications have been estimated at 0.165%, with lethality of 0.04%. The esophagus is the most affected organ, but vascular involvement is often fatal.

Conclusion (proposition de traduction) : Les enfants de moins de 6 ans sont les plus sujets à l'ingestion de piles bouton, avec des piles au lithium de 20 mm ou de taille plus grande, associée à des complications. Les complications ont été estimées à 0,165 %, avec une létalité de 0,04 %. L'œsophage est l'organe le plus touché, mais l'atteinte vasculaire est souvent fatale.

Prehospital and Disaster Medicine

Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS - A Descriptive Study.
Mix FM, Zielinski MD, Myers LA, Berns KS, Luke A, Stubbs JR, Zietlow SP, Jenkins DH, Sztajnkrycer MD. | Prehosp Disaster Med. 2018 Jun;33(3):230-236
DOI: https://doi.org/10.1017/S1049023X18000274
Keywords: ALS Advanced Life Support; DCR damage control resuscitation; ED emergency department; EMS Emergency Medical Services; HD hemodynamic; HEMS Helicopter Emergency Medical Services; HR heart rate; MCMT Mayo Clinic Medical Transport; MOI mechanism of injury; OR operating room; PRBC packed red blood cells; SBP systolic blood pressure; blood products; helicopter EMS; resuscitation; transfusion; trauma

Original Research

Introduction : Hemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).

Méthode : This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).

Résultats : A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.

Conclusion : In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.

Conclusion (proposition de traduction) : Dans la population étudiée, les paramètres hémodynamiques ne permettaient pas à eux seuls de prédire la nécessité d'administrer des produits sanguins aux urgences. Malgré des délais de transport plus longs, seulement un tiers des patients des services médicaux d'urgence qui répondaient aux critères hémodynamiques pour l'administration de sang ont reçu une transfusion préhospitalière. Alors qu'un tiers des patients présentant une atteinte hémodynamique ont reçu des produits sanguins aux urgences, cela représentait 0,2 % du transport total des traumatisés au cours de la période à l'étude. Étant donné la complexité des questions logistiques liées à l'administration des produits sanguins préhospitaliers, les possibilités d'administration en transport terrestre semblent limitées au sein du système décrit.

Weekly Checks Improve Real-Time Prehospital ECG Transmission in Suspected STEMI.
D'Arcy NT, Bosson N, Kaji AH, Bui QT, French WJ, Thomas JL, Elizarraraz Y, Gonzalez N, Garcia J, Niemann JT. | Prehosp Disaster Med. 2018 Jun;33(3):245-249
DOI: https://doi.org/10.1017/S1049023X18000341
Keywords: D2B door-to-balloon; ECG electrocardiogram; EMS Emergency Medical Services; FMC2B first-medical-contact-to-balloon; LA Los Angeles; Los Angeles; MICN mobile intensive care nurse; PCI percutaneous coronary intervention; SRC STEMI Receiving Center; STEMI ST-elevation myocardial infarction; UCLA University of California; ECG transmission; Emergency Medical Services; STEMI; electrocardiography

Original Research

Introduction : Field identification of ST-elevation myocardial infarction (STEMI) and advanced hospital notification decreases first-medical-contact-to-balloon (FMC2B) time. A recent study in this system found that electrocardiogram (ECG) transmission following a STEMI alert was frequently unsuccessful.HypothesisInstituting weekly test ECG transmissions from paramedic units to the hospital would increase successful transmission of ECGs and decrease FMC2B and door-to-balloon (D2B) times.

Méthode : This was a natural experiment of consecutive patients with field-identified STEMI transported to a single percutaneous coronary intervention (PCI)-capable hospital in a regional STEMI system before and after implementation of scheduled test ECG transmissions. In November 2014, paramedic units began weekly test transmissions. The mobile intensive care nurse (MICN) confirmed the transmission, or if not received, contacted the paramedic unit and the department's nurse educator to identify and resolve the problem. Per system-wide protocol, paramedics transmit all ECGs with interpretation of STEMI. Receiving hospitals submit patient data to a single registry as part of ongoing system quality improvement. The frequency of successful ECG transmission and time to intervention (FMC2B and D2B times) in the 18 months following implementation was compared to the 10 months prior. Post-implementation, the time the ECG transmission was received was also collected to determine the transmission gap time (time from ECG acquisition to ECG transmission received) and the advanced notification time (time from ECG transmission received to patient arrival).

Résultats : There were 388 patients with field ECG interpretations of STEMI, 131 pre-intervention and 257 post-intervention. The frequency of successful transmission post-intervention was 73% compared to 64% prior; risk difference (RD)=9%; 95% CI, 1-18%. In the post-intervention period, the median FMC2B time was 79 minutes (inter-quartile range [IQR]=68-102) versus 86 minutes (IQR=71-108) pre-intervention (P=.3) and the median D2B time was 59 minutes (IQR=44-74) versus 60 minutes (IQR=53-88) pre-intervention (P=.2). The median transmission gap was three minutes (IQR=1-8) and median advanced notification time was 16 minutes (IQR=10-25).

Conclusion : Implementation of weekly test ECG transmissions was associated with improvement in successful real-time transmissions from field to hospital, which provided a median advanced notification time of 16 minutes, but no decrease in FMC2B or D2B times.

Conclusion (proposition de traduction) : La mise en œuvre des transmissions hebdomadaires des ECG a été associée à une amélioration des transmissions en temps réel entre le terrain et l'hôpital, ce qui a permis d'obtenir un temps de notification médian avancé de 16 minutes, mais aucune diminution du temps entre le premier contact médical et le ballonnet (first-medical-contact-to-balloon) ou entre la porte et le ballonnet (door-to-balloon).

Comparison of Electronic Versus Manual Mass-Casualty Incident Triage.
Bolduc C, Maghraby N, Fok P, Luong TM, Homier V. | Prehosp Disaster Med. 2018 Jun;33(3):273-278
DOI: https://doi.org/10.1017/S1049023X1800033X
Keywords: CTAS Canadian Triage and Acuity Scale; ED emergency department; MCI mass-casualty incident; MD medical doctor; MGH Montreal General Hospital; MUHC McGill University Health Center; PM paramedic; RN registered nurse; START Simple Triage and Rapid Treatment; disaster medicine; electronic triage; health care technology; mass-casualty incidents; triage

Original Research

Introduction : Mass-casualty incidents (MCIs) easily overwhelm a health care facility's human and material resources through the extraordinary influx of casualties. Efficient and accurate triage of incoming casualties is a critical step in the hospital disaster response.Hypothesis/ProblemTraditionally, triage during MCIs has been manually performed using paper cards. This study investigated the use of electronic Simple Triage and Rapid Treatment (START) triage as compared to the manual method.

Méthode : This observational, crossover study was performed during a live MCI simulation at an urban, Canadian, Level 1 trauma center on May 26, 2016. Health care providers (two medical doctors [MDs], two paramedics [PMs], and two registered nurses [RNs]) each triaged a total of 30 simulated patients - 15 by manual (paper-based) and 15 by electronic (computer-based) START triage. Accuracy of triage categories and time of triage were analyzed. Post-simulation, patients and participating health care providers also completed a feedback form.

