Reduction of Parenteral Opioid Use in Community Emergency Departments Following Implementation of Treatment Guidelines.
Ghobadi A, Van Winkle PJ, Menchine M, Chen Q, Huang BZ, Sharp AL. | Acad Emerg Med. 2018 August;25(8):901-910
Introduction : Opioid prescribing guidelines are commonly seen as part of the solution to America's opioid epidemic. However, the effectiveness of specific treatment guidelines on altering opioid prescribing in the emergency department (ED) is unclear. We examined provider ordering patterns before and after implementation of opioid use guidelines for ED patients overall and the specific subsets of ED patients with either chronic opioid use or fracture.
Méthode : We conducted a pre-post interrupted time series analysis of adult (≥18 years old) ED encounters in 14 integrated community EDs before (2013) and after (2014) the implementation of opioid prescribing guidelines. We compared opioid use pre- and postintervention using segmented logistic regression for primary and secondary analyses. The primary outcome was parenteral opioid use in the ED, with additional subgroup analysis of chronic pain and fracture cohorts. We also examined ED oral opioid use and discharge prescribing.
Résultats : There were 508,337 pre- and 531,620 postintervention encounters. The intervention was associated with an initial reduction in the odds of parenteral opioids ordered (odds ratio [OR] = 0.89, 95% CI = 0.87-0.91) and a decrease in the monthly trend compared to the preintervention period (OR = 0.99, 95% CI = 0.99-0.99). The immediate reduction in parenteral opioid use was significantly larger in the cohort of patients with chronic pain (OR = 0.81, 95% CI = 0.72-0.91), whereas the fracture cohort showed no change (OR = 1.10, 95% CI = 0.97-1.25).
Conclusion : The use of an opioid ordering guideline was associated with significant reduction in parenteral opioid use in the ED and as intended subgroup comparisons suggest that acute fractures were not affected and chronic pain visits were associated with larger decreases in opioid use.
Conclusion (proposition de traduction) : L'utilisation de recommandation sur la prescription des opioïdes était associée à une réduction significative de la consommation d'opioïdes parentéraux au service d'urgence, et la comparaison des sous-groupes suggèrent que les douleurs de fractures aiguës n'étaient pas affectées et que les consultations pour douleur chronique diminuaient.
Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta‐analysis.
Sakamoto JT, Ward HB, Vissoci JRN, Eucker SA. | Acad Emerg Med. 2018 August;25(8):940-957
Introduction : Pain is a common complaint in the emergency department (ED). Its management currently depends heavily on pharmacologic treatment, but evidence suggests that nonpharmacologic interventions may be beneficial. The purpose of this systematic review and meta-analysis was to assess whether nonpharmacologic interventions in the ED are effective in reducing pain.
Méthode : We conducted a systematic review of the literature on all types of nonpharmacologic interventions in the ED with pain reduction as an outcome. We performed a qualitative summary of all studies meeting inclusion criteria and meta-analysis of randomized controlled studies measuring postintervention changes in pain. Interventions were divided by type into five categories for more focused subanalyses.
Résultats : Fifty-six studies met inclusion criteria for summary analysis. The most studied interventions were acupuncture (10 studies) and physical therapy (six studies). The type of pain most studied was musculoskeletal pain (34 studies). Most (42 studies) reported at least one improved outcome after intervention. Of these, 23 studies reported significantly reduced pain compared to control, 24 studies showed no difference, and nine studies had no control group. Meta-analysis included 22 qualifying randomized controlled trials and had a global standardized mean difference of -0.46 (95% confidence interval = -0.66 to -0.27) in favor of nonpharmacologic interventions for reducing pain.
Conclusion : Nonpharmacologic interventions are often effective in reducing pain in the ED. However, most existing studies are small, warranting further investigation into their use for optimizing ED pain management.
Conclusion (proposition de traduction) : Les interventions non pharmacologiques sont souvent efficaces pour réduire la douleur aux urgences. Cependant, la plupart des études existantes sont de petites tailles, ce qui justifie des recherches plus approfondies sur leur utilisation pour optimiser la prise en charge de la douleur aux urgences.
Feral-Pierssens AL, Feral-Pierssens AL, Boulain T, Carpentier F, Le Borgne P, Del Nista D, Potel G, Dray S, Hugenschmitt D, Laurent A, Ricard-Hibon A, Vanderlinden T, Chouihed T, Reignier J et pour la Société française de médecine d’urgence et la Société de réanimation de langue française. | Ann Fr Med Urgence. 2018 Aug;8:246-251
DOI: https://doi.org/10.3166/afmu-2018-0058 | Télécharger l'article au format
Recommandations pour la pratique clinique
Editorial : Depuis plusieurs décennies, le public, la communauté médicale, les sociétés savantes et les législateurs ont reconnu les droits des patients à décider des traitements qui leur sont administrés et, pour les patients en fin de vie, à mourir dignement. Les lois et recommandations françaises récusent l’obstination déraisonnable et imposent le recueil de la volonté du patient (via ses directives anticipées lorsqu’il est inconscient), la réalisation d’une procédure collégiale le cas échéant et l’organisation d’une prise en charge palliative incluant, si nécessaire, une sédation profonde en fin de vie.
Conclusion (proposition de traduction) : La société de réanimation de langue française (SRLF) et la société française de médecine d’urgence (SFMU) ont jugé utile de réunir un groupe de travail constitué d’experts issus de la médecine d’urgence et de la réanimation dont la mission était de rédiger un texte qui se veut à la fois une prise de position sur ce sujet des limitations et arrêts des traitements de suppléance vitale dans le contexte de l’urgence, mais aussi un guide pour les professionnels exerçant dans le contexte de l’urgence. Le groupe a travaillé sur la base des textes de lois, recommandations et études publiés dont une sélection est répertoriée à la suite du texte.
The Newest Threat to Emergency Department Procedural Sedation.
