Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta-analysis.
Baron BJ, Benabbas R, Kohler C, Biggs C, Roudnitsky V, Paladino L, Sinert R. | Acad Emerg Med. 2018 jul;25(7):758-68
DOI: https://doi.org/10.1111/acem.13380
Keywords: Aucun

EVIDENCE‐BASED DIAGNOSTICS

Introduction : Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined. OBJECTIVES: Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined.
The objective was to evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient?

Méthode : We searched PubMed, Embase, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and inpatient observation in those who were managed nonoperatively. In those who underwent LAP, THER-LAP was considered as disease positive. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and assess the applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model.

Résultats : Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% confidence interval [CI] = 30.5%-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity = 50% to 100%, specificity = 39% to 97%, LR+ = 1.0 to 15.7, and LR- = 0.07 to 1.0. The high heterogeneity (I2 > 75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated.

Discussion : The articles revealed a high prevalence (8.7%, 95% CI = 6.1%-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI = 30%-64%) of those injuries involved the small bowel.

Conclusion : In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.

Conclusion (proposition de traduction) : Chez les patients présentant une plaie abdominale antérieure stable, une tomodensitométrie négative sans période d'observation ne suffit pas à exclure des lésions intra-abdominales importantes.

Costal Margin Tenderness and the Risk for Intraabdominal Injuries in Children With Blunt Abdominal Trauma.
Flynn-O'Brien KT, Kuppermann N, Holmes JF. | Acad Emerg Med. 2018 juil;25(7):776-84
DOI: https://doi.org/10.1111/acem.13426
Keywords: Aucun

ORIGINAL CONTRIBUTIONS

Introduction : The risk of radiation exposure from computed tomography (CT) imaging in children is well recognized. Patient history and physical examination findings, including costal margin tenderness (CMT), influence a physician's decision to image a child with blunt torso trauma. The objective of this study was to determine the importance of CMT for identifying children with intraabdominal injuries (IAI) found on CT and IAI undergoing acute intervention.

Méthode : We conducted an analysis of the Pediatric Emergency Care Applied Research Network (PECARN) IAI public use data set, representing a large prospective multicenter cohort study from May 2007 to January 2010. Isolated CMT was defined as CMT without other identified PECARN risk factors for IAI (i.e., abdominal or thoracic wall trauma, abdominal tenderness or pain, decreased breath sounds, or vomiting). Logistic regression was used to calculate adjusted odds of IAI in children presenting with isolated and nonisolated CMT. Risk differences were calculated to estimate the risk of IAI independently attributable to CMT in the setting of isolated PECARN risk factors. Finally, CT use among exposure groups was estimated to quantify potentially avoidable imaging.

Résultats : Among 9,174 children with Glasgow Coma Scale scores of 14 or 15 who sustained blunt torso trauma, 1,267 (13.8%) had CMT. Among those with CMT, 177 (14.0%) had isolated CMT and 1,090 (86.0%) had nonisolated CMT. No children (0/177; 0%, 95% confidence interval [CI] = 0.0%-2.1%) with isolated CMT had IAI, compared to 17.2% (187/1,090; 95% CI = 15.0%-19.5%) of those with nonisolated CMT. The risk differences were not statistically significant. 36/177 (20.3%; 95% CI = 14.7%-27.0%) children with isolated CMT underwent abdominal CT scans.

Conclusion : The risk of IAI associated with isolated CMT is minimal. For children with blunt abdominal trauma and isolated CMT, abdominal CT scan is of low yield.

Conclusion (proposition de traduction) : Le risque de lésions intra-abdominales associées à une sensibilité basithoracique à la palpation est minime. Pour les enfants présentant des traumatismes abdominaux contondants et une Sensibilité basithoracique isolée à la palpation, la tomodensitométrie abdominale est de faible rendement.

Prognostic Utility of Initial Lactate in Patients With Acute Drug Overdose: A Validation Cohort.
Cheung R, Hoffman RS, Vlahov D, Manini AF. | Ann Emerg Med. 2018 Jul;72(1):16-23
DOI: https://doi.org/10.1016/j.annemergmed.2018.02.022
Keywords: Aucun

Toxicology

Introduction : Previous studies have suggested that the initial emergency department (ED) lactate concentration may be an important prognostic indicator for inhospital mortality from acute drug poisoning. We conduct this cohort study to formally validate the prognostic utility of the initial lactate concentration in a larger, distinct patient population with acute drug overdose.

Méthode : This observational, prospective, cohort study was conducted during 5 years at 2 urban teaching hospitals. Consecutive adult ED patients with acute drug overdose had serum lactate levels tested as part of clinical care. The primary outcome was inpatient fatality. Receiver operating characteristics were plotted to determine optimal cut points, test characteristics, area under the curve, odds ratios, and 95% confidence intervals (CIs).

Résultats : Of 3,739 patients screened, 1,406 were analyzed (56% women; mean age 43.1 years) and 24 died (1.7%). The difference in mean initial lactate concentration was 5.9 mmol/L (95% CI 3.4 to 8.1 mmol/L) higher in patients who died compared with survivors. The area under the curve for prediction of fatality was 0.85 (95% CI 0.73 to 0.95). The optimal lactate cut point for fatality was greater than or equal to 5.0 (odds ratio 34.2; 95% CI 13.7 to 84.2; 94.7% specificity). Drug classes for which lactate had the highest utility were salicylates, sympathomimetics, acetaminophen, and opioids (all area under the curve ≥0.97); lowest utility was for diuretics and angiotensin-converting enzyme inhibitors.

Conclusion : Initial lactate concentration is a useful biomarker for early clinical decisionmaking in ED patients with acute drug overdose. Studies of lactate-tailored management for these patient populations are warranted.

Conclusion (proposition de traduction) : La concentration initiale de lactate est un biomarqueur utile pour la prise de décision clinique précoce chez les patients des services d'urgence qui présentent une overdose aiguë de médicament. Des études sur la prise en charge adaptée au lactate pour ces populations de patients sont justifiées.

Is Procalcitonin Useful in the Diagnosis and Treatment of Acute Respiratory Infections in the Emergency Department?.
Tupchong K, Chien C. | Ann Emerg Med. 2018 Jul;72(1):57-58
DOI: https://doi.org/10.1016/j.annemergmed.2018.01.040  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Méthode : The authors searched the Cochrane Library, MEDLINE Ovid, and EMBASE.com from inception to February 10, 2017, and ClinicalTrials.gov for ongoing and completed trials on April 12, 2017. Experts were contacted for other eligible trials. There were no language or publication restrictions. Prospective randomized controlled trials comparing procalcitonin use with a control group for the initiation or discontinuation of antibiotics in adult patients with acute respiratory infections in primary care settings, EDs, and medical and surgical ICUs were included.

Résultats : A total of 32 randomized controlled trials (9,909 patients) met inclusion criteria. However, individual partici- pant data were available from only 26 trials (6,708 patients), which were used in the individual partici- pant data meta-analysis displayed in the Table. A sensitivity aggregate analysis was performed on all 32 trials, and in this analysis, mortality was not significantly different in the procalcitonin group compared with the control group.

Conclusion : A procalcitonin-guided approach to the initiation and discontinuation of antibiotics in acute respiratory infections has the potential to reduce antibiotic-related adverse effects and duration of therapy, but further study of emergency department (ED) patients is needed

Conclusion (proposition de traduction) : Une approche guidée par le taux de procalcitonine pour l'initiation et l'arrêt des antibiotiques dans les infections respiratoires aiguës a le potentiel de réduire les effets indésirables liés aux antibiotiques et la durée du traitement, mais une étude plus poussée des patients des services d'urgence est nécessaire.

Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes.
Vinson DR, Ballard DW, Huang J, Reed ME, Lin JS, Kene MV, Sax DR, Rauchwerger AS, Wang DH, McLachlan DI, Pleshakov TS, Silver MA, Clague VA, Klonecke AS, Mark DG; MAPLE Investigators of the KP CREST Network. | Ann Emerg Med. 2018 Jul;72(1):62-72.e3
DOI: https://doi.org/10.1016/j.annemergmed.2017.10.022  | Télécharger l'article au format  
Keywords: Aucun

Pulmonary

Introduction : Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge.

Méthode : The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism-related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.

Résultats : Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism-related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%).

Conclusion : Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes.

Conclusion (proposition de traduction) : Le retour à domicile des patients des services d'urgence présentant une embolie pulmonaire aiguë était rare et variait considérablement d'un établissement à l'autre. Les patients sélectionnés pour la prise en charge ambulatoire présentaient une faible incidence d'effets indésirables.

High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial.
Doshi P, Whittle JS, Bublewicz M, Kearney J, Ashe T, Graham R, Salazar S, Ellis TW Jr, Maynard D, Dennis R, Tillotson A, Hill M, Granado M, Gordon N, Dunlap C, Spivey S, Miller TL. | Ann Emerg Med. 2018 Jul;72(1):73-83.e5
DOI: https://doi.org/10.1016/j.annemergmed.2017.12.006
Keywords: Aucun

Pulmonary

Introduction : We compare high-velocity nasal insufflation, a form of high-flow nasal cannula, with noninvasive positive-pressure ventilation in the treatment of undifferentiated respiratory failure with respect to therapy failure, as indicated by requirement for endotracheal intubation or cross over to the alternative therapy.

Méthode : This was a multicenter, randomized trial of adults presenting to the emergency department (ED) with respiratory failure requiring noninvasive positive-pressure ventilation. Patients were randomly assigned to high-velocity nasal insufflation (initial flow 35 L/min; temperature 35°C (95°F) to 37°C (98.6°F); FiO2 1.0) or noninvasive positive-pressure ventilation using an oronasal mask (inspiratory positive airway pressure 10 cm H2O; expiratory positive airway pressure 5 cm H2O). The primary outcome was therapy failure at 72 hours after enrollment. A subjective outcome of crossover was allowed as a risk mitigation to support deferment of informed consent. Noninferiority margins were set at 15 and 20 percentage points, respectively.

Résultats : A total of 204 patients were enrolled and included in the analysis, randomized to high-velocity nasal insufflation (104) and noninvasive positive-pressure ventilation (100). The intubation rate (high-velocity nasal insufflation=7%; noninvasive positive-pressure ventilation=13%; risk difference=-6%; 95% confidence interval -14% to 2%) and any failure of the assigned arm (high-velocity nasal insufflation=26%; noninvasive positive-pressure ventilation=17%; risk difference 9%; confidence interval -2% to 20%) at 72 hours met noninferiority. The effect on PCO2 over time was similar in the entire study population and in patients with baseline hypercapnia. Vital signs and blood gas analyses improved similarly over time. The primary limitation was the technical inability to blind the clinical team.

Conclusion : High-velocity nasal insufflation is noninferior to noninvasive positive-pressure ventilation for the treatment of undifferentiated respiratory failure in adult patients presenting to the ED.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit (type Optiflow™) est non inférieure à la ventilation non invasive (VNI) pour le traitement de l'insuffisance respiratoire indifférenciée chez les patients adultes se présentant aux urgences.

What Is the Utility of Noninvasive Ventilation in the Management of Acute Hypercapnic Respiratory Failure Associated With Chronic Obstructive Pulmonary Disease?.
Long B, April MD. | Ann Emerg Med. 2018 Jul;72(1):84-85
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.016  | Télécharger l'article au format  
Keywords: Aucun

Pulmonary

Introduction : Investigators identified trials from the Cochrane Airways Trials Register and evaluated reference lists of included randomized controlled trials for additional studies.

Méthode : Studies chosen were randomized controlled trials of noninvasive ventilation (inspiratory and expiratory support) to usual care in adult patients admitted to the hospital with acute exacerbations of chronic obstructive pulmonary disease causing acute hypercapnic respiratory failure, defined as arterial pH less than 7.35 and mean PaCO2 greater than 45 mm Hg.

Résultats : Authors included 17 randomized controlled trials comprising 1,264 patients from 697 citations retrieved from their initial litera- ture search. Mean age of included patients was 66.8 years, and 65% of patients were men. Noninvasive ventilation decreased mortality, decreased need for intubation, and decreased length of hospital stay (Table). The number needed to treat for an additional beneficial outcome was 12 (95% confidence interval 9 to 23) for mortality benefit and 5 (95% confidence in- terval 5 to 6) for intubation.
Duration of noninvasive ventila- tion was highly variable across included studies. Risk of bias because of selection procedures was low for 8 studies, adequate participant blinding occurred in 3 studies, 4 studies had low risk of bias for complete outcome data, and 8 studies demonstrated low risk of bias for selective reporting. Heterogeneity was low for mortal- ity benefit and need for intubation.

Conclusion : In patients with acute respiratory failure from chronic obstructive pulmonary disease exacerbation, noninvasive ventilation reduces death and intubation compared with standard treatments.

Conclusion (proposition de traduction) : Chez les patients atteints d'insuffisance respiratoire aiguë due à l'exacerbation d'une maladie pulmonaire obstructive chronique, la ventilation non invasive réduit la mortalité et l'intubation par rapport aux traitements standard.

Update: Is Needle Aspiration Better Than Chest Tube Placement for the Management of Primary Spontaneous Pneumothorax?.
Tupchong K | Ann Emerg Med. 2018 Jul;72(1):e1-e2
DOI: https://doi.org/10.1016/j.annemergmed.2018.02.025  | Télécharger l'article au format  
Keywords: Aucun

Pulmonary

Introduction : The authors searched the Cochrane Library, MEDLINE (1966 to January 2017), EMBASE (1980 to January 2017), the World Health Organization International Clinical Trials Registry, and ClinicalTrials. gov for ongoing and unpublished trials (January 2017). Reference lists of included trials were checked and trial authors were contacted for additional sources. There were no language or publication restrictions.

Méthode : Randomized controlled trials of adults aged 18 years and older comparing simple (needle) aspiration versus intercostal tube drainage (chest tube placement) for the management of primary spontaneous pneumothorax were included.
Individual participant data were requested for each trial. Two review authors independently evaluated trials for eligibility and evaluated them for risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. A random-effects model was used to analyze outcomes as continuous or dichotomous. Quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach. Heterogeneity was reported with. A sensitivity analysis was conducted excluding studies at high risk of selection bias.

Résultats : A total of 6 randomized controlled trials (435 patients) met inclusion criteria. Chest tube (12 to 20 French) placement had a higher immediate success rate but a longer hospital length of stay. There was no difference in 1-year success rate, hospitalization rate, or patient satisfaction. Needle aspiration had fewer adverse events. Meta-analyses were con- ducted only for immediate success rate and hospital length of stay (Table) because there was low or very low quality of evidence for all other outcomes.
A sensitivity analysis was per- formed for hospitalization rate because of substantial heteroge- neity (I21⁄40.91) and revealed that the variability was likely due to mandatory hospital admission af- ter chest tube placement at 3 of the enrolling centers.

Conclusion : Chest tube placement is successful more often than needle aspiration in the treatment of primary spontaneous pneumothorax, yet is associated with longer hospital length of stay and potentially more adverse events. Therefore, both needle aspiration and chest tube placement are reasonable first-line options, depending on individual patient preferences and circumstances.

Conclusion (proposition de traduction) : La mise en place du drain thoracique réussit plus souvent que l'exsufflation à l'aiguille dans le traitement du pneumothorax spontané primaire, mais il est associé à une durée d'hospitalisation plus longue et potentiellement à plus d'événements indésirables.
Par conséquent, l'exsufflation à l'aiguille et le placement du tube thoracique sont des options de première ligne raisonnables, selon les préférences et les circonstances de chaque patient.