Résultats : There was no difference in accuracy of triage between the electronic and manual methods overall, 83% and 80% (P=1.0), between providers or between triage categories. On average, triage time using the manual method was estimated to be 8.4 seconds faster (P<.001) for PMs; and while small differences in triage times were observed for MDs and RNs, they were not significant. Data from the participant feedback survey showed that the electronic method was preferred by most health care providers. Patients had no preference for either method. However, patients perceived the computer-based method as "less personal" than the manual triage method, but they also perceived the former as "better organized."

Conclusion : Hospital-based electronic START triage had the same accuracy as hospital-based manual START triage, regardless of triage provider type or acuity of patient presentations. Time of triage results suggest that speed may be related to provider familiarity with a modality rather than the modality itself. Finally, according to patient and provider perceptions, electronic triage is a feasible modality for hospital triage of mass casualties. Further studies are required to assess the performance of electronic hospital triage, in the context of a rapid surge of patients, and should consider additional efficiencies built in to electronic triage systems. This study presents a framework for assessing the accuracy, triage time, and feasibility of digital technologies in live simulation training or actual MCIs.

Conclusion (proposition de traduction) : Le triage électronique START en milieu hospitalier avait la même précision que le triage manuel START en milieu hospitalier, peu importait le type d'opérateur de triage ou l'acuité des présentations des patients. Les résultats de la période de triage suggèrent que la vitesse peut être liée à la familiarité du prestataire avec une modalité plutôt qu'à la modalité elle-même. Enfin, selon les perceptions des patients et des prestataire de soins, le triage électronique est une modalité réalisable pour le triage hospitalier des victimes de masse.
D'autres études sont nécessaires pour évaluer le rendement du triage électronique en milieu hospitalier, dans le contexte d'une augmentation rapide du nombre de patients et devraient tenir compte de l'efficacité accrue des systèmes de triage électronique. Cette étude présente un cadre d'évaluation de l'exactitude, du temps de triage et de la faisabilité des technologies numériques dans le cadre de la formation par simulation en direct ou des accidents de masse réels.

Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review.
Hards M, Brewer A, Bessant G, Lahiri S. | Prehosp Disaster Med. 2018 Jun;33(3):299-307
DOI: https://doi.org/10.1017/S1049023X18000365
Keywords: FICB Fascia Iliaca Compartment Block; IV intravenous; OCEBM Oxford Centre for Evidence-based Medicine; PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT randomized controlled trial; VNPS Verbal Numerical Pain Score; Emergency Medical Services; analgesia; femoral fractures; nerve block

Comprehensive Review

Introduction : Femoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention.ProblemThe purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects.

Méthode : A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK).

Résultats : Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays.

Conclusion : The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids.

Conclusion (proposition de traduction) : Le bloc ilio-fascial est adapté à une utilisation en milieu préhospitalier pour la prise en charge des fractures fémorales. Elle a peu d'effets indésirables et peut être réalisée avec un taux de réussite élevé par des praticiens de tous horizons. Des études suggèrent que le bloc ilio-fascial est une technique analgésique utile, bien que d'autres recherches soient nécessaires pour étudier son efficacité par rapport aux opioïdes systémiques.

Commentaire : Cette méta-analyse confirme le rationnel qui propose d'utiliser le bloc ilio-fascial à l'heure de la tendance à l'épargne morphinique devant le peu d'effet secondaire et de la durée du bloc permettant également des examens de radiologie confortable pour le patient.

Dispatcher CPR Instructions Across the Age Continuum.
Weinmeister KL, Lerner EB, Guse CE, Ateyyah KA, Pirrallo RG. | Prehosp Disaster Med. 2018 Jun;33(3):342-345
DOI: https://doi.org/10.1017/S1049023X18000377
Keywords: CPR cardiopulmonary resuscitation; EMS Emergency Medical Services; OHCA out-of-hospital cardiac arrest; Emergency Medical Services; bystander CPR; dispatch-assisted CPR; out-of-hospital cardiac arrest

Brief Report

Introduction : Survival rates following out-of-hospital cardiac arrest (OHCA) increase two to three times when cardiopulmonary resuscitation (CPR) is started by bystanders, as compared to starting CPR when Emergency Medical Services (EMS) arrives. Municipalities that have implemented dispatcher-assisted bystander CPR programs have seen increased rates of bystander CPR. Cardiopulmonary resuscitation instructions are given for victims of all ages, but it is unknown if offering instructions results in similar rates of EMS-documented bystander CPR across the age continuum in these municipalities.
OBJECTIVES: The aim of this study was to determine if there is a difference in EMS-documented bystander CPR rates based on the age group of the OHCA victim when dispatcher CPR instructions are available in the community.

Méthode : This was a three-year, retrospective chart review of OHCA patients in two municipalities within a single county that provided dispatcher-assisted CPR instructions. Bystander CPR and patient age were determined based on EMS documentation. Age was stratified into three groups: child (0-12 years), adult (13-54 years), and geriatric (≥55 years). Chi square was used to compare the rate of bystander CPR in each age group.

Résultats : During the study period, 1,993 patients were identified as being in OHCA at the time of EMS arrival. The overall bystander CPR rate was 10%. The highest rate of bystander CPR was in the child age group (19%). The lowest rate of bystander CPR was in the geriatric age group (9%). There was a statistically significant difference between age groups (P≤.01).

Conclusion : The rate of EMS-documented bystander CPR was low, even though these municipalities provided dispatcher-assisted CPR instructions. The highest rates of bystander CPR were observed in children (0-12 years). Future investigations should determine why this occurs and if there are opportunities to modify dispatcher coaching based on patient age so that bystander CPR rates improve.

Conclusion (proposition de traduction) : Le taux de RCP par des témoins documenté par les services médicaux d'urgence était faible, même si les municipalités fournissaient des instructions de RCP par un gestionnaire. Les taux les plus élevés de réanimation cardiorespiratoire ont été observés chez les enfants (0-12 ans).
Des études futures devraient déterminer pourquoi cela se produit et s'il est possible de modifier l'encadrement des gestionnaires en fonction de l'âge des patients afin que les taux de RCP réalisées par des témoins s'améliorent.

Resuscitation

Association between intra- and post-arrest hyperoxia on mortality in adults with cardiac arrest: A systematic review and meta-analysis.
Patel JK, Kataya A, Parikh PB. | Resuscitation. 2018 Jun;127:83-88
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.008
Keywords: Cardiac arrest; Hyperoxemia; Hyperoxia; Mortality

Reviews

Introduction : The association between intra-arrest and post-arrest hyperoxia and mortality in adults with cardiac arrest (CA) is widely debated. We therefore conducted a systematic review and meta-analysis to investigate the association between intra-arrest and post-arrest hyperoxia and mortality in adults with CA.

Méthode : We systematically searched MEDLINE and Cochrane databases to identify observational studies from January 2008 to December 2017 investigating the relationship between hyperoxia (either intra-arrest or post-arrest) and mortality in adults with CA.

Résultats : We included 16 observational studies with a total of 40,573 adult patients. Six studies included patients only with out-of-hospital CA (OHCA), 2 studies included patients only with in-hospital CA (IHCA), and 8 studies included patients with both OHCA and IHCA. Two studies assessed intra-arrest hyperoxia while 14 studies examined post-arrest hyperoxia. Of the 10 studies included for quantitative analysis, intra-arrest hyperoxia was associated with a significantly lower mortality rate [odds ratio (OR) 0.25, 95% confidence interval (CI) 0.12-0.53, p < 0.001] while post-arrest hyperoxia was associated with higher mortality (OR 1.34, 95%CI 1.08-1.67, p = 0.008).