Green SM, Roback MG, Krauss BS. | Ann Emerg Med. 2018 Aug;72(2):115-119
DOI: https://doi.org/10.1016/j.annemergmed.2017.12.008 | Télécharger l'article au format
Pain Management and Sedation
Editorial : Procedural sedation has long been a core competency in emergency medicine and critical care medicine, and our patients depend on us to provide effective sedation and analgesia for procedures that are often extremely painful (eg, cardioversion, abscess incision and drainage, fracture and dislocation reduction) or unduly frightening (eg, facial laceration repair, neuroimaging in a child). These revised ASA guidelines restrict the use of propofol and ketamine—our 2 most commonly administered sedative agents12-17—and any adoption or enforcement of these directives would restrict emergency physician access to these drugs, resulting in widespread use of alternative agents that are less safe and provide much less effective sedation and analgesia.
Conclusion : In summary, the ASA guideline update contains numerous confusing statements on critical issues relating to ED sedation practice and misleading characterizations in regard to deep sedation, ketamine, and propofol that are contrary to the existing scientific evidence. Key issues such as deep sedation, guideline relationships, skill sets, and specific drugs lack sufficient clarity for meaningful understanding or consistent interpretation. Given the critical need for emergency physicians to advocate on behalf of their patients, and given that each of the vague or omitted areas favors previously asserted adverse ASA positions, we believe that emergency physicians must assume the document to be politically motivated until proven otherwise. Emergency physicians are fully qualified by their training to administer all levels of sedation, and emergency medicine has long been at the forefront of sedation research and safe sedation practice. Non–evidence-based efforts by another specialty to dictate our scope of practice must be vigorously opposed.
Conclusion (proposition de traduction) : Les médecins urgentistes sont parfaitement qualifiés par leur formation pour administrer tous les niveaux de sédation et la médecine d'urgence est depuis longtemps à l'avant-garde de la recherche sur la sédation et de la pratique sécuritaire de la sédation.
Il faut s'opposer énergiquement aux efforts non fondés sur des preuves de la part d'une autre spécialité pour dicter notre champ d'exercice.
Commentaire : Toute ressemblance avec des situations réelles ou avec des personnes existantes ou ayant existé ne saurait être que fortuite…
Is Low-Dose Ketamine an Effective Alternative to Opioids for the Treatment of Acute Pain in the Emergency Department?.
Gottlieb M, Ryan KW, Binkley C. | Ann Emerg Med. 2018 Aug;72(2):133-134
DOI: https://doi.org/10.1016/j.annemergmed.2017.10.028 | Télécharger l'article au format
Pain Management and Sedation
Editorial : Two investigators extracted data with a predesigned form that included variables such as year, country, study design, clinical setting, low-dose ketamine and comparator dose or route or need for redosing, pain scores, and adverse outcomes. Study strength was determined with the Grading of Recommendations Assessment, Development, and Evaluation criteria. Risk of bias was assessed with the Cochrane Collaboration Risk of Bias tool. Meta-analysis was planned but not performed because of significant heterogeneity with respect to outcomes, methods, and indications for low-dose ketamine among the included studies.
Introduction : MEDLINE, EMBASE, Allied and Complementary Medicine Database, the Cumulative Index of Nursing and Allied Health, PubMed, the Cochrane Controlled Trial Registry, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched from inception through February 2015 for relevant studies. Manual searches of abstracts presented at selected emergency medicine and anesthesia conferences from 2012 to 2014 were also performed. The investigators reviewed the bibliographies of included articles and contacted the authors for additional relevant references. The search strategy was limited to randomized controlled trials and observational studies of human subjects published in English.
Résultats : The search identified 1,396 articles, of which 44 were deemed eligible for full-text review. Of these, a total of 8 articles (n1⁄4609 patients) were included in the final qualitative analysis. The review included 6 randomized controlled trials and 2 observational studies. Five studies were conducted in the United States, with the remainder conducted in France, India, and Iran. Most of the randomized controlled trials used low-dose ketamine, with doses ranging from 0.1 to 0.5 mg/kg given intravenously; however, one study followed the initial intravenous dose with a subcutaneous infusion at 0.1 mg/kg per hour. Another study that used a dose of 0.5 mg/kg gave patients concomitant midazolam at 0.3 mg/kg in the treatment group only. The comparator group included intravenous morphine at 0.05 to 0.1 mg/kg in all 6 of the included randomized controlled trials. In terms of analgesic effect, the 6 randomized controlled trials were rated as moderate quality whereas the 2 observational studies were rated as very low quality.
Conclusion : According to limited evidence, low-dose ketamine and morphine appear to provide similar levels of pain relief at 30 minutes; however, low-dose ketamine is associated with a higher rate of self-limited neuropsychological adverse events.
Conclusion (proposition de traduction) : Selon des données limitées, une faible dose de kétamine et de morphine semble procurer des niveaux similaires de soulagement de la douleur à 30 minutes ; cependant, une faible dose de kétamine est associée à un taux plus élevé d'événements indésirables neuropsychologiques limitants.
Safety and Efficacy of Intravenous Lidocaine for Pain Management in the Emergency Department: A Systematic Review.
E Silva LOJ, Scherber K, Cabrera D, Motov S, Erwin PJ, West CP, Murad MH, Bellolio MF. | Ann Emerg Med. 2018 Aug;72(2):135-144.e3
Pain Management and Sedation
Introduction : We evaluate the safety and efficacy of intravenous lidocaine in adult patients with acute and chronic pain who are undergoing pain management in the emergency department (ED).
Méthode : We searched Ovid CENTRAL, Ovid EMBASE, and Ovid MEDLINE databases for randomized controlled trials and observational studies from inception to January 2017. Efficacy outcomes included reduction in pain scores from baseline to postintervention and need for rescue analgesia. Safety outcomes included incidence of serious (eg, cardiac arrest) and nonserious (eg, dizziness) adverse events. We used the Cochrane Collaboration tool and a modified Newcastle-Ottawa Scale to evaluate the risk of bias across studies. The Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate the confidence in the evidence available.