A Punctureless and Secure Method of Chest Tube Fixation.
Yang MX, Ault MJ. | Ann Emerg Med. 2018 Jul;72(1):106-107
DOI: https://doi.org/10.1016/j.annemergmed.2018.02.019  | Télécharger l'article au format  
Keywords: Aucun

Correspondence

Introduction : Small chest tubes and pigtail catheters are frequently placed at our institution for pleural drainage of pneumothorax and pleural effusions. After placement of a chest tube, secure fixation of the device is paramount to prevent dislodgment and patient discomfort. Traditionally, the chest tube has been anchored with suture, wound around the chest tube in a figure eight fashion, and sutured to the adjacent skin of the patient. This has been the standard of practice for many years. Other methods such as the “Roman sandal”1 or a modified mattress suture2 have been developed and tried, but either with multiple skin punctures or limited success.1,3 Most of the small chest tubes and pigtail catheters come bundled in a kit for the convenience of the operator. Other than a 3-0 or 2-0 silk suture, no additional anchoring materials are generally included in this packaging. In our practice setting, using this standard technique, we have been plagued with dislodgement of the catheters. Skin irritation becomes an issue with aggressive suturing techniques. Ultimately, we began securing the catheters by using an alternative method with materials readily available and not requiring any skin puncture.

Conclusion : The principal material is a STATLOCK Foley 2-way catheter stabilization device (BARD FOL0102; Bard Access Systems, Inc, Salt Lake City, UT), which is readily available throughout the medical center. Once the chest tube is placed, the stabilization device with a V cut into it is placed at the entry site. The catheter is placed through the anchoring clip, which is then closed securely. Given the different catheter sizes and the size of the anchoring clip, the catheter may be loose inside the clip. To prevent any slippage, however, the silk suture included in the chest tube kit is then used to tie the catheter to the stabilization device. This securely fastens the catheter to the stabilization device. No skin puncture is needed because the stabilization device is secured against the patient’s skin. Since implementing this technique for 130 placements during the past 563 days, we have had only 2 dislodgements. Although there are no baseline data available for the preimplementation period, anecdotally this has been a significant improvement. Additionally, because no sutures are placed in the patient, there is no skin irritation from suturing, and removal of the catheter is very easy, without the need for an instrument kit. The device itself is latex free and can accommodate catheters as large as 26 French (our most commonly placed catheters are 12 to 16 French). Additionally, the device is readily available at most medical centers and will not require additional inventory or incur additional cost of acquisition. Most important, our anecdotal experience is that patients genuinely appreciate this method of securing the chest tubes because no sutures are required.

Conclusion (proposition de traduction) : Une fois que le drain thoracique mis en place, le dispositif de stabilisation avec une forme en V est placé au niveau du point de ponction. Le cathéter est placé à travers du clip d'ancrage, qui est ensuite fermé en toute sécurité. Compte tenu des différentes tailles de cathéter et de la taille de l'agrafe d'ancrage, le cathéter peut être lâche à l'intérieur de l'agrafe. Pour éviter tout glissement, cependant, l'utilisation d'un fil de suture en soie incluse dans le kit de drain thoracique est ensuite utilisée pour fixer le cathéter au dispositif de stabilisation. Le cathéter est ainsi solidement fixé au dispositif de stabilisation.
Aucune ponction cutanée n'est nécessaire car le dispositif de stabilisation est fixé contre la peau du patient.

Cut and rip and cut alone techniques versus usual practice in the removal of trauma patient clothing.
Sibley AK, Jain TN, Nicholson B, Atkinson P. | CJEM. 2018 Jul;20(4):600-605
DOI: https://doi.org/10.1017/cem.2017.346  | Télécharger l'article au format  
Keywords: emergency medical services; injury; trauma

Original Research

Introduction : Rapid exposure of a trauma patient is an essential component of the primary survey. No gold standard exists regarding the best technique to remove clothing from a trauma patient. The purpose of this study is to compare two techniques of clothing removal versus usual practice using standard trauma shears.

Méthode : Advanced Care Paramedic (ACP) students were randomized to either the Cut and Rip (CAR) or Cut Alone (CAL) techniques to remove clothing from a standardized trauma mannequin. Practicing paramedics were recruited to remove clothing from the mannequin using Usual Practice (UP). Total time and time for removal of individual pieces of clothing was recorded.

Résultats : Twenty-four participants (8 per group) were recruited to participate. The student groups (CAR, CAL) were similar in mean age (29, 27), years of practice (1 student >5 years) and male gender (63, 43%). The UP group was older (mean 34), more experienced (63% practice >5 years), and had a higher level of training (63% ACP) but a similar percentage of males (63%). Removal time was significantly less in the CAR group compared to the CAL group (mean 104 seconds, 95% CI 88-120 vs. mean 136 seconds, 95% CI 119-154, p=0.02). Removal times in the UP group were not significantly different from the other groups (mean 124 seconds, 95% CI 108-140, p>0.05).

Conclusion : The CAR technique is faster than both CAL and UP groups to remove clothing from a standard trauma mannequin.

Conclusion (proposition de traduction) : La technique « couper et de déchirer » est plus rapide que les groupes « couper seulement raquo; et « pratique habituelle » pour retirer les vêtements d'un mannequin de traumatologie standard.

Definitions and pathophysiology of vasoplegic shock.
Lambden S, Creagh-Brown BC, Hunt J, Summers C, Forni LG. | Crit Care. 2018 Jul 6;22(1):174.
DOI: https://doi.org/10.1186/s13054-018-2102-1  | Télécharger l'article au format  
Keywords: Shock; Vasoplegia

Review

Editorial : Vasoplegia is the syndrome of pathological low systemic vascular resistance, the dominant clinical feature of which is reduced blood pressure in the presence of a normal or raised cardiac output. The vasoplegic syndrome is encountered in many clinical scenarios, including septic shock, post-cardiac bypass and after surgery, burns and trauma, but despite this, uniform clinical definitions are lacking, which renders translational research in this area challenging. We discuss the role of vasoplegia in these contexts and the criteria that are used to describe it are discussed. Intrinsic processes which may drive vasoplegia, such as nitric oxide, prostanoids, endothelin-1, hydrogen sulphide and reactive oxygen species production, are reviewed and potential for therapeutic intervention explored. Extrinsic drivers, including those mediated by glucocorticoid, catecholamine and vasopressin responsiveness of the blood vessels, are also discussed.

Conclusion : The optimum balance between maintaining adequate systemic vascular resistance against the potentially deleterious effects of treatment with catecholamines is as yet unclear, but development of novel vasoactive agents may facilitate greater understanding of the role of the differing pathways in the development of vasoplegia. In turn, this may provide insights into the best way to care for patients with this common, multifactorial condition.

Conclusion (proposition de traduction) : L'équilibre optimal entre le maintien des résistances vasculaires systémiques adéquates et les effets potentiellement délétères du traitement par les catécholamines n'est pas encore clair, mais le développement de nouveaux agents vasoactifs peut faciliter une meilleure compréhension du rôle des différentes voies dans le développement de la vasoplégie. En retour, cela peut fournir des indications sur la meilleure façon de soigner les patients atteints de cette affection multifactorielle commune.

Clinical Outcomes and Mortality Impact of Hyperbaric Oxygen Therapy in Patients With Carbon Monoxide Poisoning.
Rose JJ, Nouraie M, Gauthier MC, Pizon AF, Saul MI, Donahoe MP, Gladwin MT. | Crit Care Med. 2018 Jul;46(7):e649-e655
DOI: https://doi.org/10.1097/CCM.0000000000003135  | Télécharger l'article au format  
Keywords: Aucun

Online Clinical Investigations

Introduction : Carbon monoxide poisoning affects 50,000 per year in the United States alone. Mortality is approximately 3%, and up to 40% of survivors suffer from permanent neurocognitive and affective deficits. Hyperbaric oxygen therapy has shown benefit on reducing the long-term neurologic sequelae of carbon monoxide poisoning but has not demonstrated improved survival. The objective of this study is to assess the efficacy of hyperbaric oxygen for acute and long-term mortality in carbon monoxide poisoning using a large clinical databank.

Méthode :  DESIGN : Retrospective analysis.
SETTING : University of Pittsburgh Medical Center healthcare system (Pittsburgh, PA).
PATIENTS : One-thousand ninety-nine unique encounters of adult patients with carbon monoxide poisoning.
titre_en_plus: None.

Résultats : Baseline demographics, laboratory values, hospital charge transactions, discharge disposition, and clinical information from charting were obtained from the electronic medical record. In propensity-adjusted analysis, hyperbaric oxygen therapy was associated with a reduction in inpatient mortality (absolute risk reduction, 2.1% [3.7-0.9%]; p = 0.001) and a reduction in 1-year mortality (absolute risk reduction, 2.1% [3.8-0.4%]; p = 0.013).

Conclusion : These data demonstrate that hyperbaric oxygen is associated with reduced acute and reduced 1-year mortality. Further studies are needed on the mortality effects of hyperbaric oxygen therapy in carbon monoxide poisoning.

Conclusion (proposition de traduction) : Ces données montrent que l'oxygène hyperbare est associé à une mortalité aiguë, et à un an, réduite. D'autres études sont nécessaires sur les effets sur la mortalité de l'oxygénothérapie hyperbare dans l'intoxication au monoxyde de carbone.

Lidocaine-Midazolam-Fentanyl Combination in Controlling Pain for Reduction of Anterior Shoulder Dislocation; a Randomized Clinical Trial.
Arhami Dolatabadi A, Mohammadian A, Kariman H. | Emergency. 2018;6(1):e24
DOI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036533/  | Télécharger l'article au format  
Keywords: Conscious Sedation, Midazolam, Fentanyl, Lidocaine, Combined Modality Therapy

Original Research

Introduction : Finding a fast-acting compound with minimal side-effects to induce a safe and efficient analgesia with short or medium duration of action is of great interest in the emergency department. The present study has been designed with the aim of comparing the effect of midazolam + fentanyl + lidocaine combination with midazolam + fentanyl + placebo in pain management of anterior shoulder dislocation reduction.

Méthode : The present two-arm parallel double-blind randomized controlled trial was performed on patients who presented to emergency department with anterior shoulder dislocation. Patients were randomly allocated to the 2 treatment groups of midazolam + fentanyl + placebo (double-drug group) and midazolam + fentanyl + intravenous (IV) lidocaine (triple-drug group). Then outcomes such as treatment success rate and side-effects following prescription of drugs were compared between the 2 groups.

Résultats : 100 patients were included in the present study (50 patients in each group; mean age of the studied patients 27.3±8.9 years; 93.0% male). Using the double-drug regimen led to 35 (70%) cases of complete analgesia, while this rate in the triple-drug group was 41 (82%) cases (p=0.16). The calculated number needed to treat was 9 cases. This means that about one in every 9 patients in treatment arm will benefit from the treatment. The most important side-effects observed included dysrhythmia (1 patient in double drug and 1 patient in triple-drug group), apnea (2 patients in each group) and SPO2<90% (2 patients in triple-drug group) (p=0.78). Number needed to harm was 25 cases. In other words, for each 25 patients treated with the triple drug regimen, 1 case of SPO2<90% is observed.

Conclusion : Findings of the present study showed that adding IV lidocaine to IV midazolam + fentanyl drug combination does not provide additional analgesia in sedation for anterior shoulder reduction.

Conclusion (proposition de traduction) : Les résultats de la présente étude ont montré que l'ajout de lidocaïne IV à l'association midazolam + fentanyl n'apporte pas d'analgésie supplémentaire dans la sédation pour la réduction de l'épaule antérieure.

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events.
Reaney PDW, Elliott HI, Noman A, Cooper JG. | Emerg Med J. 2018 Jul;35(7):420-427
DOI: https://doi.org/10.1136/emermed-2017-207172
Keywords: acute coronary syndrome; acute myocardial infarct; cardiac care, diagnosis; emergency department; risk management

Original article

Introduction : The majority of patients presenting to the ED with cardiac sounding chest pain have a non-diagnostic ECG and the problem of differentiating those suffering an acute coronary syndrome from those without is familiar to all ED clinical staff. To stratify risk in these patients, specific scores have been developed. Recent work has focused on incorporating newer high-sensitivity cardiac troponin (hs-cTn) assays; however, issues regarding performance and availability of these assays remain.
/AIM: Prospectively compare HEART, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores, using a single contemporary cTn at admission, to predict a major adverse cardiac event (MACE) at 30 days.

Méthode : Prospective observational cohort study performed in a UK tertiary hospital in patients with suspected cardiac chest pain and no significant ST elevation on initial ECG. Data collection took place 2 December 2014 to 8 February 2016. The treating clinician recorded risk score data real time and a single contemporary cTn taken at presentation was used in score calculation. The primary endpoint was 30-day MACE. C-statistic was determined for each score and diagnostic characteristics of high-risk and low-risk cut-offs were calculated.

Résultats : 189/1000 patients in the study developed a 30-day MACE. The c-statistic of HEART for 30-day MACE (0.87 (95% CI 0.84 to 0.90)) was higher than TIMI (0.78 (95% CI 0.74 to 0.81)) and GRACE (0.74 (95% CI 0.70 to 0.78)).HEART score ≤3 identified low-risk patients with sensitivity 99.5% (95% CI 97.1% to 99.9%) and negative predictive value (NPV) 99.6% (95% CI 97.3% to 99.9%) exceeding TIMI 0 (sensitivity 97.4% (95% CI 93.9% to 99.1%) and NPV 97.8% (95% CI 94.8% to 99.1%)) and GRACE score 0-55 (sensitivity 95.2% (95% CI 91.1% to 97.8%) and NPV 95.8% (95% CI 92.2% to 97.7%)).

Conclusion : HEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.

Conclusion (proposition de traduction) : Le score HEART a surclassé à la fois TIMI et GRACE en ce qui a trait à la capacité discriminatoire globale pour prédire la survenue d'un événement cardiaque indésirable majeur (MACE) à 30 jours. En utilisant un seul dosage de troponine à l'entrée, le score HEART inférieur ou égal à 3 a démontré une sensibilité et une VPN supérieure à 95 % pour prédire la survenue d'un événement cardiaque indésirable majeur (MACE) à 30 jours.
Ces résultats atteignent le seuil d'une stratégie de rejet sécuritaire, mais devraient être interprétés de façon réfléchie à la lumière d'autres travaux.

End-tidal carbon dioxide output in manual cardiopulmonary resuscitation versus active compression-decompression device during prehospital quality controlled resuscitation: a case series study.
Setälä PA, Virkkunen IT, Kämäräinen AJ, Huhtala HSA, Virta JS, Yli-Hankala AM, Hoppu SE. | Emerg Med J. 2018 Jul;35(7):428-432
DOI: https://doi.org/10.1136/emermed-2017-207103
Keywords: cardiac arrest; prehospital care

Original article

Introduction : Active compression-decompression (ACD) devices have enhanced end-tidal carbon dioxide (ETCO2) output in experimental cardiopulmonary resuscitation (CPR) studies. However, the results in out-of-hospital cardiac arrest (OHCA) patients have shown inconsistent outcomes, and earlier studies lacked quality control of CPR attempts. We compared manual CPR with ACD-CPR by measuring ETCO2 output using an audiovisual feedback defibrillator to ensure continuous high quality resuscitation attempts.

Méthode : 10 witnessed OHCAs were resuscitated, rotating a 2 min cycle with manual CPR and a 2 min cycle of ACD-CPR. Patients were intubated and the ventilation rate was held constant during CPR. CPR quality parameters and ETCO2 values were collected continuously with the defibrillator. Differences in ETCO2 output between manual CPR and ACD-CPR were analysed using a linear mixed model where ETCO2 output produced by a summary of the 2 min cycles was included as the dependent variable, the patient as a random factor and method as a fixed effect. These comparisons were made within each OHCA case to minimise confounding factors between the cases.

Résultats : Mean length of the CPR episodes was 37 (SD 8) min. Mean compression depth was 76 (SD 1.3) mm versus 71 (SD1.0) mm, and mean compression rate was 100 per min (SD 6.7) versus 105 per min (SD 4.9) between ACD-CPR and manual CPR, respectively. For ETCO2 output, the interaction between the method and the patient was significant (P<0.001). ETCO2 output was higher with manual CPR in 6 of the 10 cases.

Conclusion : This study suggests that quality controlled ACD-CPR is not superior to quality controlled manual CPR when ETCO2 is used as a quantitative measure of CPR effectiveness.