Conclusion : In adults with CA, intra-arrest hyperoxia is associated with lower mortality while post-arrest hyperoxia is associated with higher mortality.

Conclusion (proposition de traduction) : Chez les adultes victimes d'un arrêt cardiorespiratoire, l'hyperoxie pendant l'arrêt est associée à une mortalité plus faible, tandis que l'hyperoxie après l'arrêt est associée à une mortalité plus élevée.

Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest.
Javaudin F, Leclere B, Segard J, Le Bastard Q, Pes P, Penverne 5, Le Conte P, Jenvrin J, Hubert H, Escutnaire J, Batard E, Montassier E, Gr-RéAC. | Resuscitation. 2018 Jun;127:8-13
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.020
Keywords: Out of hospital cardiac arrest; Outcome; Prognostication; Pupillary light reaction

Clinical papers

Introduction : Loss of pupillary light reactivity (PLR) three days after a cardiorespiratory arrest is a prognostic factor. Its predictive value upon hospital admission remains unclear. Our objective was to determine the prognostic value of the absence of PLR upon hospital admission in patients with out-of-hospital cardiac arrest.

Méthode : We prospectively included all out-of-hospital cardiac arrests occurring between July 2011 and July 2017 treated by a mobile medical team (MMT) based on data from a French cardiac arrest registry database. PLR was evaluated upon hospital admission and the outcome on day 30. The prognosis was classified as good for Cerebral Performance Category (CPC) 1 or 2, and poor for CPC 3-5 or in case of death.

Résultats : Data from 10151 patients was analysed. The sensitivity and specificity of the absence of PLR for a poor outcome were 72.2% (71.2-73.2) and 68.8% (66.7-70.1), respectively. We identified several variables modifying the sensitivity values and the false positive fraction of a factor, ranging from 0.49 (0.35-0.69) for the Glasgow Coma Scale to 2.17 (1.09-2.48) for pupillary asymmetry. Among those living with CPC 1 or 2 on day 30 (n = 1990; 19.6%), 621 (31.2% (29.2-33.3)) had no PLR upon hospital admission. In the multivariate analysis, loss of PLR was associated with a poor outcome (OR = 3.1 (2.7-3.5)).

Conclusion : Loss of pupillary light reactivity upon hospital admission is predictive of a poor outcome after out-of-hospital cardiac arrest. However, it does not have sufficient accuracy to determine prognosis and decision making.

Conclusion (proposition de traduction) : La perte de réactivité pupillaire à la lumière lors de l'admission à l'hôpital est prédictive d'un résultat médiocre après un arrêt cardiaque extrahospitalier. Cependant, sa précision est insuffisante pour déterminer le pronostic et la prise de décision.

Association between coronary angiography with or without percutaneous coronary intervention and outcomes after out-of-hospital cardiac arrest.
Vadeboncoeur TF, Chikani V, Hu C, Spaite DW, Bobrow BJ. | Resuscitation. 2018 Jun;127:21-25
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.023
Keywords: Cardiac arrest; Coronary angiography; Post-resuscitation care

Clinical papers

Introduction : The aim of our study was to assess the impact of coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) without ST-elevation (STE).

Méthode : Prospective observational study of adult (age ≥ 18) OHCA of presumed cardiac etiology from 1/01/2010-12/31/2014 admitted to one of 40 recognized cardiac receiving centers within a statewide resuscitation network.

Résultats : Among 11,976 cases, 1881 remained for analysis after exclusions. Of the 1230 non-STE cases, 524 (43%) underwent CAG with resultant PCI in 157 (30%). Survival in non-STE cases was: 56% in cases without CAG; 82% in cases with CAG but without PCI; and 78% in those with PCI (p < 0.0001). In cases without STE the aOR for survival with CAG alone was 2.34 (95% CI 1.69-3.24) and for CAG plus PCI was 1.98 (95% CI 1.26-3.09). The aOR for CPC 1/2 with CAG alone was 6.89 (95% CI 3.99-11.91) and for CAG plus PCI was 2.95 (95% CI 1.59-5.47). After propensity matching, CAG was associated with an aOR for survival of 2.10 (95% CI 1.30-3.55) and for CPC 1/2 it was 5.06 (95% CI 2.29-11.19).

Conclusion : In OHCA without STE, CAG was strongly and independently associated with survival regardless of whether PCI was performed. The association between CAG and positive outcomes remained after propensity matching.

Conclusion (proposition de traduction) : Parmi les arrêts cardiaques extrahospitalier sans sus-décalage du segment ST, l'angiographie coronaire était fortement et indépendamment associé à la survie, que l'intervention coronarienne percutanée ait été réalisée ou non. L'association entre le angiographie coronaire et les résultats positifs est restée après l'appariement par score de propension.

Out-of-hospital cardiac arrest survival in international airports.
Masterson S, McNally B, Cullinan J, Vellano K, Escutnaire J, Fitzpatrick D, Perkins GD, Koster RW, Nakajima Y, Pemberton K, Quinn M, Smith K, Jónsson BS, Strömsöe A, Tandan M, Vellinga A. | Resuscitation. 2018 Jun;127:58-62
DOI: https://doi.org/10.1016/j.resuscitation.2018.03.024
Keywords: International epidemiology; Out-of-hospital cardiac arrest; Resuscitation; survival

Clinical papers

Introduction : The highest achievable survival rate following out-of-hospital cardiac arrest is unknown. Data from airports serving international destinations (international airports) provide the opportunity to evaluate the success of pre-hospital resuscitation in a relatively controlled but real-life environment.

Méthode : This retrospective cohort study included all cases of out-of-hospital cardiac arrest at international airports with resuscitation attempted between January 1st, 2013 and December 31st, 2015. Crude incidence, patient, event characteristics and survival to hospital discharge/survival to 30 days (survival) were calculated. Mixed effect logistic regression analyses were performed to identify predictors of survival. Variability in survival between airports/countries was quantified using the median odds ratio.

Résultats : There were 800 cases identified, with an average of 40 per airport. Incidence was 0.024/100,000 passengers per year. Percentage survival for all patients was 32%, and 58% for patients with an initial shockable heart rhythm. In adjusted analyses, initial shockable heart rhythm was the strongest predictor of survival (odds ratio, 36.7; 95% confidence interval [CI], 15.5-87.0). In the bystander-witnessed subgroup, delivery of a defibrillation shock by a bystander was a strong predictor of survival (odds ratio 4.8; 95% CI, 3.0-7.8). Grouping of cases was significant at country level and survival varied between countries.

Conclusion : In international airports, 32% of patients survived an out-of-hospital cardiac arrest, substantially more than in the general population. Our analysis suggested similarity between airports within countries, but differences between countries. Systematic data collection and reporting are essential to ensure international airports continually maximise activities to increase survival.

Conclusion (proposition de traduction) : Dans les aéroports internationaux, 32 % des patients ont survécu à un arrêt cardiaque extrahospitalier, soit beaucoup plus que dans la population générale. Notre analyse a suggéré une similarité entre les aéroports à l'intérieur des pays, mais des différences entre les pays. La collecte systématique de données et l'établissement de rapports sont essentiels pour garantir que les aéroports internationaux maximisent continuellement les activités afin d'accroître la survie.