Résultats : From a total of 1,947 titles screened, 61 articles were selected for full-text review. Eight studies met the inclusion criteria and underwent qualitative analysis, including 536 patients. The significant clinical heterogeneity and low quality of studies precluded a meta-analysis. Among the 6 randomized controlled trials included, intravenous lidocaine had efficacy equivalent to that of active controls in 2 studies, and was better than active controls in 2 other studies. In particular, intravenous lidocaine had pain score reduction comparable to or higher than that of intravenous morphine for pain associated with renal colic and critical limb ischemia. Lidocaine did not appear to be effective for migraine headache in 2 studies. There were 20 adverse events reported by 6 studies among 225 patients who received intravenous lidocaine in the ED, 19 nonserious and 1 serious (rate 8.9%, 95% confidence interval 5.5% to 13.4% for any adverse event; and 0.4%, 95% confidence interval 0% to 2.5% for serious adverse events). The confidence in the evidence available for the outcomes evaluated was deemed to be very low because of methodological limitations, including risk of bias, inconsistency, and imprecision.
Conclusion : There is limited current evidence to define the role of intravenous lidocaine as an analgesic for patients with acute renal colic and critical limb ischemia pain in the ED. Its efficacy for other indications has not been adequately tested. The safety of lidocaine for ED pain management has not been adequately examined.
Conclusion (proposition de traduction) : Les données probantes actuelles sont limitées pour définir le rôle de la lidocaïne intraveineuse comme analgésique chez les patients souffrant de coliques rénales aiguës et d'ischémie critique des membres aux urgences.
Son efficacité pour d'autres indications n'a pas été suffisamment testée. L'innocuité de la lidocaïne pour la prise en charge de la douleur aux urgences n'a pas fait l'objet d'un examen adéquat.
Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.
April MD, Oliver JJ, Davis WT, Ong D, Simon EM, Ng PC, Hunter CJ. | Ann Emerg Med. 2018 Aug;72(2):184-193
Introduction : We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access.
Méthode : In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events.
Résultats : We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events.
Conclusion : Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.
Conclusion (proposition de traduction) : Chez les patients des services d'urgence qui ont des nausées aiguës et qui n'ont pas besoin d'un accès intraveineux immédiat, l'aromathérapie (lingettes d’alcool isopropylique) avec ou sans ondansétron oral procure un soulagement des nausées plus important que l'ondansétron oral seul.
Commentaire : Confirme une étude de Beadle KL and al. dans Ann Emerg Med. 2016 Jul;68(1):1-9.e1 . Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial.
Are Corticosteroids Superior to Nonsteroidal Anti-inflammatory Drugs in the Treatment of Acute Gout?.
Watkins JW, Seupaul RA. | Ann Emerg Med. 2018 Aug;72(2):204-205
DOI: https://doi.org/10.1016/j.annemergmed.2018.02.004 | Télécharger l'article au format
Introduction : Randomized and quasi-randomized trials comparing benefits and harms of corticosteroids and nonsteroidal anti-inflammatory drugs for treating acute gout in patients older than 18 years were included. The primary efficacy outcome was pain scores at less than 7 days and greater than or equal to 7 days; the primary safety outcome was bleeding.
Méthode : The search identified 529 references; 6 trials evaluating 817 patients met inclusion criteria. The overall risk of bias was low in these trials, whereas the quality of the evidence was rated as low to moderate according to GRADE criteria. The meta-analysis demonstrated no difference between corticosteroids and nonsteroidal anti-inflammatory drugs for the following outcomes: short-term pain relief (<7 days), long-term pain relief (>7 days), time to resolution of pain, and requirement for additional analgesics. Although there was no difference in the primary safety outcome (rates of gastrointestinal bleeding), the incidence of gastrointestinal adverse effects (nausea, vomiting, and indigestion) was lower in the corticosteroid group (Table 2). Subgroup analyses did not show a difference between either dosages or routes of administration (oral prednisolone versus intramuscular betamethasone and triamcinolone) for corticosteroids. An analysis of differences in nonsteroidal anti-inflammatory drugs (indomethacin, naproxen, and diclofenac) was not performed.
Résultats : Two authors extracted data with standardized forms and independently assessed the risk of bias with the Cochrane assessment tool. Discrepancies were resolved by consensus. Evidence quality was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system2; discrepancies were resolved by discussion. Dichotomous variables were reported as a relative risk with 95% confidence intervals (CIs), whereas continuous data were reported as a mean difference or standardized mean difference with 95% CIs. A random-effects model was used to pool data. Statistical heterogeneity was measured with the Cochrane Q and statistics.
Conclusion : Corticosteroids provide pain relief similar to that of nonsteroidal anti-inflammatory drugs for acute gout, with fewer adverse effects.
Conclusion (proposition de traduction) : Les corticostéroïdes procurent un soulagement de la douleur semblable à celui des médicaments anti-inflammatoires non stéroïdiens pour la goutte aiguë, avec moins d'effets indésirables.
β-Lactam Dosage Regimens in Septic Patients with Augmented Renal Clearance.
Jacobs A, Taccone FS, Roberts JA, Jacobs F, Cotton F, Wolff F, Creteur J, Vincent JL, Hites M. | Antimicrob Agents Chemother. 2018 Aug;27:62-9
DOI: https://doi.org/10.1128/AAC.02534-17 | Télécharger l'article au format
Keywords: creatinine clearance, meropenem, ceftazidime, cefepime, piperacillintazobactam, critically ill, pharmacokinetics
Editorial : Augmented renal clearance is commonly observed in septic patients and may result in insufficient β-lactam serum concentrations. The aims of this study were to evaluate potential correlations between drug concentrations or total body clearance of β-lactam antibiotics and measured creatinine clearance and to quantify the need for drug dosage adjustments in septic patients with different levels of augmented renal clearance. We reviewed 256 antibiotic measurements (512 drug concentrations) from a cohort of 215 critically ill patients who had a measured creatinine clearance of ≥120 ml/min and who received therapeutic drug monitoring of meropenem, cefepime, ceftazidime, or piperacillin from October 2009 until December 2014 at Erasme Hospital. Population pharmacokinetic (PK) analysis of the data was performed using the Pmetrics software package for R. Fifty-five percent of drug concentrations showed insufficient β-lactam serum concentrations to treat infections due to Pseudomonas aeruginosa There were significant, yet weak, correlations between measured creatinine clearance and trough concentrations of meropenem (r = -0.21, P = 0.01), trough concentrations of piperacillin (r = -0.28, P = 0.0071), concentrations at 50% of the dosage interval (r = -0.41, P < 0.0001), and total body clearance of piperacillin (r = 0.39, P = 0.0002). Measured creatinine clearance adequately explained changes in drug concentrations in population pharmacokinetic models for cefepime, ceftazidime, and meropenem but not for piperacillin. Therefore, specific PK modeling can predict certain β-lactam concentrations based on renal function but not on absolute values of measured creatinine clearance, easily available for clinicians.