Conclusion (proposition de traduction) : Cette étude suggère que la réanimation cardiorespiratoire avec compression-décompression active d'une qualité contrôlée n'est pas supérieure à la réanimation cardiorespiratoire manuelle à qualité contrôlée lorsque l'ETCO2 est utilisé comme mesure quantitative de l'efficacité de la réanimation cardiorespiratoire.

Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management.
Rickard AC, Vassallo J, Nutbeam T, Lyttle MD, Maconochie IK, Enki DG, Smith JE; PERUKI (Paediatric Emergency Research in the UK and Ireland). | Emerg Med J. 2018 Jul;35(7):434-439
DOI: https://doi.org/10.1136/emermed-2017-207226
Keywords: cardiac arrest; paediatric resuscitation; resuscitation; trauma

Original article

Introduction : Paediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients.

Méthode : An online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy.

Résultats : 73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrest and the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation.

Conclusion : This study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians.

Conclusion (proposition de traduction) : Cette étude a donné un cadre consensuel pour guider l'élaboration d'un protocole dans la prise en charge de l'arrêt cardiaque traumatique pédiatrique, bien que d'autres travaux soient nécessaires dans d'autres domaines clés, y compris son acceptabilité par les cliniciens.

Prehospital haemostatic dressings for trauma: a systematic review.
Boulton AJ, Lewis CT, Naumann DN, Midwinter MJ. | Emerg Med J. 2018 Jul;35(7):449-457
DOI: https://doi.org/10.1136/emermed-2018-207523
Keywords: Prehospital; haemorrhage; haemostatic; trauma

Review

Introduction : Haemorrhage is a major cause of mortality and morbidity following both military and civilian trauma. Haemostatic dressings may offer effective haemorrhage control as part of prehospital treatment.
AIM: To conduct a systematic review of the clinical literature to assess the prehospital use of haemostatic dressings in controlling traumatic haemorrhage, and determine whether any haemostatic dressings are clinically superior.

Méthode : MEDLINE and EMBASE databases were searched using predetermined criteria. The reference lists of all returned review articles were screened for eligible studies. Two authors independently undertook the search, performed data extraction, and risk of bias and Grading of Recommendations, Assessment, Development and Evaluation quality assessments. Meta-analysis could not be undertaken due to study and clinical heterogeneity.

Résultats : Our search yielded 470 studies, of which 17 met eligibility criteria, and included 809 patients (469 military and 340 civilian). There were 15 observational studies, 1 case report and 1 randomised controlled trial. Indications for prehospital haemostatic dressing use, wound location, mechanism of injury, and source of bleeding were variable. Seven different haemostatic dressings were reported with QuikClot Combat Gauze being the most frequently applied (420 applications). Cessation of bleeding ranged from 67% to 100%, with a median of 90.5%. Adverse events were only reported with QuikClot granules, resulting in burns. No adverse events were reported with QuikClot Combat Gauze use in three studies. Seven of the 17 studies did not report safety data. All studies were at risk of bias and assessed of 'very low' to 'moderate' quality.

Conclusion : Haemostatic dressings offer effective prehospital treatment for traumatic haemorrhage. QuikClot Combat Gauze may be justified as the optimal agent due to the volume of clinical data and its safety profile, but there is a lack of high-quality clinical evidence, and randomised controlled trials are warranted.

Conclusion (proposition de traduction) : Les pansements hémostatiques offrent un traitement préhospitalier efficace en cas d'hémorragie traumatique. La gaze de combat QuikClot peut être justifiée en tant qu'agent optimal en raison du volume de données cliniques et de son profil d'innocuité, mais il y a un manque de preuves cliniques de haute qualité, et des essais contrôlés randomisés sont justifiés.

Estimation of the individual residual risk of cervical cancer after vaccination with the nonavalent HPV vaccine.
Petry KU, Bollaerts K, Bonanni P, Stanley M, Drury R, Joura E, Kjaer SK, Meijer CJLM, Riethmuller D, Soubeyrand B, Van Damme P, Bosch X. | Hum Vaccin Immunother. 2018 Jul 3;14(7):1800-1806
DOI: https://doi.org/10.1080/21645515.2018.1450125  | Télécharger l'article au format  
Keywords: Human papillomavirus; Types 6, 11, 16, 18, 31, 33, 45, 52, 58, modelling; cervical cancer; human papillomavirus recombinant vaccine nonavalent; vaccination

Research article

Introduction : The nonavalent HPV (9vHPV) vaccine is indicated for active immunisation of individuals from the age of 9 years against cervical, vulvar, vaginal and anal premalignant lesions and cancers causally related to vaccine HPV high risk types 16, 18, 31, 33, 45, 52 and 58, and to the HPV low risk types 6 and 11, causing genital warts.
OBJECTIVE: To estimate the lifetime risk (up to the age of 75 years) for developing cervical cancer after vaccinating a HPV naïve girl (e.g. 9 to 12 years old) with the 9vHPV vaccine in the hypothetical absence of cervical cancer screening.

Méthode : We built Monte Carlo simulation models using historical pre-screening age-specific cancer incidence data and current mortality data from Denmark, Finland, Norway, Sweden and the UK. Estimates of genotype contribution fractions and vaccine efficacy were used to estimate the residual lifetime risk after vaccination assuming lifelong protection.

Résultats : We estimated that, in the hypothetical absence of cervical screening and assuming lifelong protection, 9vHPV vaccination reduced the lifetime cervical cancer and mortality risks 7-fold with a residual lifetime cancer risks ranging from 1/572 (UK) to 1/238 (Denmark) and mortality risks ranging from 1/1488 (UK) to 1/851 (Denmark). After decades of repetitive cervical screenings, the lifetime cervical cancer and mortality risks was reduced between 2- and 4-fold depending on the country.

Conclusion : Our simulations demonstrate how evidence can be generated to support decision-making by individual healthcare seekers regarding cervical cancer prevention.

Conclusion (proposition de traduction) : Nos simulations montrent comment des preuves peuvent être générées pour aider les demandeurs de soins de santé individuels à prendre des décisions en matière de prévention du cancer du col utérin.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Evaluation du risque de survenue d’un cancer du col utérin après vaccination avec le HPV9v chez des jeunes filles HPV naïves. Des données utiles pour communiquer  . Rédigé par le Dr Jacques Gaillat.

Association of Arterial Oxygen Tension During In-Hospital Cardiac Arrest With Return of Spontaneous Circulation and Survival.
Patel JK, Schoenfeld E, Parikh PB, Parnia S. | J Intensive Care Med. 2018 Jul;33(7):407-414
DOI: https://doi.org/10.1177/0885066616658420
Keywords: Pao2; cardiac arrest; cardiopulmonary resuscitation; oxygen; oxygen delivery; return of spontaneous circulation; survival

Review of a Large Clinical Series

Introduction : Despite numerous advances in the delivery of resuscitative care, in-hospital cardiac arrest (IHCA) continues to be associated with high morbidity and mortality. We sought to study the impact of arterial oxygen tension (Pao2) on return of spontaneous circulation (ROSC) and survival to discharge in patients with IHCA.

Méthode : The study population included 255 consecutive patients who underwent advanced cardiac life support-guided resuscitation from January 2012 to December 2013 for IHCA at an academic tertiary medical center. Of these patients, 167 underwent arterial blood gas testing at the time of the arrest. Baseline demographic, clinical, laboratory, and clinical outcome data were recorded. The primary outcome of interest was survival to hospital discharge. Secondary outcome of interest was presence of ROSC.

Résultats : Of the 167 patients studied, Pao2 categorization included the following: Pao2 < 60 mm Hg (n = 38), Pao2 of 60-92 mm Hg (n = 44), Pao2 of 93 to 159 mm Hg (n = 43), Pao2 of 160 to 299 mm Hg (n = 24), and Pao2 ≥ 300 mm Hg (n = 18). Patients with higher Pao2 levels during the time of cardiac arrest were noted to have higher rates of hypertension and chronic kidney disease. Clinical presentation of IHCA, in particular, the initial rhythm, location of IHCA, and duration of cardiopulmonary resuscitation, was similar in all groups. Patients with higher Pao2 levels had higher platelet count, higher arterial pH, and lower arterial carbon dioxide tension (Pco2). With respect to outcomes, patients with higher intra-arrest Pao2 levels had progressively higher rates of ROSC (58% vs 71% vs 72% vs 79% vs 100%, P = .021) and survival to discharge (16% vs 23% vs 30% vs 33% vs 56%, P = .031). In multivariate analysis, Pao2 ≥ 300 mm Hg was independently associated with higher survival to discharge (odds ratio 60.68; 95% confidence interval: 3.04-1210.28; P = .007; referent Pao2 < 60 mm Hg).

Conclusion : Higher intra-arrest Pao2 is independently associated with higher rates of survival to discharge in adults with IHCA.

Conclusion (proposition de traduction) : Les PaO₂ les plus hautes pendant l'arrêt sont associées de manière indépendante à des taux de survie plus élevés à la sortie chez les adultes dans l'arrêt cardiaque intrahospitalier.

Risk of Myocardial Infarction in Anticoagulated Patients With Atrial Fibrillation.
Lee CJ, Gerds TA, Carlson N, Bonde AN, Gislason GH, Lamberts M, Olesen JB, Pallisgaard JL, Hansen ML, Torp-Pedersen C. | J Am Coll Cardiol. 2018 Jul 3;72(1):17-26
DOI: https://doi.org/10.1016/j.jacc.2018.04.036
Keywords: apixaban; dabigatran; direct oral anticoagulant; rivaroxaban; vitamin K antagonist

Original Investigation

Introduction : Evidence is conflicting as to the efficacy of direct oral anticoagulation (DOAC) and vitamin K antagonist (VKA) for prevention of myocardial infarction (MI).
OBJECTIVES: This study aimed to investigate the risk of MI associated with the use of apixaban, dabigatran, rivaroxaban, and VKA in patients with atrial fibrillation.

Méthode : Patients with atrial fibrillation were identified using Danish health care registers and stratified by initial oral anticoagulant treatment. Standardized absolute 1-year risks were estimated based on Cox regression for hazard rates of MI hospitalizations and mortality. Reported were absolute risks separately for the oral anticoagulation treatments and standardized to the characteristics of the study population.

Résultats : Of the 31,739 patients included (median age, 74 years; 47% females), the standardized 1-year risk of MI for VKA was 1.6% (95% confidence interval [CI]: 1.3 to 1.8), apixaban was 1.2% (95% CI: 0.9 to 1.4), dabigatran was 1.2% (95% CI: 1.0 to 1.5), and rivaroxaban was 1.1% (95% CI: 0.8 to 1.3). No significant risk differences were observed in the standardized 1-year risks of MI among the DOACs: dabigatran versus apixaban (0.04%; 95% CI: -0.3 to 0.4), rivaroxaban versus apixaban (0.1%; 95% CI: -0.4 to 0.3), and rivaroxaban versus dabigatran (-0.1%; 95% CI: -0.5 to 0.2). The risk differences for DOACs versus VKA were all significant: -0.4% (95% CI: -0.7 to -0.1) for apixaban, -0.4% (95% CI: -0.7 to -0.03) for dabigatran, and -0.5% (95% CI: -0.8 to -0.2) for rivaroxaban.

Conclusion : No significant risk differences of MI were found in the direct comparisons of DOACs, and DOACs were all associated with a significant risk reduction of MI compared with VKA.

Conclusion (proposition de traduction) : Aucune différence significative de risque de survenu d'un infarctus du myocarde (IDM) n'a été observée pour tous les anticoagulants oraux directs (AOD) comparés entre eux, et les anticoagulants oraux directs (AOD) étaient tous associés à une réduction significative du risque de survenu d'un infarctus du myocarde par rapport aux antagonistes de la vitamine K (AVK).

Commentaire : Medscape dans son édition du dimanche 15 juillet 2018   conclu que :
Les forces de cette étude sont : sa rigueur, l’intérêt porté exclusivement à l’IDM, le nombre important de patients successifs, tous venants, âgés, bref ceux que l’on voit en pratique courante. Les auteurs notent le nombre faible d’infarctus du myocarde, qui leur a cependant permis de montrer une différence significative entre le risque absolu standardisé de survenue d’infarctus du myocarde en défaveur des AVK, innocentant le dabigatran. « Aucun des essais précédents n’avait pris la survenue d’un IDM comme critère primaire (…) le risque accru d’IDM pouvait refléter des différences dans la comorbidité, un biais de sélection » a déclaré Christina Ji-Young Lee.
De l’avis des auteurs, les points faibles de l’étude sont la non prise en compte de certains facteurs cliniques, la non connaissance de l’INR et, dans une certaine mesure l’adhérence puisque 28% des patients ont arrêté leur traitement.

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial.
Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD7; PRISMS Investigators.. | JAMA. 2018 Jul 10;320(2):156-166
DOI: https://doi.org/10.1001/jama.2018.8496  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction :  IMPORTANCE : More than half of patients with acute ischemic stroke have minor neurologic deficits (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) at presentation. Although prior major trials of alteplase included patients with low NIHSS scores, few without clearly disabling deficits were enrolled.
OBJECTIVE : To evaluate the efficacy and safety of alteplase in patients with NIHSS scores of 0 to 5 whose deficits are not clearly disabling.

Méthode : DESIGN, SETTING, AND PARTICIPANTS: The PRISMS trial was designed as a 948-patient, phase 3b, double-blind, double-placebo, multicenter randomized clinical trial of alteplase compared with aspirin for emergent stroke at 75 stroke hospital networks in the United States. Patients with acute ischemic stroke whose deficits were scored as 0 to 5 on the NIHSS and judged not clearly disabling and in whom study treatment could be initiated within 3 hours of onset were eligible and enrolled from May 30, 2014, to December 20, 2016, with final follow-up on March 22, 2017.
INTERVENTIONS : Participants were randomized to receive intravenous alteplase at the standard dose (0.9 mg/kg) with oral placebo (n = 156) or oral aspirin, 325 mg, with intravenous placebo (n = 157).
MAIN OUTCOMES AND MEASURES: The primary outcome was the difference in favorable functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days via Cochran-Mantel-Haenszel test stratified by pretreatment NIHSS score, age, and time from onset to treatment. Because of early termination of the trial, prior to unblinding or interim analyses, the plan was revised to examine the risk difference of the primary outcome by a linear model adjusted for the same factors. The primary safety end point was symptomatic intracranial hemorrhage (sICH) within 36 hours of intravenous study treatment.

Résultats : Among 313 patients enrolled at 53 stroke networks (mean age, 62 [SD, 13] years; 144 [46%] women; median NIHSS score, 2 [interquartile range {IQR}, 1-3]; median time to treatment, 2.7 hours [IQR, 2.1-2.9]), 281 (89.8%) completed the trial. At 90 days, 122 patients (78.2%) in the alteplase group vs 128 (81.5%) in the aspirin group achieved a favorable outcome (adjusted risk difference, -1.1%; 95% CI, -9.4% to 7.3%). Five alteplase-treated patients (3.2%) vs 0 aspirin-treated patients had sICH (risk difference, 3.3%; 95% CI, 0.8%-7.4%).

Conclusion : Among patients with minor nondisabling acute ischemic stroke, treatment with alteplase vs aspirin did not increase the likelihood of favorable functional outcome at 90 days. However, the very early study termination precludes any definitive conclusions, and additional research may be warranted.

Conclusion (proposition de traduction) : Chez les patients ayant subi un AVC ischémique aigu mineur non invalidant, le traitement par alteplase vs aspirine n’a pas augmenté la probabilité d’une évolution fonctionnelle favorable à 90 jours. Cependant, la fin très précoce de l’étude exclut toute conclusion définitive et des recherches supplémentaires peuvent être justifiées.