Bystander-witnessed cardiac arrest is associated with reported agonal breathing and leads to less frequent bystander CPR.
Brinkrolf P, Metelmann B, Scharte C, Zarbock A, Hahnenkamp K, Bohn A. | Resuscitation. 2018 Jun;127:114-118
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.017
Keywords: Agonal breathing; Bystander resuscitation; CPR; Gasping; OHCA; Out-of-hospital cardiac arrest; ROSC; Resuscitation; Return of spontaneous circulation; Witnessed arrest

Clinical papers

Introduction : Although the importance of bystander cardiopulmonary resuscitation has been shown in multiple studies, the rate of bystander cardiopulmonary resuscitation is still relatively low in many countries. Little is known on bystanders' perceptions influencing the decision to start cardiopulmonary resuscitation. Our study aims to determine such factors.

Méthode : Semi-structured telephone interviews with bystanders of out-of-hospital cardiac arrests between December 2014 and April 2016 were performed in a prospective manner. This single-center survey was conducted in the city of Münster, Germany. The bystander's sex and age, the perception of the victim's breathing and initial condition were correlated with the share of bystander cardiopulmonary resuscitation in the corresponding group.

Résultats : 101 telephone interviews were performed with 57 male and 44 female participants showing a mean age of 52.7 (SD ± 16.3). In case of apnoea 38 out of 46 bystanders (82.6%) started cardiopulmonary resuscitation; while in case of descriptions indicating agonal breathing 19 out of 35 bystanders (54.3%) started cardiopulmonary resuscitation (p = .007). If the patient was found unconscious 47 out of 63 bystanders (74.7%) performed cardiopulmonary resuscitation, while in cases of witnessed cardiac arrest 19 out of 38 bystanders (50%) attempted cardiopulmonary resuscitation (p = .012). Witnessed change of consciousness is an independent factor significantly lowering the probability of starting cardiopulmonary resuscitation (regression coefficient -1.489, p < .05).

Conclusion : The witnessed loss of consciousness was independently associated with a significant reduction in the likelihood that bystander-CPR was started. These data reinforce the importance of teaching the recognition of early cardiac arrest.

Conclusion (proposition de traduction) : La perte de conscience observée a été associée de manière indépendante à une réduction significative de la probabilité que la RCP par le témoin ait commencé. Ces données renforcent l'importance de l'enseignement de la reconnaissance de l'arrêt cardiaque précoce.

US-CAB protocol for ultrasonographic evaluation during cardiopulmonary resuscitation: Validation and potential impact.
Lien WC, Hsu SH, Chong KM, Sim SS, Wu MC, Chang WT, Fang CC, Ma MH, Chen SC, Chen WJ. | Resuscitation. 2018 Jun;127:125-131
DOI: https://doi.org/10.1016/j.resuscitation.2018.01.051
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Outcome; Ultrasound

Clinical papers

Introduction : We previously developed a US-CAB protocol for evaluation of circulatory-airway-breathing status during cardiopulmonary resuscitation (CPR). This study aimed at validating its application in real CPR scenarios and the potential impact on CPR outcomes.

Méthode : The US-CAB protocol was implemented at the emergency department of National Taiwan University Hospital since January 2016. The US images, initiation time and operation duration of each US-CAB procedure, and relevant CPR information were recorded for analysis.

Résultats : From January 2016 to March 2017, 177 cardiac arrest patients receiving US-CAB were included. The durations of US-C-A-B procedure were 9.0 ± 1.4, 7.5 ± 1.5, and 16.0 ± 1.9 s, respectively. Cardiac activity was identified in 47 cases (26.6%), with higher rates of return of spontaneous circulation (ROSC) (95.7% vs. 21.5%, p < .0001) and survival to hospital discharge (25.5% vs. 10.0%, p < .01). Detection of cardiac activity after 10 min of CPR exhibited 100% sensitivity, specificity, positive and negative predictive value for ROSC. Cardiac tamponade was noted in eight patients. ROSC was achieved in two (25.0%) after pericardiocentesis, and aortic dissection was diagnosed in one (12.5%). Confirmation of correct intubation was significantly faster by US than by capnography (7.4 ± 1.4 vs. 38.3 ± 110.2 s, p < .001). US detected 21 (11.9%) esophageal intubations and 3 (1.7%) one-lung intubations. All were promptly corrected.

Conclusion : The US-CAB protocol is feasible in real CPR scenarios. It confers diagnostic value and prognostic implications which potentially impact the efficacy and outcomes of CPR. However, a future prospective multi-center study to validate its feasibility and indicate the need of structured training is mandated.

Conclusion (proposition de traduction) : Le protocole US-CAB est réalisable dans les vrais scénarios de RCP. Il confère une valeur diagnostique et des implications pronostiques susceptibles d'avoir un impact sur l'efficacité et les résultats de la RCP. Cependant, une future étude prospective multicentrique pour valider sa faisabilité et indiquer le besoin d'une formation structurée est obligatoire.

Commentaire : Voir l'article de Lien WC and al. dans Resuscitation. 2017 Jun;115:e1-e2  . A novel US-CAB protocol for ultrasonographic evaluation during cardiopulmonary resuscitation.
Le protocole CAB :
C : vue sous-xiphoïde du cœur et de la veine cave inférieure (VCI) ;
A : échographie trachéale (position de la sonde d'intubation) ;
B : signe de glissement bilatéral du poumon (2-D et/ou M-mode).

Shock

Vasopressor Cumulative Dose Requirement and Risk of Early Death During Septic Shock: An Analysis From The EPISS Cohort.
Dargent A, Nguyen M, Fournel I, Bourredjem A, Charles PE, Quenot JP; and the EPISS study group. | Shock. 2018 Jun;49(6):625-630
DOI: https://doi.org/10.1097/SHK.0000000000001022
Keywords: Aucun

Clinical Science Aspects

Editorial : Septic shock is the primary cause of death in intensive care units, with about 20% of patients dying in the first 3 days. To design future trials focused on early mortality, we require knowledge of early indicators that can detect patients at high risk of early death from refractory septic shock. The aim of this study was to assess whether the cumulative dose of vasopressors (CDV), calculated as the cumulative dose of epinephrine + norepinephrine, is a predictor of early death (within 72 h) attributable to refractory septic shock (EDASS). This substudy of the EPISS trial was based on 370 patients admitted to a French ICU for septic shock between 2009 and 2011. The area under the receiving operating characteristic curve was calculated for the CDV at 6, 12, 24, 36, and 48 h after vasopressor initiation, and a strategy to predict the risk of EDASS was built based on selected times and thresholds. Among the 370 patients included, 51 (14%) died within the first 72 h with 40 (11%) EDASS. A strategy in two steps (CDV ≥ 800 μg/kg at 6 h and/or CDV ≥ 2,600 μg/kg at 24 h) was able to predict EDASS with sensitivity of 45%, specificity 97%, positive predictive value 78% and negative predictive value 94%. Overall, our results confirm that early death directly attributable to septic shock could be effectively predicted by the CDV in the first hours of treatment. These results will help to select patients eligible for innovative therapies aimed at improving early mortality in septic shock.

Conclusion : The CDVwithin the first 6 hours following ICU admission is strongly associated with the risk of early death attributable to septic shock. We describe a two-step model, which allows the identification of a very-high risk population in the first 24 hours following vasopressor initiation.
Our results propose an original approach to the ill-defined concept of refractory septic shock. Although our analysis is limited to the “vasopressor resistance” component, we believe that the population identified by the new strategy described here represents a first step towards a more broadly accepted definition of “refractory septic shock”.