Conclusion : Currently, routine therapeutic drug monitoring is required to adjust daily regimens in critically ill patients receiving standard dosing regimens.
Conclusion (proposition de traduction) : Actuellement, une surveillance thérapeutique systématique des médicaments est nécessaire pour ajuster les schémas journaliers chez les patients gravement malades recevant des schémas posologiques standard.
Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Seuls des dosages itératifs semblent permettre l’adaptation des doses des β-lactamines chez les patients septiques avec clairance rénale élevée . Rédigé par le Dr Olivier Leroy.
Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall.
Mann N, Welch K, Martin A, Subichin M, Wietecha K, Birmingham LE, Marchand TD, George RL. | BMC Emerg Med. 2018 Aug 24;18(1):27
DOI: https://doi.org/10.1186/s12873-018-0179-0 | Télécharger l'article au format
Keywords: Delayed intracranial hemorrhage; Elderly; Fall; Head injury; Intracranial hemorrhage
Introduction : Falls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy.
Méthode : Data from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported.
Résultats : Data on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications.
Conclusion : Universal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.
Conclusion (proposition de traduction) : Les protocoles de dépistage universels favorisent la sécurité du patient à court terme, mais le font à grands frais en ce qui concerne les dépenses de santé et l'exposition accrue aux rayonnements.
Cette analyse souligne la nécessité d'un outil efficace d'évaluation des risques pour les hémorragies intracrâniennes retardées qui réduiraient le coût des dépistages inutiles tout en identifiant les hémorragies intracrâniennes potentiellement mortelles chez les patients atteints.
Safety and efficiency of a redirection procedure toward an out of hours general practice before admission to an emergency department, an observational study.
Morin C, Choukroun J, Callahan JC. | BMC Emerg Med. 2018 Aug 22;18(1):26
DOI: https://doi.org/10.1186/s12873-018-0173-6 | Télécharger l'article au format
Keywords: Emergency department management; Patient redirection; Patient safety; Primary care
Introduction : Primary care patients are often cited as a cause of Emergency Department overcrowding (ED). The aim of this study was to evaluate a physician led redirection procedure of selected patients towards an out of hours general practice (OHGP) in an Emergency Department with 55,000 admissions per year.
Méthode : Observational monocentric study over a period of 2 months. Every patient redirected to the OHGP was included and subsequently contacted by telephone to answer a standardized questionnaire, in order to measure: Redirection rate over the entire period and during weekdays or weekends/holiday Rate of redirected patients who went to the OHGP Rate of redirected patients who consulted in an ED in the next 72 h for the same reason Redirected patients' satisfaction rate.
Résultats : During the study period 9551 patients presented to the ED, of which 288 were redirected towards the OHGP (3%). The redirection rate was 1.9% during weekdays and 5.7% during weekends/holiday (p < 0.001). Of the redirected patients, 77% answered the telephone interview. Ninety percent of these patients consulted the OHGP. The main reasons for not consulting were: unduly long wait, opening hours not suitable, too costly. The rate of redirected patients who consulted in an ED in the following 72 h for the same reason was 4.1%. The satisfaction rate was 79.6% among interviewed patients.
Conclusion : A physician led procedure to redirect selected patients from the ED towards an OHGP results in a low redirection rate, unlikely to have a significant effect on ED patient flow. However, the procedure is safe and well accepted by a majority of patients.
Conclusion (proposition de traduction) : Une procédure dirigée par un médecin pour réorienter certains patients du service des urgences vers une pratique de médecine générale en dehors des heures d'ouverture des cabinets entraîne un faible taux de réorientation, peu susceptible d'avoir un effet significatif sur le flux de patients des services d'urgence. Cependant, la procédure est sûre et bien acceptée par la majorité des patients.
Manual ventilation to prevent hypoxaemia during endotracheal intubation of critically ill adults: protocol and statistical analysis plan for a multicentre randomised trial.
Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, Brown RM, Lester MG, Zouk AN, Gulati S, Stigler WS, Rice TW, Semler MW; PreVent Investigators and the Pragmatic Critical Care Research Group. | BMJ Open. 2018 Aug 10;8(8):e022139
DOI: https://doi.org/10.1136/bmjopen-2018-022139 | Télécharger l'article au format
Introduction : Hypoxaemia is the most common complication during endotracheal intubation of critically ill adults, and it increases the risk of cardiac arrest and death. Manual ventilation between induction and intubation has been hypothesised to decrease the incidence of hypoxaemia, but efficacy and safety data are lacking.
Méthode : The Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation trial is a prospective, multicentre, non-blinded randomised clinical trial being conducted in seven intensive care units in the USA. A total of 400 critically ill adults undergoing endotracheal intubation will be randomised 1:1 to receive prophylactic manual ventilation between induction and endotracheal intubation using a bag-valve-mask device or no prophylactic ventilation. The primary outcome is the lowest arterial oxygen saturation between induction and 2 min after successful endotracheal intubation, which will be analysed as an unadjusted, intention-to-treat comparison of patients randomised to prophylactic ventilation versus patients randomised to no prophylactic ventilation. The secondary outcome is the incidence of severe hypoxaemia, defined as any arterial oxygen saturation of less than 80% between induction and 2 min after endotracheal intubation. Enrolment began on 2 February 2017 and is expected to be complete in May 2018.
Conclusion : The trial was approved by the institutional review boards or designees of all participating centres. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.
Conclusion (proposition de traduction) : L'essai a été approuvé par les comités d'examen institutionnels ou les délégués de tous les centres participants. Les résultats seront soumis pour publication dans une revue à comité de lecture et présentés lors d'une ou plusieurs conférences scientifiques.