Commentaire : Etude arrêtée avant la fin par le laboratoire arguant du manque de moyen financier pour la poursuite de l'étude…

Red Flags in Torticollis: A Historical Cohort Study.
Starc M, Norbedo S, Tubaro M, Ronfani L, Bassanese G, Barbi E. | Pediatr Emerg Care. 2018 Jul;34(7):463-466
DOI: https://doi.org/10.1097/PEC.0000000000001377
Keywords: Aucun

Original Articles

Introduction : This study aimed to assess the spectrum of pathologies responsible for torticollis in children presenting to the emergency department and to evaluate the associated symptoms to determine clinical red flags for hospitalization.

Méthode : This was a historical retrospective cohort study. Medical records of children evaluated in our emergency department for torticollis from 2008 to 2013 were reviewed.

Résultats : Among 392 identified patients, 61% had postural torticollis,19.4% infection related, 16.3% traumatic, and 3.5% other. Twenty-five patients (6.4%) were hospitalized. Four variables were strongly and independently related to the severe outcome: fever, sore throat, headache, and age.

Conclusion : The association of 2 or 3 of these 4 features carried a risk of 32% and 58%, respectively, of having a severe illness.

Conclusion (proposition de traduction) : L'association de 2 ou 3 de ces 4 caractéristiques (fièvre, mal de gorge, céphalée et âge) comportait respectivement un risque de 32 % et 58 % de maladie grave.

Interventions to Increase Point-of-Care Ultrasound Use in a Pediatric Emergency Department.
Musisca MA, Neuman MI, Gravel CA, Monuteaux MC, Rempell RG. | Pediatr Emerg Care. 2018 Jul;34(7):518-523
DOI: https://doi.org/10.1097/PEC.0000000000001534
Keywords: Aucun

Ultrasound Case Review

Introduction : We sought to determine which interventions have effectively increased point-of-care ultrasound (US) use in a pediatric emergency department (ED).

Méthode : We evaluated the impact of specific interventions conducted over a 5-year period (2010-2015) on point-of-care US performance in a tertiary care pediatric ED. Ultrasound use by attending physicians and fellows was ascertained from a departmental database. Interventions assessed included the following: (1) initiation of an US fellowship, (2) acquisition of a second US machine, (3) performance of an US-related research project in the department, (4) initiation of faculty US curriculum, (5) earlier introduction of US education for pediatric emergency medicine fellows, and (6) administrative mandate dictating faculty requirements for credentialing. Mean monthly US use was trended over time using statistical process control methodology, and the impact of major interventions was analyzed using interrupted time-series analyses.

Résultats : The mean number of US scans increased from 2.0 to 5.9 per attending per month and from 4.3 to 7.1 per fellow per month over the study period. Using interrupted time-series analyses, we observed the only intervention to significantly increase attending US utilization was an administrative credentialing mandate, with an associated increase of 6% per month (incidence rate ratio, 1.06; 95% confidence interval, 1.01-1.11).

Conclusion : Point-of-care US use has increased over time for both fellows and attending physicians. We observed that an administrative mandate led to a significant increase in US use among attending physicians.

Conclusion (proposition de traduction) : L'utilisation de l'échographie au sein du service a augmenté au fil du temps, tant pour les résidents que pour les médecins titulaire du service. Nous avons observé qu'une incitation administrative a entraîné une augmentation significative de l'utilisation des ultrasons chez les médecins titulaire du service.

Oxygen titration after resuscitation from out-of-hospital cardiac arrest: A multi-centre, randomised controlled pilot study (the EXACT pilot trial).
Bray JE, Hein C, Smith K, Stephenson M, Grantham H, Finn J, Stub D, Cameron P, Bernard S; EXACT Investigators. | Resuscitation. 2018 Jul;128:211-215
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.019
Keywords: Heart arrest; Hyperoxia; Out-of-hospital cardiac arrest; Oxygen; Post-resuscitation care

Clinical papers

Introduction : Recent studies suggest the administration of 100% oxygen to hyperoxic levels following return-of-spontaneous-circulation (ROSC) post-cardiac arrest may be harmful. However, the feasibility and safety of oxygen titration in the prehospital setting is unknown. We conducted a multi-centre, phase-2 study testing whether prehospital titration of oxygen results in an equivalent number of patients arriving at hospital with oxygen saturations SpO2 ≥ 94%.

Méthode : We enrolled unconscious adults with: sustained ROSC; initial shockable rhythm; an advanced airway; and an SpO2 ≥ 95%. Initially (Sept 2015-March 2016) patients were randomised 1:1 to either 2 L/minute (L/min) oxygen (titrated) or >10 L/min oxygen (control) via a bag-valve reservoir. However, one site experienced a high number of desaturations (SpO2 < 94%) in the titrated arm and this arm was changed (April 2016) to an initial reduction of oxygen to 4 L/min then, if tolerated, to 2 L/min, and the desaturation limit was decreased to <90%.

Résultats : We randomised 61 patients to titrated (n = 37: 2L/min = 20 and 2-4 L/min = 17) oxygen or control (n = 24). Patients allocated to titrated oxygen were more likely to desaturate compared to controls ((SpO2 < 94%: 43% vs. 4%, p = 0.001; SpO2 < 90%: 19% vs. 4%, p = 0.09). The majority of desaturations (81%) occurred at 2L/min. On arrival at hospital the majority of patients had a SpO2 ≥ 94% (titrated: 90% vs. control: 100%) and all patients had a SpO2 ≥ 90%. One patient (control) re-arrested. Survival to hospital discharge was similar.

Conclusion : Oxygen titration post-ROSC is feasible in the prehospital environment, but incremental titration commencing at 4L/min oxygen flow may be needed to maintain an oxygen saturation >90%

Conclusion (proposition de traduction) : Le titrage de l'oxygène après la récupération d'activité cardiaque spontanée (RACS) est possible dans l'environnement du préhospitalier, mais un titrage incrémentiel commençant à 4 L/min peut être nécessaire pour maintenir une saturation en oxygène > 90 %.

Comparison of optimal point on the sternum for chest compression between obese and normal weight individuals with respect to body mass index, using computer tomography: A retrospective study.
Lee J, Oh J2, Lim TH3, Kang H3, Park JH4, Song SY5, Shin GH5, Song Y. | Resuscitation. 2018 Jul;128:1-5.
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.023
Keywords: Basic life support; Body mass index; Cardiopulmonary resuscitation; Chest compression; Proper hand position

Clinical papers

Introduction : Abdominal fatty tissue deposition in obese individuals could alter the proper hand position for chest compression during cardiopulmonary resuscitation, similar to that in pregnant women. This study aimed to identify the difference in body mass index between obese and normal weight individuals by measuring the optimal point of maximal left ventricular diameter (OP^LV), using computed tomography (CT).

Méthode : We performed a retrospective analysis of chest CT scans between January 2012 and August 2016 and measured the sternal length and OP^LV and estimated the ratio of OP^LV to that individual sternal length. We also investigated whether OP^LV was within the clinically relevant range of 20 mm to the position advised by the Guidelines 2015. We compared these outcomes between the two groups.

Résultats : We randomly selected and analysed 50 of 7229 normal weight and 50 of 394 obese individuals from a database. The mean ± standard deviation of the ratio of OP^LV was 22.0 ± 5.7% and 14.8 ± 6.6% of the sternal length, as measured from its most caudal point, respectively, for the obese and normal weight groups (p < 0.001). Both are more caudal than at the middle point of "the lower half of the sternum" as currently recommended. Notably, 96% of the OP^LV in the obese group was within ±20 mm of the guideline point versus 52% for normal weight group.

Conclusion : OP^LV on the sternum in obese individuals was more cranial than that in normal weight individuals. The optimal point for chest compression in obese individuals could be slightly more cranial than that in the others.

Conclusion (proposition de traduction) : Le point de compression optimal du sternum sur le thorax chez les personnes obèses était plus en position céphalique que chez les individus de poids normal. Le point optimal pour la compression thoracique chez les personnes obèses pourrait être légèrement plus céphalique que chez les autres.

Timing of advanced airway management by emergency medical services personnel following out-of-hospital cardiac arrest: A population-based cohort study.
Izawa J, Iwami T2, Gibo K3, Okubo M4, Kajino K5, Kiyohara K6, Nishiyama C7, Nishiuchi T8, Hayashi Y9, Kiguchi T2, Kobayashi D2, Komukai S10, Kawamura T2, Callaway CW4, Kitamura T. | Resuscitation. 2018 Jul;128:16-23
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.024
Keywords: Emergency medical technicians; Heart arrest; Intubation

Clinical papers

Introduction : Early prehospital advanced airway management (AAM) by emergency medical services (EMS) personnel has been intended to improve patient outcomes from out-of-hospital cardiac arrest (OHCA). However, few studies examine the effectiveness of early prehospital AAM. We investigated whether early prehospital AAM was associated with functionally favourable survival after adult OHCA.

Méthode : We conducted a population-based cohort study of OHCA in Osaka, Japan, between 2005 and 2012. We included all consecutive, non-traumatic adult OHCA in which EMS personnel performed cardiopulmonary resuscitation (CPR) and AAM. Main exposure was time from CPR to AAM. Primary outcome was functionally favourable survival at one-month. As the primary analysis, we estimated adjusted odds ratio (OR) of time from CPR to AAM using multivariable logistic regression in the original cohort. In the secondary analysis, we divided the time from CPR to AAM into early (0-4 min) and late (5-29 min). We calculated propensity scores (PS) for early AAM and performed PS-matching.

Résultats : We included 27,471 patients who received prehospital AAM by EMS personnel. In this original cohort, time from CPR to AAM was inversely associated with functionally favourable survival (adjusted OR 0.90 for one-increment of minute, 95% confidence interval [CI] 0.87-0.94). In the PS-matched cohort of 17,022 patients, early AAM, compared to late AAM, was associated with functionally favourable survival: 2.2% vs 1.4%; adjusted OR 1.58 (95% CI 1.24-2.02).

Conclusion : Earlier prehospital AAM by EMS personnel was associated with functionally better survival among adult patients who received AAM.

Conclusion (proposition de traduction) : Plus la prise en charge avancée des voies aériennes par le personnel des services médicaux d'urgence était précoce meilleure était la survie fonctionnelle des patients adultes ayant bénéficiés d'une prise en charge avancée des voies aériennes.

Major traumatic complications after out-of-hospital cardiac arrest: Insights from the Parisian registry.
Champigneulle B, Haruel PA, Pirracchio R, Dumas F, Geri G, Arnaout M, Paul M, Pène F, Mira JP, Bougouin W, Cariou A. | Resuscitation. 2018 Jul;128:70-75
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.022
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Injury; Trauma

Clinical papers

Introduction : Due to collapse and cardiopulmonary resuscitation (CPR) maneuvers, major traumatic injuries may complicate the course of resuscitation for out-of-hospital cardiac arrest patients (OHCA). Our goals were to assess the prevalence of these injuries, to describe their characteristics and to identify predictive factors.

Méthode : We conducted an observational study over a 9-year period (2007-2015) in a French cardiac arrest (CA) center. All non-traumatic OHCA patients admitted alive in the ICU were studied. Major injuries identified were ranked using a functional two-level scale of severity (life-threatening or consequential) and were classified as CPR-related injuries or collapse-related injuries, depending of the predominant mechanism. Factors associated with occurrence of a CPR-related injury and ICU survival were identified using multivariable logistic regression.

Résultats : A major traumatic injury following OHCA was observed in 91/1310 patients (6.9%, 95%CI: 5.6, 8.3%), and was classified as a life-threatening injury in 36% of cases. The traumatic injury was considered as contributing to the death in 19 (21%) cases. Injuries were related to CPR maneuvers in 65 patients (5.0%, (95%CI: 3.8, 6.1%)). In multivariable analysis, age [OR 1.02; 95%CI (1.00, 1.04); p = 0.01], male gender [OR 0.53; 95%CI (0.31, 0.91); p = 0.02] and CA occurring at home [OR 0.54; 95%CI (0.31, 0.92); p = 0.02] were significantly associated with the occurrence of a CPR-related injury. CPR-related injuries were not associated with the ICU survival [OR 0.69; 95%CI (0.36, 1.33); p = 0.27].

Conclusion : Major traumatic injuries are common after cardiopulmonary resuscitation. Further studies are necessary to evaluate the interest of a systematic traumatic check-up in resuscitated OHCA patients in order to detect these injuries.

Conclusion (proposition de traduction) : Les traumatismes majeurs sont fréquents après une réanimation cardiorespiratoire. D'autres études sont nécessaires pour évaluer l'intérêt d'un contrôle systématique des traumatismes chez les patients réanimés victimes d'un arrêt cardiaque extrahospitalier afin de détecter ces lésions.

Direct transport to a PCI-capable hospital is associated with improved survival after adult out-of-hospital cardiac arrest of medical aetiology.
McKenzie N, Williams TA, Ho KM, Inoue M, Bailey P, Celenza A, Fatovich D, Jenkins I, Finn J. | Resuscitation. 2018 Jul;128:76-82
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.039
Keywords: Direct transport; Emergency medical services; Neurological outcome; Out-of-hospital cardiac arrest; Percutaneous-coronary-intervention; Post-resuscitation care; Survival

Clinical papers

Introduction : o compare survival outcomes of adults with out-of-hospital cardiac arrest (OHCA) of medical aetiology directly transported to a percutaneous-coronary-intervention capable (PCI-capable) hospital (direct transport) with patients transferred to a PCI-capable hospital via another hospital without PCI services available (indirect transport) by emergency medical services (EMS).

Méthode : This retrospective cohort study used the St John Ambulance Western Australia OHCA Database and medical chart review. We included OHCA patients (≥18 years) admitted to any one of five PCI-capable hospitals in Perth between January 2012 and December 2015. Survival to hospital discharge (STHD) and survival up to 12-months after OHCA were compared between the direct and indirect transport groups using multivariable logistic and Cox-proportional hazards regression, respectively, while adjusting for so-called "Utstein variables" and other potential confounders.

Résultats : Of the 509 included patients, 404 (79.4%) were directly transported to a PCI-capable hospital and 105 (20.6%) transferred via another hospital to a PCI-capable hospital; 274/509 (53.8%) patients STHD and 253/509 (49.7%) survived to 12-months after OHCA. Direct transport patients were twice as likely to STHD (adjusted odds ratio 1.97, 95% confidence interval [CI] 1.13-3.43) than those transferred via another hospital. Indirect transport was also associated with a possible increased risk of death, up to 12-months, compared to direct transport (adjusted hazard ratio 1.36, 95% CI 1.00-1.84).

Conclusion : Direct transport to a PCI-capable hospital for post-resuscitation care is associated with a survival advantage for adults with OHCA of medical aetiology. This has implications for EMS transport protocols for patients with OHCA.

Conclusion (proposition de traduction) : Le transport direct vers un hôpital autorisé à pratiquer des interventions coronariennes percutanées pour les soins post-réanimation est associé à un avantage de survie pour les adultes présentant un arrêt cardiaque extrahospitalier d'étiologie médicale. Cela a des implications pour les protocoles de transport EMS pour les patients en arrêt cardiaque extrahospitalier.

Is initial rhythm in OHCA a predictor of preceding no flow time? Implications for bystander response and ECPR candidacy evaluation.
Tanguay-Rioux X, Grunau B, Neumar R, Tallon J, Boone R, Christenson J. | Resuscitation. 2018 Jul;128:88-92
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.002
Keywords: ECPR; Extracorporeal cardiopulmonary resuscitation; No-flow duration; OHCA; Out-of-hospital cardiac arrest; Shockable rhythms

Clinical papers

Introduction : Shockable cardiac rhythms are associated with improved outcomes among out-of-hospital cardiac arrests (OHCA). Initial cardiac rhythm may also be predictive of a short preceding no-flow duration. We examined the relationship between no-flow duration and initial cardiac rhythm, which may demonstrate the urgency in rescuer response and assist with candidacy evaluation for extracorporeal-cardiopulmonary resuscitation (ECPR).