Conclusion (proposition de traduction) : La dose cumulée de vasopresseurs dans les 6 heures suivant l’admission en soins intensifs est fortement associée au risque de décès précoce attribuable au choc septique. Nous décrivons un modèle en deux étapes, qui permet d'identifier une population à très haut risque dans les 24 heures suivant l'initiation du vasopresseur. Nos résultats proposent une approche originale du concept mal défini du choc septique réfractaire. Bien que notre analyse se limite à la composante "résistance aux vasopresseurs", nous pensons que la population identifiée par la nouvelle stratégie décrite ici représente un premier pas vers une définition plus largement acceptée du "choc septique réfractaire".

Stroke

Delays in the Air or Ground Transfer of Patients for Endovascular Thrombectomy.
Regenhardt RW, and al. | Stroke. 2018 June;49:1419-1425
DOI: https://doi.org/10.1161/STROKEAHA.118.020618  | Télécharger l'article au format  
Keywords: algorithms; telemedicine; thrombectomy; transfer; triage

Original contributions

Introduction : For suspected large vessel occlusion patients efficient transfer to centers that provide endovascular therapy (ET) is critical to maximizing treatment opportunity. Our objective was to examine associations between transfer time, modes of transfer, ET, and outcomes within a hub-and-spoke telestroke network.

Méthode : Patients with ischemic stroke were included if transferred to a single hub hospital between January 2011 and October 2015 with National Institutes of Health Stroke Scale>6, onset<12 hours from hub arrival with complete clinical, imaging, and transfer data. Transfer time was the interval between initiation of telestroke consult and arrival at the hub. Algorithms were created for ideal transfer times; ideal time was subtracted from actual time to calculate delay. We examined bivariate relationships between transfer time and several clinical outcomes and used multivariable regression modeling to explore possible predictors of delay.

Résultats : Of 234 patients that met inclusion criteria, 51% were transferred by ambulance and 49% by helicopter; 27% underwent ET (36% achieved modified Rankin Scale score of 0–2 at 90 days). Median actual transfer time was 132 minutes (interquartile range, 103–165), compared with median ideal transfer time at 102 minutes (interquartile range, 96–123). Longer transfer time was associated with decreased likelihood of undergoing ET (odds ratio, 0.990; P=0.003). Nocturnal transfer (18:00 to 06:00 hours) was associated with significantly longer delay (β=20.5; P<0.0005), whereas intravenous tissue-type plasminogen activator (tPA) delivery at spoke hospital was not. The median delay for nocturnal transfer was 31 minutes (interquartile range, 11–51), compared with daytime at 14 minutes (interquartile range, −9 to 36).

Conclusion : Within a large telestroke network, there was an association between longer transfer time and decreased likelihood of undergoing ET. Nocturnal transfers were associated with a substantial delay relative to daytime transfers. In contrast, delivery of tPA was not associated with delays, underscoring the impact of effective protocols at spoke hospitals. More efficient transfer may enable higher ET treatment rates. Metrics and protocols for transfer, especially at night, may improve transfer times.

Conclusion (proposition de traduction) : Dans un grand réseau de télé-AVC, il y avait une association entre un temps de transfert plus long et la probabilité moindre de bénéficier d'un traitement endovasculaire. Les transferts nocturnes étaient associés à un retard important par rapport aux transferts de jour. En revanche, l'administration du tPA n'a pas été associée à des retards, soulignant l'impact de protocoles efficaces dans les hôpitaux périphériques du réseau. Un transfert plus efficace peut permettre des taux plus élevés de traitement endovasculaire. Les paramètres et les protocoles de transfert, en particulier la nuit, peuvent améliorer les temps de transfert.

Commentaire : Voir le document de la HAS : Télé AVC. Prise en charge en urgence – Service des Urgences, SAMU/SMUR, Service de radiologie, UNV –  

Antiplatelet Treatment After Transient Ischemic Attack and Ischemic Stroke in Patients With Cerebral Microbleeds in 2 Large Cohorts and an Updated Systematic Review.
Kui Kai Lau, Caroline E. Lovelock, Linxin Li, Michela Simoni, Sergei Gutnikov, Wilhelm Küker, Henry Ka Fung Mak, Peter M. Rothwell. | Stroke. 2018 Jun; 49(6): 1434–1442
DOI: https://dx.doi.org/10.1161%2FSTROKEAHA.117.020104  | Télécharger l'article au format  
Keywords: cerebral small vessel disease, magnetic resonance imaging, stroke, transient ischemic attack

Original contribution

Introduction : In patients with transient ischemic attack/ischemic stroke, microbleed burden predicts intracerebral hemorrhage (ICH), and ischemic stroke, but implications for antiplatelet treatment are uncertain. Previous cohort studies have had insufficient follow-up to assess the time course of risks, have not stratified risks by antithrombotic use, and have not reported extracranial bleeds or functional outcome of ICH versus ischemic stroke.

Méthode : In 2 independent prospective cohorts with transient ischemic attack/ischemic stroke (Oxford Vascular Study/mainly white; University of Hong Kong/mainly Chinese), antiplatelet treatment was started routinely irrespective of microbleed burden. Risks, time course and outcome of ICH, extracranial bleeds, and recurrent ischemic events were determined and stratified by microbleed burden (0 versus 1, 2–4, and ≥5), adjusting for age, sex, and vascular risk factors.

Résultats : Microbleeds were more frequent in the Chinese cohort (450 of 1003 versus 165 of 1080; P<0.0001), but risk associations were similar during 7433 patient-years of follow-up. Among 1811 patients on antiplatelet drugs, risk of major extracranial bleeds was unrelated to microbleed burden (Ptrend=0.87), but the 5-year risk of ICH was steeply related (Ptrend<0.0001), with 11 of 15 (73%) of ICH in 140 of 1811 (7.7%) patients with ≥5 microbleeds. However, risk of ischemic stroke also increased with microbleed burden (Ptrend=0.013), such that risk of ischemic stroke and coronary events exceeded ICH and major extracranial bleeds during the first year, even among patients with ≥5 microbleeds (11.6% versus 3.9%). However, this ratio changed over time, with risk of hemorrhage (11.2%) matching that of ischemic events (12.0%) after 1 year. Moreover, whereas the association between microbleed burden and risk of ischemic stroke was due mainly to nondisabling events (Ptrend=0.007), the association with ICH was accounted for (Ptrend<0.0001) by disabling/fatal events (≥5 microbleeds: 82% disabling/fatal ICH versus 40% disabling/fatal ischemic stroke; P=0.035).

Conclusion : In white and Chinese patients with ≥5 microbleeds, withholding antiplatelet drugs during the first year after transient ischemic attack/ischemic stroke may be inappropriate. However, the risk of ICH may outweigh any benefit thereafter.

Conclusion (proposition de traduction) : Chez les patients blancs et chinois ayant ≥ 5 micro-saignements, l'absence de prescription d'antiagrégants plaquettaires au cours de la première année après un accident ischémique transitoire ou un accident vasculaire cérébral ischémique peut être inappropriée. Cependant, le risque de survenue d'hémorragie intracérébrale peut dépasser tout le bénéfice par la suite.