Commentaire : Publication des résultats
Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, Brown RM, Zouk AN, Gulati S, Heideman BE, Lester MG, Toporek AH, Bentov I, Self WH, Rice TW, Semler MW; PreVent Investigators and the Pragmatic Critical Care Research Group. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2019 Feb 28;380(9):811-821 .
Prophylactic Antimicrobial Therapy for Acute Aspiration Pneumonitis.
Dragan V, Wei Y, Elligsen M, Kiss A, Walker SAN, Leis JA. | Clin Infect Dis. 2018 Aug 1;67(4):513-518
Introduction : Prophylactic antimicrobial therapy is frequently prescribed for acute aspiration pneumonitis, with the intent of preventing the development of aspiration pneumonia. However, few clinical studies have examined the benefits and harms of this practice.
Méthode : A retrospective cohort study design was used to compare outcomes of patients with aspiration pneumonitis who received prophylactic antimicrobial therapy with those managed with supportive care only during the initial 2 days following macroaspiration. The primary outcome was in-hospital mortality within 30 days. Secondary outcomes included transfer to critical care and antimicrobial therapy received between days 3 and 14 following macroaspiration including escalation of therapy and antibiotic-free days.
Résultats : Among 1483 patients reviewed, 200 met the case definition for acute aspiration pneumonitis, including 76 (38%) who received prophylactic antimicrobial therapy and 124 (62%) who received supportive management only. After adjusting for patient-level predictors, antimicrobial prophylaxis was not associated with any improvement in mortality (odds ratio, 0.9; 95% confidence interval [CI], 0.4-1.7; P = .7). Patients receiving prophylactic antimicrobial therapy were no less likely to require transfer to critical care (5% vs 6%; P = .7) and subsequently received more frequent escalation of antibiotic therapy (8% vs 1%; P = .002) and fewer antibiotic-free days (7.5 vs 10.9; P < .0001).
Conclusion : Prophylactic antimicrobial therapy for patients with acute aspiration pneumonitis does not offer clinical benefit and may generate antibiotic selective pressures that results in the need for escalation of antibiotic therapy among those who develop aspiration pneumonia.
Conclusion (proposition de traduction) : Le prophylaxie antimicrobienne chez les patients présentant une pneumopathie d'inhalation aiguë ne présente aucun avantage clinique et peut générer des pressions sélectives sur les antibiotiques qui nécessitent une augmentation de l'antibiothérapie chez ceux qui développent une pneumonie d'inhalation.
Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Pneumonie d’inhalation : l’antibioprophylaxie est inutile . Rédigé par le Dr Philippe Lesprit.
A three-step approach to patients with suspected acute diverticulitis in the emergency department: An interdisciplinary algorithm proposal.
Paolillo C, Sartelli M,Miele V,Ansaloni L,Valentino M,Merli C,Coccolini F,Toso F,Madia C,Catena F. | Emerg Care J. 2018 August;14(7339):46-50
DOI: https://doi.org/10.4081/ecj.2018.7339 | Télécharger l'article au format
Keywords: Acute colonic diverticulitis; Clinical diagnosis; Abdominal pain; Diagnostic accuracy; Imaging modality; Abdominal ultrasound; Computed tomography.
Editorial : Patients with acute abdominal pain due to acute colonic diverticulitis are a frequent cause of hospital admission. Diverticuar disease increases with age. In Western populations, diverticular disease is diagnosed in 50% individuals over 70 years and 80% over 85 years of age. The identification of patients with acute diverticulitis is a considerable challenge, since numerous other acute abdominal conditions mimic its clinical characteristics. Another problem is the atypical presentation in older patients. A high index of suspicion in the setting of a compatible history and physical examination serves as the cornerstone of early diagnosis. The purpose of this review is to underline the importance of an intimately integrate multidisciplinary approach between emergency physicians, radiologists and surgeons.
Conclusion : Over the last 10 years, the number of patients suffering of AD is increasing in all over the world.42 It is now classified as the third most common gastrointestinal discharge diagnosis. Most of the time signs and symptoms associated with AD are aspecific and commons to other intra-abdominal pathologic conditions. In recent years, integrated imaging has revolutionized the classical approach to acute abdominal pain and close cooperation is essential among emergency physicians, radiologists and surgeons for improving treatment outcomes. A high index of suspicion in the setting of a compatible history and physical examination is the cornerstone of early diagnosis. Inclusion of an appropriate diagnostic modality is crucial to validate initial suspicion of the disease, to exclude other potential diseases that mimic diverticulitis, and to evaluate the severity and extent of disease. Only a collaborative strategy that takes into account the extension of the disease, the clinical condition and the compliance of the patients permits to plan a tailored treatment.
Conclusion (proposition de traduction) : Au cours des 10 dernières années, le nombre de patients souffrant de diverticulite aiguë a augmenté dans le monde entier. Il est désormais classé au troisième rang des diagnostics des sortie de gastroentérologie les plus fréquentes. La plupart des signes et symptômes associés à la diverticulite aiguë sont spécifiques et communs à d'autres pathologies intra-abdominales. Ces dernières années, l'imagerie intégrée a révolutionné l'approche classique des douleurs abdominales aiguës et une coopération étroite est essentielle entre les médecins des urgences, les radiologues et les chirurgiens pour améliorer les résultats du traitement. Un indice élevé de suspicion dans l'établissement d'une histoire compatible et d'un examen physique est la pierre angulaire du diagnostic précoce. L'inclusion d'une modalité diagnostique appropriée est cruciale pour valider la suspicion initiale de la maladie, exclure d'autres maladies potentielles qui imitent la diverticulite et pour évaluer la gravité et l'étendue de la maladie. Seule une stratégie collaborative prenant en compte l'extension de la maladie, l'état clinique et la conformité des patients permet de planifier un traitement sur mesure.
Extending the Sydney Triage to Admission Risk Tool (START+) to predict discharges and short stay admissions.
Ebker-White A, Bein KJ, Dinh MM. | Emerg Med J. 2018 Aug;35(8):471-476
Keywords: assessment; efficiency; emergency care systems; emergency departments; triage
Introduction : This study aims to validate previously reported triage tool titled Sydney Triage to Admission Risk Tool (START+) and investigate whether an extended version of the tool could be used to identify and stream appropriate short stay admissions to ED observation units or specialised short stay inpatient wards.