Méthode : We examined consecutive adult OHCA's identified by a prospective registry in British Columbia (2005-2016). We included those with witnessed OHCA but no bystander CPR. The variable of interest was no-flow duration, defined as time from 9-1-1 call to EMS arrival. We fit an adjusted logistic regression model to estimate the association of no-flow duration and initial cardiac rhythm. Among those with shockable initial rhythms, we calculated the cumulative proportion with no-flow durations under incremental time cut-offs.

Résultats : Of 26 621 EMS-treated OHCA's, 2532 were included. Overall survival was 13.8%, and 34% had initial shockable rhythms. The probability of having an initial shockable rhythm decreased with increasing no-flow durations (adjusted OR 0.88 per minute, 95% CI 0.85-0.91). Among those found with initial shockable rhythms, 94% (95% CI 92-96%) had a no-flow time under 10 min.

Conclusion : The odds of a shockable initial rhythm declined with each additional minute of no-flow time, highlighting the importance of early access to defibrillation. Among those with initial shockable rhythms, the preceding no-flow duration was highly likely to be under 10 min, which may inform decisions about ECPR candidacy among select patients with unwitnessed arrests.

Conclusion (proposition de traduction) : Les chances d'un rythme initial choquable diminuaient avec chaque minute supplémentaire de temps sans débit, soulignant l'importance d'un accès précoce à la défibrillation. Parmi ceux qui avaient des rythmes choquables initiaux, la durée précédente sans flux était très probablement inférieure à 10 minutes, ce qui pourrait éclairer les décisions concernant la candidature à l'ExtraCorporeal Life Support (ECLS) chez certains patients présentant un arrêt cardiaque sans témoin.

Commentaire : Remarque  on définit le « no flow » comme la durée durant laquelle le débit cardiaque est nul, avant toute pratique de réanimation cardiopulmonaire. La quantification de la durée de « no flow » suppose la constatation de l’arrêt cardiaque par un témoin.

Recognition of out-of-hospital cardiac arrest during emergency calls and public awareness of cardiopulmonary resuscitation in communities: A multilevel analysis.
Lee SY, Ro YS, Shin SD, Song KJ, Hong KJ, Park JH, Kong SY. | Resuscitation. 2018 Jul;128:106-111
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.008
Keywords: Cardiopulmonary resuscitation; Community; Out-of-hospital cardiac arrest

Clinical papers

Introduction : For an effective dispatcher-assisted cardiopulmonary resuscitation (CPR) program, recognition of out-of-hospital cardiac arrest (OHCA) by a dispatcher is the first step in initiating bystander CPR. This study evaluated whether CPR awareness in the community is associated with recognition of arrest, dispatcher-provided CPR instructions, and bystander CPR.

Méthode : All emergency medical services (EMS)-treated adult OHCAs with cardiac etiology were enrolled between 2013 and 2015, excluding cases witnessed by EMS providers. Exposure was CPR awareness in the community where the OHCA occurred. Endpoints were recognition of arrest, dispatcher-provided CPR instructions, and bystander CPR. Multilevel logistic regression analysis was performed to calculate adjusted odds ratios (AORs) per 10% increment in community CPR awareness adjusting for potential confounders.

Résultats : Of 44,185 eligible OHCAs, 20,255 (45.8%) cases were recognized by a dispatcher, 17,858 (40.4%) received dispatcher-provided CPR instructions, and 22,255 (50.4%) received bystander CPR (39.8% with dispatcher assistance and 10.6% without dispatcher assistance). Compared with OHCAs that occurred in the communities with low awareness, dispatchers were more likely to provide CPR instructions to the caller, and bystanders were more likely to perform CPR for OHCAs that occurred in the communities with high CPR awareness. AORs (95% CIs) per 10% increment in public awareness of CPR in the community were 1.05 (1.01-1.10) for recognition of arrest, 1.11 (1.06-1.16) for dispatcher-provided CPR instructions, and 1.07 (1.03-1.11) for bystander CPR.

Conclusion : Public CPR awareness of the communities where OHCAs occurred was associated with recognition of arrest during an emergency call, dispatcher-provided CPR instructions, and bystander CPR.

Conclusion (proposition de traduction) : La sensibilisation du public à la réanimation cardiorespiratoire dans les collectivités où se sont produits des arrêts cardiaques extrahospitalier était associée à la reconnaissance de l'arrêt cardiaque pendant un appel d'urgence, aux instructions de réanimation cardiorespiratoire fournies par le répartiteur et à la réanimation cardiorespiratoire par le témoin.

Age and benefit of early coronary angiography after out-of-hospital cardiac arrest in patients presenting with shockable rhythm: Insights from the Sudden Death Expertise Center registry.
Aissaoui N, Bougouin W, Dumas F, Beganton F, Chocron R, Varenne O, Spaulding C, Karam N, Montalescot G, Aubry P, Sideris G, Marijon E, Jouven X, Cariou A; on behalf SDEC Investigators. | Resuscitation. 2018 Jul;128:126-131
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.006
Keywords: Coronary angiography; Elderly; OHCA; Percutaneous coronary intervention; Post-resuscitation care; Target temperature management

Clinical papers

Introduction : Little is known about the association between provision of post-resuscitation care and prognosis of out-of-hospital cardiac arrest (OHCA) in elderly patients. Previous studies have suggested futility after 65 years of age.
OBJECTIVES: We aimed to evaluate the association of early coronary angiogram (CAG) followed if necessary by percutaneous coronary intervention (PCI), with favorable outcome after OHCA among elderly patients, compared to younger patients.

Méthode : Using a large French registry, we included all OHCA patients with an initial shockable rhythm, transported to hospital from 2011 to 2015. Favorable outcome was defined as hospital discharge with Cerebral Performance Category (CPC) 1 or 2. and were evaluated by multivariate logistic regression. Subgroup analyses were performed according to age groups: <65, 65-75 and >75 years.

Résultats : Among 1502 included patients, 31% were older than 65 and 12% older than 75 years. An early CAG was performed in 79%, 88% and 76% of patients below 65, between 65 and 75 and above 75, respectively (P = 0.002). The rate of patients discharged with CPC1 or 2 was 42% below 65, 38% between 65 and 75 and 24% above 75 (P < 0.001). Among the whole population, early CAG (OR = 6.4, 95% CI = 3.9-10.5, P < 0.001) was associated with favorable outcome. In subgroups analysis, CAG was associated with favorable outcome among patients <65 and 65-75. In patients >75, there was a trend towards a favorable outcome (OR2.9, 95CI = 0.9-9.1).

Conclusion : In a large registry of OHCA survivors, the early CAG use was associated with a better prognosis. This benefit was persistent up to 75 years of age, suggesting that age alone should not guide the decision for early invasive strategy.

Conclusion (proposition de traduction) : Dans un large registre de survivants après un arrêt cardiaque extrahospitalier, l’utilisation précoce des angiographie coronarienne était associée à un meilleur pronostic. Cet avantage était persistant jusqu'à l'âge de 75 ans, ce qui suggère que l'âge seul ne devrait pas guider la décision d'une stratégie invasive précoce.

Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium.
Kurz MC, Schmicker RH, Leroux B, Nichol G, Aufderheide TP, Cheskes S, Grunau B, Jasti J, Kudenchuk P, Vilke GM, Buick J, Wittwer L, Sahni R, Straight R, Wang HE; ROC Investigators. | Resuscitation. 2018 Jul;128:132-137
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.031
Keywords: Advanced life support; Basic life support; Cardiac arrest; Cardiopulmonary resuscitation; Emergency medical services

Clinical papers

Introduction : Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC).

Méthode : Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLS + late ALS; 3) BLS + early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site.

Résultats : Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56-80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLS + late ALS, 17.2% BLS + early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6 min after BLS arrival (BLS + late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome.

Conclusion : ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.

Conclusion (proposition de traduction) : Les soins spécialisés de réanimation cardiopulmonaire étaient associés à la survie à la sortie de l'hôpital lorsqu'ils étaient dispensés initialement ou dans les six minutes suivant l'arrivée des équipes réalisant les gestes élémentaires de survie. Les soins avancés de réanimation cardiopulmonaire, avec ou sans gestes élémentaires de survie initiaux, étaient associés à un retour accru à une circulation spontanée, mais ils n'étaient pas associés à un meilleur résultat fonctionnel.

Commentaire : Le Resuscitation Outcomes Consortium (ROC)   est un réseau d'essais cliniques axé sur la recherche dans le domaine de l'arrêt cardio-pulmonaire préhospitalier et des lésions traumatiques graves.

Analysis of bystander CPR quality during out-of-hospital cardiac arrest using data derived from automated external defibrillators.
Fernando SM, Vaillancourt C, Morrow S, Stiell IG. | Resuscitation. 2018 Jul;128:138-143
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.012
Keywords: Automated external defibrillators; CPR quality; Cardiac arrest; Cardiopulmonary resuscitation; Critical care; Emergency medicine; Prehospital

Clinical papers

Introduction : Little is known regarding the quality of cardiopulmonary resuscitation (CPR) performed by bystanders in out-of-hospital cardiac arrest (OHCA). We sought to determine quality of bystander CPR provided during OHCA using CPR quality data stored by Automated External Defibrillators (AEDs).

Méthode : We used the Resuscitation Outcomes Consortium database to identify OHCA cases of presumed cardiac etiology where an AED was utilized. We then matched AED data to each case identified. AED data was analyzed using manufacturer software in order to determine overall measures of bystander CPR quality, changes in bystander CPR quality over time, and adherence to existing 2010 Resuscitation Quality Guidelines.

Résultats : 100 cases of OHCA of presumed cardiac etiology involving bystander CPR and with corresponding AED data. Mean age was 62.3 years, and 75% were male. Bystanders demonstrated high-quality CPR over all minutes of resuscitation, with a chest compression fraction of 76%, a compression depth of 5.3 cm, and a compression rate of 111.2 compressions/min. Mean perishock pause was 26.8 s. Adherence rates to 2010 Resuscitation Guidelines for compression rate and depth were found to be 66% and 55%, respectively. CPR quality was lowest in the first minute, resulting from increased delay to rhythm analysis (mean 40.7 s). In cases involving shock delivery, latency from initiation of AED to shock delivery was 59.2 s.

Conclusion : We found that bystanders perform high-quality CPR, with strong adherence rates to existing Resuscitation Guidelines. High-quality CPR is maintained over the first five minutes of resuscitation, but was lowest in the first minute.

Conclusion (proposition de traduction) : Nous avons constaté que les témoins effectuaient une RCP de haute qualité, avec de forts taux d’observance par rapport aux directives de réanimation existantes. Une RCP de haute qualité est maintenue pendant les cinq premières minutes de réanimation, mais était la plus faible pendant la première minute.

Optimal mean arterial pressure in comatose survivors of out-of-hospital cardiac arrest: An analysis of area below blood pressure thresholds.
Russo JJ, Di Santo P, Simard T, James TE, Hibbert B, Couture E, Marbach J, Osborne C, Ramirez FD, Wells GA, Labinaz M, Le May MR; from the CAPITAL study group. | Resuscitation. 2018 Jul;128:175-180
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.028
Keywords: Anoxic brain injury; Hemodynamic targets; Out-of-hospital cardiac arrest; Post-cardiac arrest care; Resuscitation

Clinical papers

Introduction : To determine the optimal mean arterial pressure (MAP) during the early-to-intermediate phase care of comatose survivors of out-of-hospital cardiac arrest (OHCA).

Méthode : We identified consecutive comatose survivors of OHCA with an initial shockable rhythm. Using blood pressure-over-time plots, we calculated the area below pre-specified MAP thresholds (ABT; mmHg*hours) during the first 96 h of admission. We used incremental MAP thresholds ranging between 65 and 85 mmHg. Logistic regression analyses were used to examine the association between ABT and clinical outcomes for each MAP threshold and to adjust for age, duration of cardiac arrest, and bystander CPR. The primary outcome was severe neurological dysfunction as defined by a cerebral performance category (CPC) ≥3.

Résultats : We identified 122 consecutive OHCA patients meeting inclusion criteria. The rate of the primary outcome was 33%. There was a significant association between ABT and the rate of the primary outcome when MAP thresholds of 60 (p = 0.01), 65 (p < 0.01), 70 (p < 0.01), 75 (p < 0.01), and 80 mmHg (p < 0.01) were used. This association was lost once a MAP threshold of 85 mmHg was reached (p = 0.63). In the adjusted analysis, the association between ABT and the primary outcome was no longer present when the MAP threshold reached 75 mmHg.

Conclusion : In comatose survivors of OHCA with an initial shockable rhythm, higher ABT is associated with increased rates of severe neurological dysfunction when MAP thresholds <75 mmHg are used. The current findings support the hypothesis that higher MAP targets (≥75 mmHg) may be indicated in this patient population.

Conclusion (proposition de traduction) : Chez les survivants comateux après un arrêt cardiaque extrahospitalier avec un rythme choquable initial, une surface supérieure en dessous des seuils de pression artérielle moyenne préétablis est associée à des taux accrus de dysfonctionnement neurologique grave lorsque des seuils de pression artérielle moyenne < 75 mmHg sont utilisés.
Les résultats actuels appuient l'hypothèse selon laquelle des cibles de pression artérielle moyenne plus élevées (≥ 75 mmHg) peuvent être indiquées dans cette population de patients.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative.
Sweberg T, Sen AI, Mullan PC, Cheng A, Knight L, Del Castillo J, Ikeyama T, Seshadri R, Hazinski MF, Raymond T, Niles DE, Nadkarni V, Wolfe H; pediatric resuscitation quality (pediRES-Q) collaborative investigators. | Resuscitation. 2018 Jul;128:181-187
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.015
Keywords: Hot debriefing; In hospital cardiac arrest (IHCA)

Clinical papers

Introduction : The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA.

Méthode : Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments.

Résultats : Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%).

Conclusion : Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

Conclusion (proposition de traduction) : Environ la moitié des arrêts cardiaques intrahospitaliers pédiatriques ont été suivis de debriefings à chaud. Les debriefings à chaud étaient multidisciplinaires, opportuns et portaient souvent sur des questions de coopération/coordination au sein de l'équipe, de communication, de normes cliniques et d'équipement. Des études supplémentaires sont justifiées pour identifier les obstacles aux debriefings à chaud et pour évaluer l'impact de ces debriefings sur les résultats pour les patients.

Commentaire : Pour plus d'information sur le « Pediatric Resuscitation Quality Collaborative », consulter le site Internet pediRES-Q  .

The effect of different retraining intervals on the skill performance of cardiopulmonary resuscitation in laypeople-A three-armed randomized control study.
Hsieh MJ, Chiang WC, Jan CF, Lin HY, Yang CW, Ma MH. | Resuscitation. 2018 Jul;128:151-157
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.010
Keywords: Basic life support; Cardiopulmonary resuscitation; Education; Retraining

Simulation and Education

Introduction : Our study aimed to compare cardiopulmonary resuscitation (CPR) performance among laypeople with different retraining intervals.

Méthode : Ninety-six non-medical university students were randomly allocated into 3 groups after receiving initial CPR and automated external defibrillator (AED) training. Sixty participants completed the study. The participants in the 3-, 6-, and 12-month groups received the same retraining every 3-, 6-, and 12 months. An 80-min retraining course comprised a video lecture and hands-on practice, with feedback from the instructors and the Resusci Anne® QCPR. The primary outcome was a skill pass rate one year post-initial training. The secondary outcomes included a skill pass rate prior to each retraining course, knowledge test scores, and individual skill performance evaluated by assessors and by SkillReporter® software one year post-initial training.

Résultats : The characteristics among the groups were similar. The 3-month group had the highest pass rate (3-month group: 6-month group: 12-month group, 100.0%: 78.9%: 19.0%, p < 0.001) in the primary outcome. In secondary outcomes, the 3-month group had a higher pass rate than the 6-month group at 6 months post-initial training. The 3-month group achieved the highest knowledge test scores, and performed best in many ventilation items. They showed similar performance to the 6-month group and better performance than the 12-month group in chest compression items. The 3 groups performed similarly in AED manipulation.

Conclusion : Although young laypeople with a 3-month retraining interval had the highest pass rate when performing conventional CPR, a 6-month retraining interval may be considered for training compression-only CPR and AED when balancing outcomes and resources.