The American Journal of Emergency Medicine

Hemodynamic changes after propacetamol administration in patients with febrile UTI in the ED.
Kang S, Durey A, Suh YJ, Kim AJ. | Am J Emerg Med. 2018 Jun;36(6):935-941
DOI: https://doi.org/10.1016/j.ajem.2017.10.054
Keywords: Fever; Hemodynamics; Hypotension; Paracetamol; Propacetamol; Urinary tract infection

Original contribution

Introduction : Clinical studies have indicated that transient hypotension can occur after propacetamol administration. This study aimed to analyze the hemodynamic changes after propacetamol administration in patients visiting the ED due to febrile UTI. We also examined the incidence of propacetamol-induced hypotension and compared the clinical characteristics of patients with persistent hypotension, defined as requiring additional fluids or vasopressors, to those with transient hypotension.

Méthode : A retrospective analysis of the electronic medical records of patients who visited the ED between June 2015 and May 2016, were diagnosed with febrile UTI, and treated with propacetamol, was conducted.

Résultats : We included 195 patients in this study; of these, 87 (44.6%) showed hypotension. In all patients, significant decreases in systolic blood pressure (SBP; 135.06±20.45mmHg vs 117.70±16.41mmHg), diastolic blood pressure (DBP; 79.74±12.17mmHg vs 69.69±10.96mmHg), and heart rate (97.46±17.14mmHg vs 90.72±14.90mmHg) were observed after propacetamol administration. The basal SBP and DBP were higher in the hypotension than in the non-hypotension group (basal SBP: 144.4±22.3mmHg vs 127.6±15.3mmHg; basal DBP: 83.3±12.6mmHg vs 76.9±11.0mmHg). Patients with persistent hypotension had a lower baseline BP, which was not elevated despite fever, and a higher rate of bacteremia than those with transient hypotension.

Conclusion : Although febrile UTI patients treated with propacetamol in the ED showed hemodynamic changes, these changes did not have a large effect on their prognosis. However, in patients who showed bacteremia or a normal initial BP despite fever, the possibility of developing persistent hypotension should be considered.

Conclusion (proposition de traduction) : Bien que les patients atteints d'infections urinaires fébriles traités au paracétamol aux urgences présentaient des modifications hémodynamiques, ces changements n'ont pas eu d'effet important sur leur pronostic.
Toutefois, chez les patients qui présentaient une bactériémie ou une TA initiale normale malgré la fièvre, il faut envisager la possibilité de développer une hypotension persistante.

The value of lactate clearance in admission decisions of patients with acute exacerbation of COPD.
Durmuş U, Doğan NÖ, Pekdemir M, Yılmaz S, Yaka E, Karadaş A, Güney Pınar S. | Am J Emerg Med. 2018 Jun;36(6):972-976
DOI: https://doi.org/10.1016/j.ajem.2017.11.002
Keywords: Biomarkers (MeSH database); Chronic obstructive pulmonary disease (COPD); Emergency department (ED); Lactic acid

Original contribution

Introduction : Lactate and lactate clearance are being used as biomarkers in several critical conditions. The aim of this study was to examine the value of sixth hour lactate clearance in patients who were hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations.

Méthode : This single-center, cross-sectional study was conducted in a tertiary emergency department (ED) on patients who presented with acute exacerbation of COPD. Discharge or admission decisions were specified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and the clinician's decision. In the study, lactate clearance was defined as the percent decrease in lactate from the time of presentation to the ED to the sixth hour.

Résultats : A total of 495 patients were evaluated and 397 patients were excluded. Among included patients, 53 (54.1%) were admitted to the hospital and 45 (45.9%) were discharged. The median lactate clearance was found to be -11.8% (95% CI: -50.0 to 34.5) in the admitted group and 14.7% (95% CI: -11.3 to 42.3) in the discharged group. Between the two groups, the median difference of lactate clearance was found to be 26.5% (95% CI: 0.6 to 52.4). Multivariate logistic regression analysis revealed that the delta lactate value can determine the hospitalization need of patients (OR: 0.91, 95% CI: 0.85 to 0.97).

Conclusion : Lactate clearance can be evaluated as a useful marker in patients with COPD exacerbations. This study suggests that lactate monitoring in the ED has clinical benefits in addition to GOLD guidelines when deciding whether to discharge or hospitalize a patient.

Conclusion (proposition de traduction) : La clairance du lactate peut être évaluée comme un marqueur utile chez les patients atteints d'exacerbations de BPCO. Cette étude suggère que la surveillance du lactate aux urgences présente des avantages cliniques quand elle est associé aux recommandations « Global Initiative for Chronic Obstructive Lung Disease » (GOLD) lorsqu'il s'agit de décider s'il faut laisser sortir ou hospitaliser un patient.

Etiologies of altered mental status in patients with presumed ethanol intoxication.
Martel ML, Klein LR, Lichtenheld AJ, Kerandi AM, Driver BE, Cole JB. | Am J Emerg Med. 2018 Jun;36(6):1057-1059
DOI: https://doi.org/10.1016/j.ajem.2018.03.020
Keywords: Alcoholic intoxication; Altered level of consciousness; Emergency department; Ethanol

BRIEF REPORT

Introduction : Altered mental status is a commonly evaluated problem in the ED. Ethanol intoxication is common, and prehospital history may bias emergency physicians to suspect this as the cause of altered mental status. Quantitative ethanol measurement can rapidly confirm the diagnosis, or if negative, prompt further evaluation. Our objective was to identify the etiologies of altered mental status in ED patients initially presumed to be intoxicated with ethanol but found to have negative quantitative ethanol levels.

Méthode : This was a 5-year (2012-2016) electronic medical record review of ED patients presenting with altered mental status. Patients were included if they presented with presumed ethanol intoxication and had an initial ethanol concentration of zero. Etiologies of altered mental status were categorized into medical, traumatic, psychiatric, and drug-related causes.

Résultats : 29,322 patients presented during the study period with presumed alcohol intoxication, 1875 patients had negative ethanol levels. The etiology of altered mental status was due to illicit substances in 1337 patients (71%), psychiatric causes in 354 patients (19%), medical causes in 166 patients (9%) and trauma in 18 patients (1%). A total of 179 patients (10%) were admitted to the hospital; 19 patients (1%) to the ICU.

Conclusion : The presumptive diagnosis of ethanol intoxication in patients presenting to the ED with altered mental status was inaccurate in 5% of patients. The etiology of altered mental status was serious and required hospitalization in 10% of the cohort. Rapid assessment of quantitative ethanol levels should be performed, breathalyzers may be preferred over serum testing.

Conclusion (proposition de traduction) : Le diagnostic présumé d'intoxication éthylique chez les patients se présentant aux urgences avec un état mental altéré était inexact chez 5 % des patients.
L'étiologie de l'altération de l'état mental était grave et a nécessité une hospitalisation dans 10 % des patients de la cohorte. Une évaluation rapide du taux quantitatif d'éthanol devrait être effectuée, les éthylotests peuvent être préférés aux tests sériques.

The British Journal of Clinical Pharmacology

Trends in analgesic consumption in France over the last 10 years and comparison of patterns across Europe.
Hider-Mlynarz KP, Cavalié P1, Maison P. | Br J Clin Pharmacol. 2018 Jun;84(6):1324-1334
DOI: https://doi.org/10.1111/bcp.13564  | Télécharger l'article au format  
Keywords: Europe; France; analgesics; consumption; non-opioids; opioids

ORIGINAL ARTICLE

Introduction : The aims of the present study were to describe the consumption trends of three groups of analgesics (non-opioids, and mild and strong opioids) between 2006 and 2015 in France, and compare this pattern of use with six European countries in 2015.