Méthode : This was a prospective study at two metropolitan EDs in Sydney, Australia. Consecutive triage encounters were observed by a trained researcher and START scores calculated. The primary outcome was length of stay <48 hours. Multivariable logistic regression was used to estimate area under curve of receiver operator characteristic (AUROC) for START scores. The original START tool was then extended to include frailty and multiple or major comorbidities as additional variables to assess for further predictive accuracy.
Résultats : There were 894 patients analysed during the study period. Of the 894 patients, there were 732 patients who were either discharged from ED or admitted for <2 days. The AUROC for the original START+ tool was 0.80 (95% CI 0.77 to 0.83). The presence of frailty was found to add a further five points and multiple comorbidities added another four points on top of the START score, and the AUROC for the extended START score 0.84 (95% CI 0.81 to 0.88).
Conclusion : The overall performance of the extended ED disposition prediction tool that included frailty and multiple medical comorbidities significantly improved the ability of the START tool to identify patients likely to be discharged from ED or require short stay admission <2 days.
Conclusion (proposition de traduction) : Le rendement global de l'extension de l'outil de triage des besoins d'admission dans le service des urgences, qui comprenait la fragilité et les comorbidités médicales multiples, a considérablement amélioré la capacité de l'outil START à identifier les patients susceptibles d'être sortants du service des urgences ou d'avoir besoin d'une admission de courte durée de moins de 2 jours.
Prehospital neurological deterioration in stroke.
Slavin SJ, Sucharew H, Alwell K, Moomaw CJ, Woo D, Adeoye O, Flaherty ML, Ferioli S, McMullan J, Mackey J, De Los Rios La Rosa F, Martini S, Kissela BM, Kleindorfer DO. | Emerg Med J. 2018 Aug;35(8):507-510
Keywords: neurology; prehospital care; stroke
Introduction : Patients with stroke can experience neurological deterioration in the prehospital setting. We evaluated patients with stroke to determine factors associated with prehospital neurological deterioration (PND).
Méthode : Among the Greater Cincinnati/Northern Kentucky region (population ~1.3 million), we screened all 15 local hospitals' admissions from 2010 for acute stroke and included patients aged ≥20. The GCS was compared between emergency medical services (EMS) arrival and hospital arrival, with decrease ≥2 points considered PND. Data obtained retrospectively included demographics, medical history and medication use, stroke subtype (eg, ischaemic stroke (IS), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH)) and IS subtype (eg, small vessel, large vessel, cardioembolic), seizure at onset, time intervals between symptom onset, EMS arrival and hospital arrival, EMS level of training, and blood pressure and serum glucose on EMS arrival.
Résultats : Of 2708 total patients who had a stroke, 1092 patients (median (IQR) age 74 (61-83) years; 56% women; 21% black) were analysed. PND occurred in 129 cases (12%), including 9% of IS, 24% of ICH and 16% of SAH. In multivariable analysis, black race, atrial fibrillation, haemorrhagic subtype and ALS level of transport were associated with PND.
Conclusion : Haemorrhage and atrial fibrillation is associated with PND in stroke, and further investigation is needed to establish whether PND can be predicted. Further studies are also needed to assess whether preferential transport of patients with deterioration to hospitals equipped with higher levels of care is beneficial, identify why race is associated with deterioration and to test therapies targeting PND.
Conclusion (proposition de traduction) : L'hémorragie et la fibrillation atriale sont associées à une détérioration neurologique préhospitalière des accidents vasculaires cérébraux (AVC), et d'autres études sont nécessaires pour établir si la détérioration neurologique préhospitalière peut être prédite.
D'autres études sont également nécessaires pour évaluer si le transport préférentiel des patients présentant une détérioration vers des hôpitaux dotés de niveaux de soins plus élevés est bénéfique, identifier les causes de la détérioration et tester les thérapies ciblant la détérioration neurologique préhospitalière.
Fluid therapy in the emergency department: an expert practice review.
Harris T, Coats TJ, Elwan MH. | Emerg Med J. 2018 Aug;35(8):511-515
DOI: https://doi.org/10.1136/emermed-2017-207245 | Télécharger l'article au format
Keywords: acute care; cardiac care; intensive care; resuscitation; ultrasound
Editorial : Le remplissage vasculaire aux urgences : une revue de pratique d'experts
Introduction : Intravenous fluid therapy is one of the most common therapeutic interventions performed in the ED and is a long-established treatment. The potential benefits of fluid therapy were initially described by Dr W B O’Shaughnessy in 1831 and first administered to an elderly woman with cholera by Dr Thomas Latta in 1832, with a marked initial clinical response. However, it was not until the end of the 19th century that medicine had gained understanding of infection risk that practice became safer and that the practice gained acceptance. The majority of fluid research has been performed on patients with critical illness, most commonly sepsis as this accounts for around two-thirds of shocked patients treated in the ED. However, there are few data to guide clinicians on fluid therapy choices in the non-critically unwell, by far our largest patient group. In this paper, we will discuss the best evidence and controversies for fluid therapy in medically ill patients.
Conclusion : Crystalloids are the first choice for non-blood product fluid resuscitation, balanced solutions may offer a small advantage in preserving renal function as compared with 0.9% saline. Under-resuscitation and over-resuscitation are associated with harm in critically unwell patients. Stroke volume assessment to a fluid challenge is widely used to guide fluid volumes in critical care, but is not well studied in the ED population and the optimal time of delivery and infused volumes are not established. A significant proportion of patients in the ED do not respond to infused fluids, thus applying simple physiological ‘rules’ to this complex situation may lead to overinfusion and harm. We should be wary of applying evidence derived from ICU patients, as the majority of ED patients are not critically ill and so should lobby the funders of research to invest in the large clinical trials that are required to better define optimal fluid therapy in emergency care.