Conclusion (proposition de traduction) : Bien que les intervenants non professionnels les plus jeunes ayant un intervalle de reformation de 3 mois aient eu le taux de réussite le plus élevé lors de la réanimation cardiopulmonaire conventionnelle, un intervalle de rééducation de 6 mois peut être envisagé pour la réanimation cardiopulmonaire pour le massage cardiaque seul et la défibrillation externe lorsqu'il s'agit d'équilibrer les résultats et les ressources.

Effects of head-up vs. supine CPR on cerebral oxygenation and cerebral metabolism - a prospective, randomized porcine study.
Putzer G, Braun P, Martini J, Niederstätter I, Abram J, Lindner AK, Neururer S, Mulino M, Glodny B, Helbok R, Mair P. | Resuscitation. 2018 Jul;128:51-55
DOI: https://doi.org/10.1016/j.resuscitation.2018.04.038
Keywords: Animals; Blood pressure; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral cortex/metabolism; Heart arrest/therapy; Microdialysis/methods; Near infrared spectroscopy; Pigs; oxygen/blood; oxygen/metabolism

Experimental

Introduction : Recent studies have shown that during cardiopulmonary resuscitation (CPR) head-up position (HUP) as compared to standard supine position (SUP) decreases intracranial pressure (ICP) and increases cerebral perfusion pressure (CPP). The impact of this manoeuvre on brain oxygenation and metabolism is not clear. We therefore investigated HUP as compared to SUP during basic life support (BLS) CPR for their effect on brain oxygenation and metabolism.

Méthode : Twenty pigs were anaesthetized and instrumented. After 8 min of cardiac arrest (CA) pigs were randomized to either HUP or SUP and resuscitated mechanically for 20 min. Mean arterial pressure (MAP), ICP, CPP, cerebral regional oxygen saturation (rSO2) and brain tissue oxygen tension (PbtO2) were measured at baseline, after CA and every 5 min during CPR. Cerebral venous oxygen saturation (ScvO2) was measured at baseline, after CA and after 20 min of CPR. Cerebral microdialysis parameters, e.g. lactate/pyruvate ratio (L/P ratio) were taken at baseline and the end of the experiment.

Résultats : ICP was significantly lower in HUP compared to SUP animals after 5 min (18.0 ± 4.5 vs. 24.1 ± 5.2 mmHg; p = 0.033) and 20 min (12.0 ± 3.4 vs. 17.8 ± 4.3 mmHg; p = 0.023) of CPR. Accordingly, CPP was significantly higher in the HUP group after 5 min (11.2 ± 9.5 vs. 1.0 ± 9.2 mmHg; p = 0.045) and 20 min (3.4 ± 6.4 vs. -3.8 ± 2.8 mmHg; p = 0.023) of CPR. However, no difference was found in rSO2, PbtO2, ScvO2 and L/P ratio between groups after 20 min of CPR.

Conclusion : In this animal model of BLS CPR, HUP as compared to SUP did not improve cerebral oxygenation or metabolism.

Conclusion (proposition de traduction) : Dans ce modèle animal de réanimation cardiopulmonaire non médicalisé, la surélévation de la tête par rapport au décubitus dorsal n'a pas amélioré l'oxygénation cérébrale ni le métabolisme.

Baroreflex Sensitivity and Blood Pressure Variability can Help in Understanding the Different Response to Therapy During Acute Phase of Septic Shock.
Carrara M, Bollen Pinto B, Baselli G, Bendjelid K, Ferrario M. | Shock. 2018 Jul;50(1):78-86
DOI: https://doi.org/10.1097/SHK.0000000000001046  | Télécharger l'article au format  
Keywords: Aucun

Clinical Science Aspects

Introduction : Mean values of hemodynamic variables are poorly effective in evaluating an actual recovery of the short-term autonomic mechanisms for blood pressure (BP) and heart rate (HR) regulation. The aim of this work is to analyze the response to therapy in the early phase of septic shock to verify possible associations between BP recovery and BP autonomic control.

Méthode : This is an ancillary study from the multicenter prospective observational trial Shockomics (NCT02141607). A total of 21 septic shock patients were studied at two time points during the acute phase of shock and were classified according to changes in SOFA score. Time series of BP components and HR were analyzed in time and frequency domain. Baroreflex sensitivity (BRS) was assessed, and a mathematical model for the decomposition of diastolic arterial pressure (DAP) oscillations was used to understand the different contributions of BRS and HR on peripheral vascular resistance control.

Résultats : Only those patients, who significantly improved organ function (responders, R), showed an increase of mean value and low frequency (LF) power in BP time series. Fluid accumulation was higher in the non-responders (NR). BRS increased in NR and the model of DAP variability showed that the contribution of HR was highly reduced in NR.

Conclusion : Although patients reached the mean BP target of 65 mmHg, our analyses highlighted important differences in terms of autonomic nervous system control. BP variability, HR variability and baroreflex trends can add information to individual vital sign measure such as mean BP, and can help in understanding the responsiveness to the combination of symphatomimetic drugs and fluid therapy.

Conclusion (proposition de traduction) : Bien que les patients aient atteint la cible de pression artérielle moyenne de 65 mmHg, nos analyses ont mis en évidence des différences importantes en termes de contrôle du système nerveux autonome. La variabilité de la pression artérielle, la variabilité de la fréquence cardiaque et les tendances baroréflexes peuvent ajouter des informations à la mesure des signes vitaux individuels, comme la pression artérielle moyenne, et aider à comprendre la réponse à la combinaison de médicaments symphatomimétiques et du remplissage.

Efficacy of Endovascular Therapy in Acute Ischemic Stroke Depends on Age and Clinical Severity.
Le Bouc R, and al. | Stroke. 2018 July;49:1686-1694
DOI: https://doi.org/10.1161/ STROKEAHA.117.020511  | Télécharger l'article au format  
Keywords: ischemia; prognosis; stroke; thrombectomy

Original contributions

Introduction : Efficacy of endovascular treatment (EVT) for ischemic stroke because of large vessel occlusion may depend on patients’ age and stroke severity; we, therefore, developed a prognosis score based on these variables and examined whether EVT efficacy differs between patients with good, intermediate, or poor prognostic score.

Méthode : A total of 4079 patients with an acute ischemic stroke were identified from the Paris Stroke Consortium registry. We developed the stroke checkerboard (SC) score (SC score=1 point per decade ≥50 years of age and 2 points per 5 points on the National Institutes of Health Stroke Scale) to predict spontaneous outcome. The primary outcome was the adjusted common odds ratio for an improvement in the modified Rankin Scale at 90 days after EVT, in patients with low, intermediate, or high SC scores. To rule out potential selection biases, a nested case-control analysis, with individual matching for all major prognostic factors, was also performed, to compare patients with large vessel occlusion in the anterior circulation treated or not with EVT.

Résultats : In patients untreated with EVT, SC scores <8 were predictive of good outcomes (modified Rankin Scale score, 0–2; area under the curve, 0.87), whereas SC scores >12 were predictive of poor outcomes (modified Rankin Scale score, 4–6; area under the curve, 0.88). In the overall population, there was an interaction between EVT and prognosis group (P<0.001). EVT was associated with improved outcome in patients with SC scores >12 (common odds ratio, 1.70; 95% confidence interval, 1.13–2.56) and SC scores 8 to 12 (odds ratio, 1.37; 95% confidence interval, 1.11–1.69) but not in patients with SC scores <8 (odds ratio, 0.72; 95% confidence interval, 0.56–0.93). Similar results were obtained in the case-control analysis among 449 patients treated with EVT and 449 matched patients untreated with EVT.

Conclusion : In patients stratified with the SC score, EVT was associated with improved functional outcome in older and more severe patients but not in younger and less severe patients.

Conclusion (proposition de traduction) : Chez les patients stratifiés avec le score SC en AVC, le traitement endovasculaire était associé à une amélioration des résultats fonctionnels chez les patients âgés et les plus sévères, mais pas chez les patients les plus jeunes et moins sévères.

Elevated Plasma D-Dimer Level Is Associated With Short-Term Risk of Ischemic Stroke in Patients With Acute Heart Failure.
Hamatani Y, and al. | Stroke. 2018 July;49:1737-1740
DOI: https://doi.org/10.1161/STROKEAHA.118.021899  | Télécharger l'article au format  
Keywords: brain ischemia; fibrin; heart failure; humans; incidence; stroke

Brief Reports

Introduction : The incidence of heart failure increases the subsequent risk of ischemic stroke, and its risk could be higher in the short-term period after an acute heart failure (AHF) event. However, its determinants remain to be clarified. Plasma D-dimer level reflects fibrin turnover and exhibits unique properties as a biomarker of thrombosis. The aim of this study is to investigate whether D-dimer level is a determinant of short-term incidence of ischemic stroke in patients with AHF.

Méthode : We examined 721 consecutive hospitalized AHF patients with plasma D-dimer level on admission from our prospective registry between January 2013 and May 2016. The study end points were incidence of ischemic stroke during hospitalization and at 30 days after admission.

Résultats : Of the total participants (mean age, 76 years; male, 60%; atrial fibrillation, 54%; mean left ventricular ejection fraction, 38%), in-hospital ischemic stroke occurred in 18 patients (2.5%) during a median hospitalization period of 21 days, and 30-day ischemic stroke occurred in 16 patients (2.2%). Higher D-dimer level on admission was an independent determinant of subsequent risk of in-hospital ischemic stroke even after adjustment by CHA2DS2-VASc score (odds ratio, 2.29; 95% confidence interval, 1.46–3.60; P<0.001) or major confounders, including age, atrial fibrillation, and antithrombotic therapy (odds ratio, 2.31; 95% confidence interval, 1.43–3.74; P<0.001). Subgroup analyses showed consistent findings in patients without atrial fibrillation (odds ratio, 2.46; 95% confidence interval, 1.39–4.54; P=0.002) and those without antithrombotic therapy (odds ratio, 2.79; 95% confidence interval, 1.53–5.57; P<0.001). Similar results were obtained for 30-day ischemic stroke as an alternative outcome.

Conclusion : Elevated plasma D-dimer level on admission was significantly associated with increased incidence of ischemic stroke shortly after admission for AHF, suggesting a predictive role of D-dimer for short-term ischemic stroke events in patients with AHF.

Conclusion (proposition de traduction) : Un taux élevé de D-dimères plasmatiques à l'admission était significativement associé à une incidence accrue d'AVC ischémique peu après l'admission pour insuffisance cardiaque aiguë, suggérant un rôle prédictif des D-dimères dans les accidents vasculaires ischémiques à court terme.

Low Serum Calcium and Magnesium Levels and Rupture of Intracranial Aneurysms.
Can A, and al. | Stroke. 2018 July;49:1747-1750
DOI: https://doi.org/10.1161/STROKEAHA.118.020963  | Télécharger l'article au format  
Keywords: aneurysm; calcium; magnesium; rupture; subarachnoid hemorrhage

Brief reports

Introduction : Both low serum calcium and magnesium levels have been associated with the extent of bleeding in patients with intracerebral hemorrhage, suggesting hypocalcemia- and hypomagnesemia-induced coagulopathy as a possible underlying mechanism. We hypothesized that serum albumin-corrected total calcium and magnesium levels are associated with ruptured intracranial aneurysms.

Méthode : The medical records of 4701 patients, including 1201 prospective patients, diagnosed at the Brigham and Women’s Hospital and Massachusetts General Hospital between 1990 and 2016 were reviewed and analyzed. One thousand two hundred seventy-five patients had available serum calcium, magnesium, and albumin values within 1 day of diagnosis. Individuals were divided into cases with ruptured aneurysms and controls with unruptured aneurysms. Univariable and multivariable logistic regression analyses were performed to determine the association between serum albumin-corrected total calcium and magnesium levels and ruptured aneurysms.

Résultats : In multivariable analysis, both albumin-corrected calcium (odds ratio, 0.33; 95% confidence interval, 0.27–0.40) and magnesium (odds ratio, 0.40; 95% confidence interval, 0.28–0.55) were significantly and inversely associated with ruptured intracranial aneurysms.

Conclusion : In this large case–control study, hypocalcemia and hypomagnesemia at diagnosis were significantly associated with ruptured aneurysms. Impaired hemostasis caused by hypocalcemia and hypomagnesemia may explain this association.

Conclusion (proposition de traduction) : Dans cette vaste étude cas-témoins, l'hypocalcémie et l'hypomagnésémie, au moment du diagnostic, étaient significativement associées à des anévrismes rompus. Un trouble de l'hémostase occasionnée par une hypocalcémie et une hypomagnésémie peut expliquer cette association.

Continuation or Discontinuation of Anticoagulation in the Early Phase After Acute Ischemic Stroke.
Groot AE, and al. | Stroke. 2018 July;49:1762-1765
DOI: https://doi.org/10.1161/STROKEAHA.118.021514  | Télécharger l'article au format  
Keywords: anticoagulants; embolism; heparin; secondary prevention; stroke

Brief reports

Introduction : There is no consensus on whether anticoagulation should be continued or temporarily stopped in patients suffering acute ischemic stroke while using anticoagulation. We assessed treatment variations and outcomes in these patients.

Méthode : Post hoc analysis of PASS (Preventive Antibiotics in Stroke Study). We included patients with acute ischemic stroke who used anticoagulation at admission. We compared clinical outcomes, thrombotic, and major bleeding events at 3 months.

Résultats : Nine percent (192/2101) of the patients with acute ischemic stroke used anticoagulation at admission (186 vitamin K antagonists). Anticoagulation was discontinued in 35/192 (18%) patients. These patients had higher National Institutes of Health Stroke Scale scores than patients in whom anticoagulation was continued (median, 13 versus 4; P<0.001). Thrombotic events occurred more frequently in patients in whom anticoagulation was discontinued (11% versus 3%; P=0.038). There were no major bleeding events in either group. Mortality and clinical outcomes at 90 days were worse in patients in whom anticoagulation was discontinued (mortality, 31% versus 15%; P=0.019 and modified Rankin Scale score of 0–2, 20% versus 55%; P<0.001). After adjustment for potential confounders, there were no statistically significant differences between groups.

Conclusion : In our study, clinicians tended to continue anticoagulation in patients with acute ischemic stroke. Discontinuation was associated with an increased risk of thrombotic events and worse clinical outcome. Risk of major bleeding was not increased in patients in whom anticoagulation was continued.

Conclusion (proposition de traduction) : Dans notre étude, les praticiens ont eu tendance à poursuivre l’anticoagulation chez les patients ayant subi un AVC ischémique aigu. L'arrêt du traitement était associé à un risque accru d'événements thrombotiques et à une aggravation des résultats cliniques. Le risque d'hémorragie majeure n'a pas augmenté chez les patients chez qui l'anticoagulation a été poursuivie.

Blood Pressure in Acute Stroke. To Treat or Not to Treat: That Is Still the Question.
Bath PM, Appleton JP, Krishnan K, Sprigg N. | Stroke. 2018 July;49:1784-1790
DOI: https://doi.org/10.1161/STROKEAHA.118.021254  | Télécharger l'article au format  
Keywords: Aucun

Topical Review

Editorial : One of the oldest questions in acute stroke management, and perhaps the most challenging since it has yet to be solved after more than half a century of published research, is how to manage high blood pressure (BP).

Conclusion : In contrast to remaining questions about efficacy within 6 hours, no agents appear to be beneficial when given later than 6 hours; worse, some classes appear to be hazardous includ- ing angiotensin receptor antagonist in intracerebral hemorrhage, intravenous calcium channel blocker in ischemic stroke, and β–receptor antagonist in either stroke type. Guidelines that recommend the use of labetalol (with predominant β–receptor antagonist activity) and calcium channel blocker for lowering blood pressure in acute stroke may need to be revised.