Méthode : Annual drugs sales were extracted from the French national authority's consumption database, and from the IMS Multinational Integrated Data Analysis System and national databases for European countries.

Résultats : The use of mild opioids in France was found to have decreased by 53% over the past 10 years, owing to the declining use of dextropropoxyphene combinations, along with an increase in the use of non-opioids and strong opioids (from 72 to 93, and 2 to 2.8 defined daily doses/1000 inhabitants/day, respectively). Paracetamol, the most consumed analgesic, increased over this period, particularly for the adult high dose (+140%). The use of tramadol and codeine combinations also increased, by 62% and 42%, respectively. Morphine remained the most used strong opioid, although there were also large increases in the consumption of oxycodone (+613%) and fentanyl (+263% and +72% for transmucosal and transdermal forms, respectively). A comparison of the patterns of use in Europe in 2015 showed a higher consumption of mild and strong opioids in the UK. France ranked first and third place, respectively, for paracetamol and mild opioid consumption, whereas its use of strong opioids was among the lowest.

Conclusion : Paracetamol consumption is clearly highest in France, whereas its use of strong opioids is among the lowest in Europe, although its consumption of oxycodone has increased significantly. Further studies are required specifically to monitor these drugs.

Conclusion (proposition de traduction) : La consommation de paracétamol est clairement la plus élevée en France, alors que l'utilisation d'opioïdes forts y est l'une des plus faibles d'Europe, bien que sa consommation d'oxycodone ait considérablement augmenté. Des études complémentaires sont nécessaires spécifiquement pour surveiller ces médicaments.

Commentaire : Voir l'analyse de l'article sur le site Vidal : Première analyse sur 10 ans de l’évolution de l’utilisation des antalgiques en France  . Rédigé par Jean-Philippe RIVIERE.

The Journal of Emergency Medicine

Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration..
Fernando SM, Barnaby DP, Herry CL, Gallagher EJ, Shapiro NI, Seely AJE. | J Emerg Med. 2018 Jun;54(6):766-773
DOI: https://doi.org/10.1016/j.jemermed.2018.01.040
Keywords: critical care; emergency department; intensive care unit; lactate; risk-stratification; sepsis

Original Contributions

Introduction : Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration.
OBJECTIVE: Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis.

Méthode : We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded.

Résultats : Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7).

Conclusion : High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

Conclusion (proposition de traduction) : Un taux élevé de lactate aux urgences permet de prédire la détérioration ultérieure d'une septicémie dans les 72 heures, et peut être utile pour en déterminer l'évolution, mais un faible taux de lactate n'est pas efficace pour dépister les patients stables à risque de détérioration.

Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques.
Gottlieb M, Schiebout J. | J Emerg Med. 2018 Jun;54(6):849-854
DOI: https://doi.org/10.1016/j.jemermed.2018.02.011
Keywords: dislocation; elbow; reduction; relocation

Techniques and Procedures

Introduction : Elbow dislocations are one of the most common large joint dislocations and they require urgent reduction in the emergency department. Posterior dislocations are the most common type, with anterior dislocations occurring in rare cases.

Discussion : Reduction techniques include traction-countertraction, patient-assisted countertraction, the leverage approach, and the modified Stimson technique. Complications can include nerve injury, vascular injury, and compartment syndrome.

Conclusion : It is important for emergency physicians to be familiar with several different reduction techniques for elbow dislocations in case the initial reduction attempt is unsuccessful. This article reviews the current evidence for reduction of elbow dislocations and any variations on these approaches.

Conclusion (proposition de traduction) : Il est important que les médecins urgentistes connaissent plusieurs techniques de réduction des luxations du coude en cas d'échec de la première tentative de réduction. Cet article passe en revue les données actuelles sur la réduction des dislocations du coude et toutes les variations sur ces approches.

The Journal of Trauma and Acute Care Surgery

Indications and outcomes of extracorporeal life support in trauma patients.
Swol J, Brodie D, Napolitano L, Park PK, Thiagarajan R, Barbaro RP, Lorusso R, McMullan D, Cavarocchi N, Hssain AA, Rycus P, Zonies D; Extracorporeal Life Support Organization (ELSO). | J Trauma Acute Care Surg. 2018 Jun;84(6):831-837
DOI: https://doi.org/10.1097/TA.0000000000001895
Keywords: Aucun

AAST 2017 Podium Paper

Introduction : The use of extracorporeal life support (ECLS) in the trauma population remains controversial and has been reported only in small cohort studies. Recent ECLS technical advances have increased its use as an advanced critical care option in trauma. Given the degree of resource utilization, costs, and expertise required to provide ECLS support in trauma patients, we sought to perform a multi-institutional study to assess the indications and outcomes of ECLS in trauma.

Méthode : A retrospective review of adult (≥16 years) trauma patients receiving ECLS support in the Extracorporeal Life Support Organization (ELSO) registry (1989-2016) was performed. Standardized data from the contributing ELSO centers includes patient demographics, diagnoses, and ECLS technique and procedures. Additionally, baseline characteristics, precannulation and postcannulation physiologic data, complications, and outcomes were recorded. Survival was categorized both by transition off ECLS support and survival to hospital discharge.

Résultats : Two hundred seventy-nine trauma patients were identified (0.92% of 30,273 adult ECLS patients). Extracorporeal life support increased significantly in the last 5 years (173 in 2011-2016, 62%) compared with 106 in the prior 18 years. Trauma patients were predominantly male (78%), with a mean age of 34.8 ± 15.4 years (range, 16-88 years). Thoracic injury was the most common diagnosis; acute respiratory distress syndrome was the most common indication. Extracorporeal life support was venovenous for respiratory failure (89%), VA for cardiac failure (7%), and VA for ECLS-assisted cardiopulmonary resuscitation (CPR) (E-CPR) (4%). Extracorporeal life support duration was 8.8 ± 9.5 days (longest 83 days), and was longer for respiratory support (9.3 ± 9.3 days) vs. cardiac support (4.1 ± 4.5 days) and E-CPR (6.5 ± 16.8 days). Overall survival from ECLS was 70% and survival to hospital discharge was 61% in the total cohort (63% respiratory, 50% cardiac, 25% E-CPR), similar to survival rates in other ELSO registry cohorts. More than 80% of patients had a reported complication during ECLS support. The most common complication was cardiovascular (51%) followed by a bleeding complication (29%). Multiple organ failure was the most common cause of death (15.4%).

Conclusion : Data from the largest registry of critically ill trauma patients receiving ECLS support demonstrates reasonable survival. With growing experience and improved safety profile, trauma should not be considered a contraindication for ECLS. Further analysis of the ELSO registry regarding trauma-specific risk factors and ECLS-specific practices may identify best candidates and improve trauma ECLS outcomes.

Conclusion (proposition de traduction) : Les données du plus grand registre de patients en traumatologie en situation critique recevant un système d'assistance extracorporelle (ECLS) mettent en évidence une survie raisonnable.
Avec l'expérience croissante et le profil de sécurité amélioré, le traumatisme ne devrait pas être considéré comme une contre-indication à l'ECLS. Une analyse plus approfondie du registre ELSO concernant les facteurs de risque spécifiques aux traumatismes et les pratiques spécifiques à l'ECLS pourrait permettre d'identifier les meilleurs candidats et d'améliorer les résultats des ECLS en matière de traumatisme.