Conclusion (proposition de traduction) : Les cristalloïdes sont le premier choix pour le remplissage vasculaire sans produit sanguin, des solutions équilibrées peuvent offrir un petit avantage pour préserver la fonction rénale par rapport à une solution saline à 0,9 %. La sous-réanimation et la sur-réanimation sont associées à des effets secondaires chez les patients gravement malades. L'évaluation du volume de l'AVC à un test liquidien est largement utilisée pour guider les volumes de remplissage vasculaire aux soins intensifs, mais elle n'est pas bien étudiée dans la population des services d'urgence et le moment optimal d'administration et les volumes perfusés ne sont pas établis. Une proportion importante des patients du service d'urgence ne répondent pas aux perfusions de liquides, de sorte que l'application de « règles » physiologiques simples à cette situation complexe peut mener à un excès de remplissage et à des effets secondaires. Nous devrions nous méfier de l'application des données provenant des patients des USI car la majorité des patients des urgences ne sont pas gravement malades et on devraient donc faire pression sur les promoteurs d'études cliniques pour qu'ils investissent dans les grands essais cliniques nécessaires pour mieux définir le remplissage vasculaire optimale aux urgences.
Intravenous tranexamic acid for the treatment of post-partum haemorrhage.
Coss C, Singh M, Jones J. | Emerg Med J. 2018 Aug;35(8):523-524
Keywords: emergency care systems
Best evidence topic reports
Editorial : A short-cut review was carried out to see if administering tranexamic acid reduced mortality in patients with postpartum haemorrhage. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. Two randomised controlled trials were found, a smaller one suggesting that treatment with tranexamic acid reduced the volume of blood lost and a much larger study that showed a reduction in mortality due to bleeding in this patient group.
Conclusion : There were no significant side effects from this treatment found in either study.
Conclusion (proposition de traduction) : Aucun effet secondaire significatif avec ce traitement n'a été observé dans l'une ou l'autre des études.
Antiemetic use in paediatric sedation with ketamine.
Dunlop L, Hall D. | Emerg Med J. 2018 Aug;35(8):524-525
Keywords: emergency care systems
BEST EVIDENCE TOPIC REPORTS
Editorial : A short cut review was carried out to see if administering anti-emetics reduced the incidence of vomiting when sedating children for procedures. The author, date and country of publication, patient group studied, study type, relevant outcomes, results study weaknesses of these papers are tabulated. Three randomised, controlled trials were found and one cohort study.
Conclusion : The studies suggested that administration of an anti-emetic was associated with a reduced risk of vomiting during the procedural sedation.
Conclusion (proposition de traduction) : Les études suggèrent que l'administration d'un antiémétique était associée à un risque réduit de vomissements pendant la sédation procédurale.
The utility of scrotal ultrasonography in the emergent setting: beyond epididymitis versus torsion.
McAdams CR, Del Gaizo AJ. | Emerg Radiol. 2018 Aug;25(4):341-348
Keywords: Epididymis; Scrotal emergencies; Scrotum; Spermatic cord; Testicle; Ultrasonography
Editorial : Scrotal pain is a common acute presentation for medical care. Testicular torsion and epididymo-orchitis are two diagnoses for which early detection is critical and their sonographic imaging features have been thoroughly described in the radiologic literature. Other important conditions for which radiologists must be aware have received less attention. This article will highlight key traumatic and non-traumatic causes of acute scrotal pain other than testicular torsion and epididymo-orchitis that may present in the emergency department setting.
Conclusion : Timely diagnosis of male genitourinary emergencies is aided by careful sonographic examination of the scrotal contents. While testicular torsion and epididymo-orchitis are two of the most common and grave scrotal emergencies, other critical diagnoses must be considered. Torsed testicular appendages, penile and testicular trauma, and para- and intratesticular mimics often have unique sonographic findings that facilitate their diagnoses.
Conclusion (proposition de traduction) : Le diagnostic en temps opportun des urgences génito-urinaires masculines est facilité par un examen échographique minutieux du contenu scrotal. Bien que la torsion testiculaire et l'épididymo-orchite soient deux des urgences scrotales les plus courantes et les plus graves, d'autres diagnostics critiques doivent être envisagés. Les appendices testiculaires torsadés, les traumatismes du pénis et des testicules, et les imitateurs para- et intratesticulaires ont souvent des résultats échographiques uniques qui facilitent leur diagnostic.
Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study.
Pries-Heje MM, Hasselbalch RB, Raaschou H, Rezanavaz-Gheshlagh B, Heebøll H, Rehman S, Kristensen M, Andersen EH, Ravn L, Nèmery MC, Lind MN, Boel T, Ulriksen PS, Iversen KK. | Emerg Radiol. 2018 Aug;25(4):357-365
Keywords: Acute care; CT; CT screening; Early diagnostics; Emergency department; Emergency radiology
Introduction : Several large trials have evaluated the effect of CT screening based on specific symptoms, with varying outcomes. Screening of patients with CT based on their prognosis alone has not been examined before. For moderate-to-high risk patients presenting in the emergency department (ED), the potential gain from a CT scan might outweigh the risk of radiation exposure. We hypothesized that an accelerated "multiple rule out" CT screening of moderate-to-high risk patients will detect many clinically unrecognized diagnoses that affect change in treatment.
Méthode : Patients ≥ 40 years, triaged as high-risk or moderate-to-high risk according to vital signs, were eligible for inclusion. Patients were scanned with a combined ECG-gated and dual energy CT scan of cerebrum, thorax, and abdomen. The impact of the CT scan on patient diagnosis and treatment was examined prospectively by an expert panel.
Résultats : A total of 100 patients were included in the study, (53% female, mean age 73 years [age range, 43-93]). The scan lead to change in treatment or additional examinations in 37 (37%) patients, of which 24 (24%) were diagnostically significant, change in acute treatment in 11 (11%) cases and previously unrecognized malignant tumors in 10 (10%) cases. The mean size specific radiation dose was 15.9 mSv (± 3.1 mSv).
Conclusion : Screening with a multi-rule out CT scan of high-risk patients in an ED is feasible and result in discovery of clinically unrecognized diagnoses and malignant tumors, but at the cost of radiation exposure and downstream examinations. The clinical impact of these findings should be evaluated in a larger randomized cohort.