Conclusion (proposition de traduction) : Contrairement aux autres questions sur l'efficacité dans les 6 heures, aucun agent ne semble être bénéfique après 6 heures ; Pire encore, certaines classes semblent être dangereuses, notamment les antagonistes des récepteurs de l'angiotensine (candesartan po) dans les hémorragies intracérébrales, les inhibiteurs calciques (nimodipine) intraveineux dans les accidents vasculaires cérébraux ischémiques et les antagonistes des récepteurs β (atenolol, propranolol po) dans les deux types d'AVC. Il faudra peut-être réviser les lignes directrices recommandant l'utilisation du labétalol (avec une activité prédominante antagoniste des récepteurs β) et des inhibiteurs calciques pour abaisser la tension artérielle en cas d'AVC aigu.

Factor Xa Inhibitors Versus Vitamin K Antagonists for Prevention of Cerebral or Systemic Embolism in Patients With Atrial Fibrillation.
Bruins Slot KM1, Berge E. | Stroke. 2018 July;49:e235-e236
DOI: https://doi.org/10.1161/STROKEAHA.118.021521  | Télécharger l'article au format  
Keywords: atrial fibrillation; factor Xa inhibitors; stroke; vitamin K antagonists

Cochrane Corner

Editorial : Anticoagulant treatment is recommended for the preven- tion of stroke and systemic embolic events in people with atrial fibrillation. Factor Xa inhibitors have practical advan- tages over vitamin K antagonists and are increasingly being used in clinical practice.

Conclusion : Factor Xa inhibitors reduced the number of strokes and sys- temic embolic events compared with warfarin in people with atrial fibrillation. Factor Xa inhibitors also reduced the number of major bleedings, intracranial hemorrhages, and all-cause deaths, but the evidence for the reduction in major bleedings is of lower quality because of the higher heterogeneity for this end point.

Conclusion (proposition de traduction) : Les inhibiteurs du facteur Xa ont réduit le nombre d'accidents vasculaires cérébraux et d'événements emboliques systémiques par rapport à la warfarine chez les personnes atteintes de fibrillation auriculaire. Les inhibiteurs du facteur Xa ont également réduit le nombre d'hémorragies majeures, d'hémorragies intracrâniennes et de décès toutes causes confondues, mais la preuve de la réduction des hémorragies majeures est de moindre qualité en raison de l'hétérogénéité plus élevée pour ce critère.

Commentaire : Pour mémoire, on distingue deux modes d’anticoagulation directe :
- les inhibiteurs directs du facteur Xa : apixaban (Eliquis®), rivaroxaban (Xarelto®) et edoxaban (Lixiana®). Ce dernier n’est pas commercialisé ;
- et un inhibiteur direct de la thrombine (anti-IIa) : dabigatran (Pradaxa®).
Enfin, vous pouvez consulter le document de bon usage de la HAS : Bon usage du médicament - Fibrillation auriculaire non valvulaire. Quelle place pour les anticoagulants oraux ?  .

Analgosedative interventions after rapid sequence intubation with rocuronium in the emergency department.
Kilber E, Jarrell DH, Sakles JC, Edwards CJ, Patanwala AE. | Am J Emerg Med. 2018 Jul;36(7):1129-1133
DOI: https://doi.org/10.1016/j.ajem.2017.11.022
Keywords: Anesthesia and analgesia; Awareness; Emergency medical services; Hypnotics and sedatives; Intubation; Neuromuscular blocking agents

Original Contribution

Introduction : The use of etomidate and rocuronium for rapid sequence intubation (RSI) results in a duration of paralysis that exceeds the duration of sedation. The primary objective of this study was to compare the number of analgosedative (AGS) interventions early versus late post-RSI, with this drug combination. The secondary objective was to descriptively assess time to first AGS intervention.

Méthode : This was a retrospective cohort study conducted in an academic ED in the United States between January 2015 and June 2016. The study was conducted after a pharmacy-led education program. Consecutive adult patients who received the combination of etomidate and rocuronium for RSI were included. The primary outcome measure was the number of AGS interventions post-RSI. An AGS intervention was defined as initiation of an opioid or sedative, or a dose increase of an infusion rate. Interventions were categorized as early (0-30min post-RSI) or late (60-90min post-RSI).

Résultats : The sample (n=108) had a mean age of 58±19years, and the majority was male (n=62, 57%). The mean rocuronium dose was 1.1±0.3mg/kg. There was a median of 2 interventions (IQR 1-3) that occurred early versus 0 interventions (IQR 0 to 1) that occurred late post-RSI (p<0.001). The median time to first AGS intervention was 7min (IQR 3 to 13min).

Conclusion : When rocuronium was used for RSI in the ED there was no delay in provision of post-intubation sedation or analgesia, after a pharmacy-led educational program.

Conclusion (proposition de traduction) : Lorsque le rocuronium a été utilisé pour l'intubation à séquence rapide aux urgences, il n'y a pas eu de retard dans la mise en oeuvre de la sédation post-intubation ou l'analgésie, après un programme éducatif dirigé par la pharmacie.

Visualization of the inferoposterior thoracic wall (VIP) and boomerang signs-novel sonographic signs of right pleural effusion.
Lau JSK, Yuen CK, Mok KL, Yan WW, Kan PG. | Am J Emerg Med. 2018 Jul;36(7):1134-1138
DOI: https://doi.org/10.1016/j.ajem.2017.11.023
Keywords: Boomerang; FAST scan; Pleural effusion; Point-of-care ultrasound; VIP

Original Contribution

Introduction : This study is to present the diagnostic values of the novel sonographic visualization of the inferoposterior thoracic wall (VIP) and boomerang signs in detecting right pleural effusion by sonologists with little to no experience in ultrasound.

Méthode : A prospective analysis of a convenience sample of patients who were assessed by junior intensive care physicians was performed. The patients all underwent computed tomography (CT) of the chest or abdomen with lung bases as part of their care regardless of indication; the results were interpreted by radiologists and were considered the gold standard. Sonography was performed to assess for the presence of the VIP and boomerang signs. Sonographic and chest radiographic findings were compared against CT results.

Résultats : 73 patients were enrolled. The sensitivity and specificity for the VIP sign were 0.85 (95% confidence interval [CI], 0.67-0.94) and 0.86 (95% CI, 0.70-0.95). The sensitivity and specificity for the boomerang sign were 0.78 (95% CI, 0.60-0.90) and 0.87 (95% CI, 0.71-0.95). However, the sensitivity and specificity for the traditional approach of detecting an anechoic collection above the diaphragm to indicate pleural effusion were only 0.54 (95% CI, 0.37-0.71) and 0.86 (95% CI, 0.80-0.99).

Conclusion : Despite inexperience in sonography, the novel VIP and boomerang signs show high diagnostic values in detecting right pleural effusion compared to the traditional methods.

Conclusion (proposition de traduction) : Malgré l'inexpérience en échographie, les nouveaux signes VIP et boomerang montrent des valeurs diagnostiques élevées dans la détection de l'épanchement pleural droit par rapport aux méthodes traditionnelles.

Peri-intubation factors affecting emergency physician choice of paralytic agent for rapid sequence intubation of trauma patients.
West JR, Lott C, Donner L, Kanter M, Caputo ND. | Am J Emerg Med. 2018 Jul;36(7):1151-1154
DOI: https://doi.org/10.1016/j.ajem.2017.11.038
Keywords: Aucun

Original contribution

Introduction : No study has assessed predictors of physician choice between the succinylcholine (Succ) and rocuronium (Roc) for rapid sequence intubation (RSI) during the initial resuscitation of trauma patients in the emergency department (ED).

Méthode : We retrospectively evaluated of the use of Succ and Roc for adult trauma patients undergoing RSI at a Level 1 trauma center. The primary outcome was to identify factors affecting physician choice of paralytic agent for RSI analyzed by cluster analysis using pre-intubation vital signs and early mortality. The secondary outcome was to identify factors influencing physician choice of paralytic agent using a logistic regression model reported as adjusted odds ratios (aOR).

Résultats : The analysis included 215 patients, including 148 receiving Succ and 67 receiving Roc. The two groups were similar in regard to age, provider level of training, mean GCS (10 vs. 10) and median ISS (27 vs. 27). Cluster analysis using peri-intubation patient vital signs and early mortality indicates that patients with predominantly abnormal vital signs and early mortality were more likely to receive Roc (74%) than those without abnormal vital signs prior to intubation or early mortality (24%). Hypoxemia prior to RSI (aOR 12.3 [2.5-60.9]) and the use of video laryngoscopy (VL) (aOR 5.5 [1.2-24.6]) were associated with the choice to use Roc.

Conclusion : Roc was more frequently chosen for paralysis in the patient cluster with predominantly abnormal peri-intubation vital signs and higher rate of early ED mortality. The use of Roc was associated with hypoxemia prior to RSI and VL.

Conclusion (proposition de traduction) : Le rocuronium a été plus fréquemment choisi comme curare dans le groupe des patients avec des signes vitaux per-intubation anormaux prédominants et a été associé à un taux plus élevé de mortalité précoce dans les services d'urgence. L'utilisation du rocuronium a entraîné plus d'hypoxémie lors de l'intubation en séquence rapide rapide et avec l'utilisation de la vidéolaryngoscopie.

Initial inferior vena cava diameter predicts massive transfusion requirements in blunt trauma patients: A retrospective cohort study.
Takada H, Hifumi T, Yoshioka H, Okada I, Kiriu N, Inoue J, Morimoto K, Matsumoto J, Koido Y, Kato H. | Am J Emerg Med. 2018 Jul;36(7):1155-1159
DOI: https://doi.org/10.1016/j.ajem.2017.11.049
Keywords: Inferior vena cava diameter; Massive transfusion; Trauma; Whole body CT

Original contribution

Introduction : The inferior vena cava (IVC) diameter is associated with shock and increased mortality in trauma patients. However, there are no reports examining the association between the IVC diameter and massive transfusion (MT) requirements in trauma patients. The aim of this study was to evaluate the association between IVC diameter and MT requirements in patients with blunt trauma.

Méthode : We retrospectively reviewed all patients who were consecutively hospitalized with blunt trauma (Injury Severity Score [ISS] ≥16) between from November 1, 2011 to March 30, 2016. Univariate and multivariate analyzes were performed to identify the independent predictors of MT (defined as >10units of red cell concentrate transfusions within 24h of admission). Receiver operating characteristic curve and the area under the curve (AUC) were estimated.

Résultats : Of the 222 patients included in this study, MT occurred in 22.5% patients. On multiple regression analysis, IVC diameter [Odds ratio (OR), 0.88; 95% confidence interval (CI), 0.80-0.96; p<0.01], fibrin degradation product (FDP; OR, 1.01; 95% CI, 1.00-1.01; p<0.01), and fibrinogen level (OR, 0.99; 95% CI, 0.98-1.00; p<0.01) were strong predictors of MT. IVC diameter demonstrated moderate accuracy (AUC, 0.74; cutoff level, 13.0mm; sensitivity, 67%; specificity, 73%). Combined cutoff levels of FDP <80.5μg/ml, fibrinogen ≥165mg/dl, and IVC diameter ≥13mm could also determine how unnecessary a MT was with 100% accuracy.

Conclusion : Initial IVC diameter is a predictor of MT in blunt trauma patients.

Conclusion (proposition de traduction) : Le diamètre initial de la veine cave inférieure est un facteur prédictif de transfusion massive chez les patients présentant un traumatisme contondant.

Commentaire : Les auteurs concluent que les seuils combinés du taux de produit de dégradation de la fibrine (PDF) < 80.5 μg/ml, du taux de fibrinogène ≥ 165 mg/dl et du diamètre de la VCI ≥ 13 mm pourraient exclurent avec une précision de 100 % la nécessité d'une transfusion massive pour ces patients.

Point-of-care hip ultrasound in a pediatric emergency department.
Cruz CI, Vieira RL, Mannix RC, Monuteaux MC, Levy JA. | Am J Emerg Med. 2018 Jul;36(7):1174-1177
DOI: https://doi.org/10.1016/j.ajem.2017.11.059
Keywords: Pediatric, Point-of-care, Ultrasound, Hip

original contribution

Introduction : Use of point-of-care ultrasound (POCUS) by Pediatric Emergency Medicine (PEM) physicians is becoming increasingly common. Detecting a hip effusion with POCUS could narrow a broad differential diagnosis and result in change in management. We sought to evaluate the test characteristics of PEM-physician performed hip POCUS to identify hip effusions and to determine the association between ultrasound accuracy and sonographer experience.

Méthode : We performed a single-center, retrospective study of hip POCUS studies performed by PEM physicians. All studies were reviewed and assessed for accuracy by ultrasound faculty, which was considered the gold standard. Standard performance metrics (sensitivity, specificity, positive and negative predictive values) and statistical accuracy were calculated. To evaluate the association between sonographer accuracy and prior experience with POCUS, we estimated a logistic regression model with study accuracy as the dependent variable and prior number of hip POCUS studies as the independent variable.

Résultats : 926 hip POCUS exams were performed in 516 patients by 72 different PEM providers, which included 42 PEM attending physicians and 30 PEM fellow physicians. PEM physician- performed hip POCUS had a sensitivity of 85% (95% confidence interval [CI] 79 to 89) and a specificity of 98% (CI 96 to 99). Overall accuracy was 93% (CI 92 to 95). There was a positive association between sonographer experience and hip POCUS accuracy (test for linear trend: OR [95% CI] = 1.02 [1.01 to 1.04]).

Conclusion : PEM physician-performed hip POCUS has excellent test characteristics, and increased experience results in increased accuracy.

Conclusion (proposition de traduction) : L'échographie au point d'intervention de la hanche réalisée par un urgentiste pédiatre est un test avec d'excellentes caractéristiques et l'expérience accrue entraîne une précision accrue.

Commentaire : Consulter à ce propos l'article de Tsung JW et Blaivas M dans J Emerg Med. 2008 Nov;35(4):393-9   intitulé : Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound.

An alternative tool for triaging patients with possible acute coronary symptoms before admission to a chest pain unit.
Tsai KC, Lin RF, Lee C, Li AH. | Am J Emerg Med. 2018 Jul;36(7):1222-1230
DOI: https://doi.org/10.1016/j.ajem.2017.12.026
Keywords: Acute coronary syndrome; Chest pain unit; Emergency department; Observation unit; Tria

Original contribution

Introduction : This study aimed to develop a triage tool to more effectively triage possible ACS patients presenting to the emergency department (ED) before admission to a protocol-driven chest pain unit (CPU).

Méthode : Seven hundred ninety-three clinical cases, randomly selected from 7962 possible ACS cases, were used to develop and test an ACS triage model using cluster analysis and stepwise logistic regression.

Résultats : The ACS triage model, logit (suspected ACS patient)=-5.283+1.894×chest pain+1.612×age+1.222×male+0.958×proximal radiation pain+0.962×shock+0.519×acute heart failure, with a threshold value set at 2.5, was developed to triage patients. Compared to four existing methods, the chest-pain strategy, the Zarich's strategy, the flowchart, and the heart broken index (HBI), the ACS triage model had better performance.

Conclusion : This study developed an ACS triage model for triaging possible ACS patients. The model could be used as a rapid tool in EDs to reduce the workloads of ED nurses and physicians in relation to admissions to the CPU.

Conclusion (proposition de traduction) : Cette étude a permis d'élaborer un modèle de triage des symptômes coronariens aigus pour le triage d'éventuels patients présentant des symptômes coronariens aigus. Le modèle pourrait être utilisé comme outil rapide dans les services d'urgence pour réduire la charge de travail des infirmières et des médecins des services d'urgence en ce qui concerne les admissions à l'unité des douleurs thoraciques.

Pain management of acute limb trauma patients with intravenous lidocaine in emergency department.
Farahmand S, Hamrah H, Arbab M, Sedaghat M, Basir Ghafouri H, Bagheri-Hariri S. | Am J Emerg Med. 2018 Jul;36(7):1231-1235
DOI: https://doi.org/10.1016/j.ajem.2017.12.027
Keywords: Acute pain; Emergency service, hospital; Lidocaine; Morphine; Pain management

Original contribution

Introduction : This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management.

Méthode : This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant.