Commentaire : Consulter le site Internet de l'Extracorporeal Life Support Organization (ELSO) registry  .

The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures.
Christian NT, Burlew CC, Moore EE, Geddes AE, Wagenaar AE, Fox CJ, Pieracci FM. | J Trauma Acute Care Surg. 2018 Jun;84(6):924-928
DOI: https://doi.org/10.1097/TA.0000000000001838
Keywords: Aucun

original articles

Introduction : The focused abdominal sonography for trauma (FAST) examination has been reported to be unreliable in pelvic fracture patients. Additionally, given the advent of new therapeutic interventions, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), rapid identification of intra-abdominal hemorrhage compared with Zone III hemorrhage may guide different therapeutic strategies. We hypothesized that FAST is reliable for detecting clinically significant intra-abdominal hemorrhage in the face of complex pelvic fractures.

Méthode : Our pelvic fracture database of all hemodynamically unstable patients requiring intervention from January 1, 2005, to July 1, 2015, was reviewed. The FAST examination was compared with operative and computed tomography (CT) scan findings. Confirmatory evaluation for FAST(-) patients was considered positive if therapeutic intervention was required.

Résultats : During the study period, 81 patients in refractory shock with FAST imaging in our emergency department (ED) underwent pelvic packing. Mean age was 45 ± 2 years and Injury Severity Score was 50 ± 1.5. The FAST examination was negative in 53 patients; 52 patients did not require operative intervention for abdominal bleeding while one patient required splenectomy. The FAST examination was positive in 28 patients; 26 had findings confirmed by CT or laparotomy while two patients did not have intra-abdominal hemorrhage on further evaluation. The sensitivity and specificity for FAST in this population was 96% and 96%, respectively, positive predictive value was 93%, and negative predictive value was 98%. The false-negative and -positive rates for FAST were 2% and 7%.

Conclusion : Focused abdominal sonography for trauma examination reliably identifies clinically significant hemoperitoneum in life-threatening, pelvic fracture related hemorrhage. The incidence of a false-negative FAST in this unstable pelvic fracture population was 2%. FAST results may be used when determining the role of REBOA in these multisystem trauma patients and requires further study. REBOA placement should be considered in hemodynamically unstable pelvic fracture patients who are FAST(-), while laparotomy should be used in FAST(+) patients.

Conclusion (proposition de traduction) : Une échographie abdominale ciblée pour un examen traumatique identifie de manière fiable un hémopéritoine cliniquement significatif dans une hémorragie liée à une fracture pelvienne menaçant le pronostic vital. L'incidence d'une écho FAST faussement négative dans cette population instable de fractures pelviennes était de 2 %.
Les résultats de la FAST écho peuvent être utilisés pour déterminer la place du clampage aortique par sonde d'occlusion aortique endovasculaire (resuscitative endovascular balloon occlusion of the aorta [REBOA]) chez ces patients traumatisés multisystémiques et nécessitent un complément d'étude. Un clampage aortique par sonde d'occlusion aortique endovasculaire ( resuscitative endovascular balloon occlusion of the aorta [REBOA]) doit être envisagée chez les patients présentant une fracture pelvienne instable sur le plan hémodynamique et qui sont FAST (-), alors que la laparotomie doit être utilisée chez les patients FAST (+).

World Journal of Emergency Medicine

Sub-dissociative dose ketamine administration for managing pain in the emergency department.
Motov S, Drapkin J, Likourezos A, Doros J, Monfort R, Marshall J. | World J Emerg Med. 2018 Jun;9(4):249-255
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2018.04.002  | Télécharger l'article au format  
Keywords: Analgesia; Emergency department; Infusion; Ketamine; Sub-dissociative

Original Articles

Introduction : We describe our experience of utilizing sub-dissociative dose ketamine (SDK) in managing a variety of acute and chronic painful conditions in the emergency department (ED).

Méthode : A descriptive study was conducted in our ED over a period of seven years (2010-2016) by retrospectively reviewing charts of patients aged 18 and older presenting to the ED with painful complaints and receiving SDK analgesia. Primary data analyses included type of SDK administration (intravenous push [IVP], short-infusion [SI] or continuous infusion [CI]), dosing, rates of analgesic utilization before and after SDK administration, and adverse effects.

Résultats : Three hundred sixty-two patients were enrolled in the study. Mean ketamine doses given by IVP, SI and CI were 26.3 mg, 23.4 mg, and 11.3 mg. The mean duration of CI was 135.87 minutes. The percentage of patients not requiring post-SDK analgesia increased by 16%, 18%, and 37% in IVP, SI and CI groups. Adverse effects were recorded for 13% of patients.

Conclusion : SDK administered by IVP, SI, and CI in the ED for a variety of painful conditions is a feasible analgesic modality in the ED that is associated with a decrease in overall requirements of post-ketamine analgesia and opioid sparing.

Conclusion (proposition de traduction) : Une dose sous-dissociative de kétamine administrée par injection intraveineuse, une perfusion courte et une perfusion continue au service des urgences pour diverses affections douloureuses est une modalité analgésique réalisable au service des urgences associée à une diminution des besoins généraux en analgésie post-kétamine et épargnant les opioïdes.

Effect of sedative agent selection on morbidity, mortality and length of stay in patients with increase in intracranial pressure.
Cornelius BG, Webb E, Cornelius A, Smith KWG, Ristic S, Jain J, Cvek U, Trutschl M. | World J Emerg Med. 2018;9(4):256-261
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2018.04.003  | Télécharger l'article au format  
Keywords: Craniocerebral trauma; Head injury; Intracranial hypertension; Intubation; Ketamine

Original articles

Introduction : To identify the effects of sedative agent selection on morbidity, mortality, and length of stay in patients with suspected increase in intracranial pressure. Recent trends and developments have resulted in changes to medications that were previously utilized as pharmacological adjuncts in the sedation and intubation of patients with suspected increases in intracranial pressure. Medications that were previously considered contraindicated are now being used with increasing regularity without demonstrated safety and effectiveness. The primary objective of this study is to evaluate and compare the use of Ketamine as an induction agent for patients with increased intracranial pressure. The secondary objective was to evaluate and compare the use of Etomidate, Midazolam, and Ketamine in patients with increased intracranial pressure.

Méthode : We conducted a retrospective chart review of patients transported to our facility with evidence of intracranial hypertension that were intubated before trauma center arrival. Patients were identified during a 22-month period from January 2014 to October 2015. Goals were to evaluate the impact of sedative agent selection on morbidity, mortality, and length of stay.

Résultats : During the review 148 patients were identified as meeting inclusion criteria, 52 were excluded due to incomplete data. Of those the patients primarily received; Etomidate, Ketamine, and Midazolam. Patients in the Ketamine group were found to have a lower mortality rate after injury stratification.

Conclusion : Patients with intracranial hypertension should not be excluded from receiving Ketamine during intubation out of concern for worsening outcomes.

Conclusion (proposition de traduction) : la kétamine ne doit pas être évitée chez les patients présentant une hypertension intracrânienne lors de l’intubation, par souci de mauvais résultats.


Mois de juin 2018