Résultats : Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49).

Conclusion : The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

Conclusion (proposition de traduction) : La réduction du score de douleur à l'aide de lidocaïne IV n'est pas supérieure à la morphine IV chez les patients adultes souffrant de douleurs traumatiques au niveau des membres.

Commentaire : Voir sur les articles dans la bibliographie du mois de juillet : Am J Emerg Med. 2018 Jul 9. pii: S0735-6757(18)30578-3   (lidocaïne dans la colique néphrétique), Am J Ther. 2018 Jan 23   (lidocaïne dans la colique néphrétique avec douleur réfractaire) et Emerg (Tehran). 2018;6(1):e24   (lidocaïne dans la luxation de l’épaule).
A ce sujet consulter également la méta-analyse de E Silva LOJ dans Ann Emerg Med. 2018 Aug;72(2):135-144.e3  .

Pain management of renal colic in the emergency department with intravenous lidocaine.
Motov S, Drapkin J, Butt M, Monfort R, Likourezos A, Marshall J. | Am J Emerg Med. 2018 Jul 9. pii: S0735-6757(18)30578-3.
DOI: https://doi.org/10.1016/j.ajem.2018.07.021
Keywords: Emergency department; Lidocaine; Renal colic

Original article

Introduction : To describe our experience with intravenous lidocaine (IVL) to manage pain of renal colic origin in the emergency department (ED).

Méthode : A retrospective analysis of all patients presenting with pain of renal colic origin from the periods of 2014 to 2017 by using the ED electronic medical record database (Allscripts™).

Résultats : Forty-four patients received IVL for renal colic over a three-year period. The average dose of IVL as a primary analgesic was 117.2 mg, and as a rescue was 108 mg. Administration of IVL resulted in a decrease in overall pain score by 6.3 points (numerical rating scale), by 7.4 points when IVL was used as a primary analgesic, and by 5.2 points when IVL was given as a rescue. There were no documented adverse effects.

Conclusion : Intravenous lidocaine has a potential of being used for patients presenting to the ED with a pain of renal colic origin as a primary analgesic or as a rescue. Although promising, this therapy will need to be studied in prospective randomized fashion and larger patients' population with underlying cardiac disease before it can be recommended for broad use in the ED.

Conclusion (proposition de traduction) : La lidocaïne intraveineuse peut être utilisée chez les patients se présentant au service des urgences avec une douleur de colique néphrétique en tant qu'analgésique primaire ou en tant que secours. Bien que prometteuse, cette thérapie devra être étudiée de manière prospective et randomisée et la population de patients plus grands présentant une maladie cardiaque sous-jacente avant de pouvoir être recommandée pour une large utilisation au service des urgences.

Topical tranexamic acid for the treatment of acute epistaxis in the emergency department.
Birmingham AR, Mah ND, Ran R, Hansen M. | Am J Emerg Med. 2018 Jul;36(7):1242-1245
DOI: https://doi.org/10.1016/j.ajem.2018.03.039
Keywords: Acute epistaxis; Emergency medicine; Intranasal; Nosebleed; Otolaryngology; Pharmacy; Topical; Tranexamic acid

Brief Reports

Introduction : To evaluate the effectiveness and potential benefits of topical tranexamic acid (TXA) in the management of acute epistaxis.

Méthode : Retrospective review was performed among all patients presenting to the institution's emergency department (ED) with epistaxis between September 2014 and August 2016. Patients achieving hemostasis with standard of care agents, such as oxymetazoline, lidocaine, or epinephrine were excluded. The primary outcome was the ED length of stay (LOS). Secondary outcomes included the incidence of hospital admission, otolaryngologist consultation, nasal packing, prophylactic antibiotic use, and ED visit for rebleeding within seven days of treatment.

Résultats : Among 122 patients, 30 received topical TXA (500mg injectable solution soaked onto packing material and applied to the affected nostril) and 92 were managed with standard care. Nearly half (46.7%) of TXA-treated subjects received TXA either alone or in combination with standard of care agents as their initial treatment strategy. No significant difference was observed in the ED LOS (272 vs 232min in TXA and standard care arms, respectively, p=0.26). However, TXA was associated with a significant reduction in otolaryngologist consults (30.0% vs 65.2%, p=0.002) and nasal packing (16.7% vs 23.9%, p=0.003).

Conclusion : This investigation did not demonstrate a significant difference in ED LOS among patients with acute epistaxis treated with topical TXA or standard care. However, this data does add to existing evidence that TXA may be associated with a reduction in resource utilization, suggesting it may provide more effective bleeding control. Overall, more data is needed to confirm the potential benefits of this practice.

Conclusion (proposition de traduction) : Cette étude n'a pas démontré de différence significative dans la durée du séjour aux urgences chez les patients présentant une épistaxis aiguë traitée avec de l'acide tranexamique topique ou des soins standard. Cependant, ces données s'ajoutent aux preuves existantes selon lesquelles l'acide tranexamique topique peut être associé à une réduction de l'utilisation des ressources, ce qui laisse entendre qu'il peut fournir un contrôle plus efficace des saignements.
Dans l'ensemble, il faut plus de données pour confirmer les avantages potentiels de cette pratique.

Association between body mass index and clinical outcomes of patients after cardiac arrest and resuscitation: A meta-analysis.
Ma Y, Huang L, Zhang L, Yu H, Liu B. | Am J Emerg Med. 2018 Jul;36(7):1270-1279
DOI: https://doi.org/10.1016/j.ajem.2018.03.079
Keywords: Body mass index; Cardiac arrest; Meta-analysis; Resuscitation

Reviews

Introduction : Obesity as one of the risk factors for cardiovascular diseases increases mortality in general population. Several clinical studies investigated clinical outcomes in patients with different body mass index (BMI) after cardiac arrest (CA). Controversial data regarding BMI on clinical outcomes in those patients exist in those studies. Therefore, we conducted a meta-analysis to evaluate the effect of BMI on survival condition and neurological prognosis in those patients.

Méthode : We searched Pubmed, Embase, Ovid/Medline and EBM reviews databases for relational studies investigating the association between BMI and clinical outcomes of patients after CA. Seven studies involving 25,035 patients were included in this meta-analysis. Primary outcome was survival condition and secondary outcome was neurological prognosis. Three comparisons were conducted: underweight (BMI<18.5) versus normal weight (18.5≤BMI<25), overweight (25≤BMI<30) versus normal weight and obese (BMI≥30) versus normal weight.

Résultats : Using normal weight patients as reference, underweight patients had a higher mortality (odds ratio [OR] 1.35; 95% confidence interval [CI] 1.10 to 1.66; P=0.004; I2=17%). Overweight was associated with increased hospital survival (OR 0.80; 95% CI 0.65 to 0.98; P=0.03; I2=62%) and better neurological recovery (OR 0.72; 95% CI 0.61 to 0.85; P<0.001; I2=0%). No significant difference was found in clinical outcomes between obese and normal weight patients.

Conclusion : Low BMI was associated with lower survival rate in CA patients. Overweight was associated with a higher survival rate and better neurological recovery. Clinical outcomes did not differ between obese and normal weight patients. Further studies are needed to explore the underlying mechanisms.

Conclusion (proposition de traduction) : Un faible IMC était associé à un taux de survie plus faible chez les patients ayant subi un arrêt cardiaque. Le surpoids était associé à un taux de survie plus élevé et à une meilleure récupération neurologique. Les résultats cliniques ne différaient pas entre les patients obèses et les patients de poids normal. D'autres études sont nécessaires pour explorer les mécanismes sous-jacents.

Ventricular assist device in the emergency department: Evaluation and management considerations.
Brady W, Weigand S, Bergin J. | Am J Emerg Med. 2018 Jul;36(7):1295-1299
DOI: https://doi.org/10.1016/j.ajem.2018.04.047
Keywords: Heart failure; LVAD; Left ventricular assist device

Review

Introduction : Ventricular assist devices (VAD) are being used at increasing rates in patients with severe, end-stage heart failure. Specific indications include VAD placement as a bridge to cardiac function recovery, a bridge to cardiac transplantation, or destination therapy (long-term support for patients ineligible for transplant). The assessment and management of the VAD patient is rather complex, requiring a basic knowledge of device structure and function. This article reviews the basic structure and function, discusses the approach to the VAD patient in the ED, and reviews the more common presentations and complications encountered in these technology-complex patients who are critically ill at baseline.

Conclusion : With the increasing prevalence of LVADs, emergency providers will likely manage these patients. Presentations can include inconsequential events unrelated to the VAD as well as life threatening situations resulting from or complicated by the presence of the device. Specialty guidance and consultation are recommended in most of these situations.

Conclusion (proposition de traduction) : Avec l'augmentation de la prévalence des dispositifs d'assistance ventriculaire gauche, les urgentistes vont probablement prendre en charge ces patients. Les présentations cliniques peuvent comprendre des événements sans importance sans rapport avec le dispositif d'assistance ventriculaire ainsi que des situations mettant la vie en danger résultant de la présence du dispositif ou compliquées par la présence du dispositif.
Des conseils et des consultations spécialisés sont recommandés dans la plupart de ces situations.

A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers.
Noorvash Snider MA, Wan JY, Jacobs J, Kink R, Gilmore B, Arnold SR. | J Emerg Med. 2018 Jul;55(1):7-14
DOI: https://doi.org/10.1016/j.jemermed.2018.03.002
Keywords: Pediatric Asthma Score; asthma exacerbation; breath-actuated nebulizer; emergency department length of stay; intravenous magnesium sulfate; metered-dose inhaler; respiratory therapist; small volume nebulizer

Original Contributions

Introduction : Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department.
OBJECTIVE: We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations.

Méthode : This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10.

Résultats : We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority.

Conclusion : Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.

Conclusion (proposition de traduction) : Le traitement à l'albutérol par inhalateur doseur n'est pas inférieur au nébuliseur à action respiratoire pour le traitement des exacerbations légères à modérées de l'asthme chez les enfants de 2 à 17 ans.

No Radiographic Safe Margin Found in the "Easy IJ" Internal Jugular Vein Procedure.
McCarter RN, Moayedi S, Witting MD. | J Emerg Med. 2018 Jul;55(1):29-33
DOI: https://doi.org/10.1016/j.jemermed.2018.04.011
Keywords: administration; catheterization; central; intravenous; jugular vein; pneumothorax

Brief Report

Introduction : The Easy IJ procedure involves placement of a 4.8-cm intravenous catheter into the internal jugular (IJ) vein using ultrasound guidance. It is not known whether this needle length has the potential to cause a pneumothorax.
OBJECTIVE: The objective of this study was to determine if a radiographic "safe margin" exists. We hypothesized that an average margin of ≥2 cm would exist between the catheter tip and the pleura.

Méthode : Operators used a central approach to the IJ vein. We reviewed radiographic images taken immediately after the Easy IJ procedure. Using digital software, we measured the distance from the catheter tip to the closest point of the pleura and from the catheter tip to the level of the lung apex. We defined distances exceeding the margin of safety-either passing the pleura or ending inferior to the apex-as negative for the purpose of calculating an average. We used the t distribution to calculate 95% confidence intervals (CIs) for average values.

Résultats : Radiographs showing the catheter tip were available from 62 patients. The mean needle-to-pleura distance was -0.1 cm (95% CI -0.7 to 0.5 cm). The mean vertical distance to the apex was -0.2 cm (95% CI -0.8 to 0.3 cm), with a standard deviation of 2.25 cm.

Conclusion : Radiographic analysis failed to show a margin of safety for the Easy IJ procedure. Postprocedure imaging may still be necessary to exclude pneumothorax.

Conclusion (proposition de traduction) : L'analyse radiographique n'a pas réussi à montrer une marge de sécurité pour la procédure Easy IJ. L'imagerie post-opératoire peut encore être nécessaire pour exclure le pneumothorax.

Commentaire : L'accès veineux périphérique (avec un cathlon standard pour voie veineuse périphérique) dans la veine jugulaire interne (internal jugular vein « Easy IJ ») avec guidage par ultrasons est utilisé aux urgences, aux Etats-Unis, chez des patients stables qui sont impiquables [patients nécessitant un accès veineux mais avec tentatives infructueuses d'établir l'accès à la veine jugulaire externe ou périphérique (y compris les tentatives utilisant des ultrasons)] avant d'avoir recours à l'intra-osseuse.

Systematic Review: Rectal Administration of Medications for Pediatric Procedural Sedation.
Lam SHF, Li DR, Hong CE, Vilke GM. | J Emerg Med. 2018 Jul;55(1):51-63
DOI: https://doi.org/10.1016/j.jemermed.2018.04.025
Keywords: pediatric; rectal; review; sedation

Clinical Reviews

Introduction : Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic.
OBJECTIVE: Our aim was to provide emergency physicians with an overview of PR procedural sedation medications in pediatric patients.

Méthode : We performed a PubMed literature search of relevant keywords limited to studies of human subjects published in English between January 1, 1990 and December 31, 2017. We excluded case reports, general review articles, editorial/opinion pieces, correspondence, and abstracts. Two of the authors then conducted a structured review of the selected studies.

Résultats : A total of 315 PubMed citations meeting the search criteria were found. Twenty-eight articles were included for final detailed review. Only 4 of the 28 included studies were conducted in the emergency department setting. A total of 9 different medications have been studied for PR procedural sedation. Sedation effectiveness ranged from 40% to 98%. No life-threatening complications were reported in any of the included clinical trials. Hypoxia was found to occur in up to 10% of those receiving PR sedation.

Conclusion : Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed.

Conclusion (proposition de traduction) : La sédation chirurgicale pédiatrique avec des médicaments administrés par voie rectale semble être faisable, modérément efficace et sans danger d'après notre revue de la littérature actuelle. Toutefois, d'autres études sur son applicabilité dans les services d'urgence sont nécessaires.

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, Regan S, Long J, Slowther A, Pocock H, Black JJM, Moore F, Fothergill RT, Rees N, O'Shea L, Docherty M, Gunson I, Han K, Charlton K, Finn J, Petrou S, Stallard N, Gates S, Lall R; PARAMEDIC2 Collaborators. | N Engl J Med. 2018 Jul 18
DOI: https://doi.org/10.1056/NEJMoa1806842  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients.

Méthode : In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]).

Résultats : At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]).

Conclusion : In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.

Conclusion (proposition de traduction) : Chez les adultes ayant subi un arrêt cardiaque hors hôpital, l'utilisation de l'épinéphrine a entraîné un taux de survie à 30 jours significativement plus élevé que l'utilisation d'un placebo, mais il n'y avait pas de différence significative entre les groupes dans le taux d'issue neurologique favorable parce que plus de survivants présentaient une atteinte neurologique grave dans le groupe épinéphrine.

Commentaire : Selon l’étude clinique randomisée britannique PARAMEDICS2 parue dans le New England Journal of Medicine, l’injection d’adrénaline durant la prise en charge en urgence de l’arrêt cardiaque extra-hospitalier permettrait d’améliorer le retour de la circulation spontanée et le taux de prise en charge en soins intensifs. Mais la survie à 30 jours avec un pronostic neurologique favorable, qui constituait le critère principal d’évaluation, n’était pas différent entre les deux bras de l’étude (2,2 % vs 1,9 %), le taux de sujets conservant des séquelles neurologiques sévères étant supérieur (31 vs 17,8 %). La posologie et le délai d’administration de l’adrénaline, tous deux élevés, pourraient avoir influencé ces résultats ; d’autres conditions expérimentales auraient pu aboutir à un résultat différent. Pour autant, ces résultats ne soutiennent pas l’utilisation hors les murs de l’adrénaline dans la prise en charge de l’arrêt cardiaque.
En termes de mécanisme physiopathologique, les auteurs posent deux hypothèses : au niveau du tissu cérébral, l’adrénaline pourrait à la fois améliorer la circulation macrovasculaire tout en la réduisant au niveau microvasculaire. Il se pourrait aussi que le cerveau soit plus vulnérable aux effets de la reperfusion ou d’ischémie (Univadis  ).