Conclusion (proposition de traduction) : Le dépistage par un contrôle multidimensionnel par tomodensitométrie des patients à haut risque dans un service d'urgence est réalisable et aboutit à la découverte de diagnostics cliniquement non reconnus et de tumeurs malignes, mais au prix d'une exposition aux rayonnements et d'examens d'aval. L'impact clinique de ces résultats doit être évalué dans une cohorte randomisée plus large.
Clinical impact of computed tomography in the emergency department in nontraumatic chest and abdominal conditions.
Pescatori LC, Brambati M, Messina C, Mauri G, Di Leo G, Silvestri E, Sardanelli F, Sconfienza LM. | Emerg Radiol. 2018 Aug;25(4):393-398
Keywords: Clinical impact; Computed tomography; Emergency department; Outcome
Introduction : To evaluate the clinical impact of CT scan in modifying the clinical management in patients referred to the emergency department.
Méthode : We prospectively evaluated 300 patients (177 males, 63 ± 18 years old) admitted in the emergency department (ED) of a single institution, who underwent a CT examination for thoracic and/or abdominal complains. Demographic and clinical data were collected. Hypothesized outcome prior to CT scan and final management (i.e., discharge, short observation in the ED, hospitalization, and department of admission) were compared.
Résultats : After CT examination, a major variation in diagnosis occurred in 37% of cases and clinical management changed in 43%, occurring in 51% of patients who underwent abdominal CT, in 40% of chest CT, and in 29% of chest/abdominal CT (P = 0.015). Department of hospitalization changed in 26% of cases (P < 0.001). Clinical impact of CT scan was significantly associated (P = 0.001) with the color code at admission. In particular, the more severe was the clinical condition, the lower was the variation of management after CT examination.
Conclusion : This work confirms the crucial role of CT examination in the management of nontraumatic patients admitted to the ED, both in terms of better clarifying the diagnosis and in influencing the clinical management.
Conclusion (proposition de traduction) : Ces travaux confirment la place crucial de l'examen scanographique dans la prise en charge des patients non traumatiques admis à l'urgence, tant pour mieux clarifier le diagnostic que pour influencer la prise en charge clinique.
Is elevated body mass index protective against cervical spine injury in adults?.
Beckmann NM, Cai C, Spence SC, Prasarn ML, Clark West O. | Emerg Radiol. 2018 Aug;25(4):415-424
Keywords: Body mass index; Cervical spine; Injury; Obesity; Trauma
Introduction : Correlate body mass index (BMI) with incidence and type of cervical spine injury seen on CT in adult patients presenting with blunt trauma.
Méthode : Retrospective chart review of all adult blunt trauma patients who had a cervical spine CT performed at our level 1 trauma center during an approximately 3-year period.
Résultats : A statistically significant (p = 0.01) difference in cervical spine injury incidence was present between different BMI groups. Cervical spine injury incidence was 7.7% for underweight (BMI ≤ 18) patients, 7.1% for normal weight (BMI 18-25) patients, 6.2% for overweight/obese (BMI 25-35) patients, and 4.7% for morbidly obese (BMI > 35) patients. Using BMI > 18-25 as a reference group, females with BMI > 25-35 had an adjusted odds ratio (aOR) of 0.56 (CI 0.41-0.75) and females with BMI > 35 had an aOR of 0.42 (CI 0.26-0.70). Males with a BMI ≤ 18 had an aOR of 2.20 (CI 1.12-4.32) and males with BMI > 35 had an aOR of 0.66 (CI 0.46-0.95). A particularly low incidence of cervical spine injury was observed in patients older than 65 in the obese group with a cervical spine injury rate of only 1.4% in this patient population. No statistical significant difference was seen in injury morphology across the BMI groups.
Conclusion : An inverse relationship exists between BMI and the overall incidence of cervical spine injury. This protective effect appears to be influenced by gender with elevated BMI having lower relative odds of cervical spine injury in women than in men. A particularly low rate of cervical spine injury was identified in obese patients over the age of 65. Routine imaging of all elderly, obese trauma patients with low energy mechanism of injury may not be warranted.
Conclusion (proposition de traduction) : Il existe une relation inverse entre l'IMC et l'incidence globale des lésions cervicales. Cet effet protecteur semble être influencé par le sexe, l'IMC élevé ayant moins de risques relatifs de lésions cervicales chez les femmes que chez les hommes. Un taux particulièrement faible de lésions cervicales a été identifié chez les patients obèses de plus de 65 ans. L'imagerie de routine de tous les patients âgés et obèses ayant subi un traumatisme avec un mécanisme de blessure à faible énergie peut ne pas être justifiée.
Practical management of concomitant acute heart failure and worsening renal function in the emergency department.
Ferreira JP, Chouihed T, Nazeyrollas P, Levy B, Seronde MF, Bilbault P, Braun F, Roul G, Kénizou D, Zannad N, Girerd N, Rossignol P. | Eur J Emerg Med. 2018 Aug;25(4):229-236
Editorial : Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.
Conclusion : Acute HF is often accompanied by WRF and vice versa in the emergency department. However, WRF is only relevant in the context of clinical deterioration and should not preclude clinicians from initiating therapies that can improve patient outcome.
Conclusion (proposition de traduction) : L'insuffisance cardiaque aiguë s'accompagne souvent d'une détérioration de la fonction rénale et vice versa aux urgences. Toutefois, l'aggravation de la fonction rénale n'est pertinente que dans le contexte de la détérioration clinique et ne devrait pas empêcher les cliniciens d'entreprendre des traitements qui peuvent améliorer les résultats pour le patient.
Influences on emergency department length of stay for older people.
Street M, Mohebbi M, Berry D, Cross A, Considine J. | Eur J Emerg Med. 2018 Aug;25(4):242-249
Introduction : The aim of this study was to examine the influences on emergency department (ED) length of stay (LOS) for older people and develop a predictive model for an ED LOS more than 4 h.
Méthode : This retrospective cohort study used organizational data linkage at the patient level from a major Australian health service. The study population was aged 65 years or older, attending an ED during the 2013/2014 financial year. We developed and internally validated a clinical prediction rule. Discriminatory performance of the model was evaluated by receiver operating characteristic (ROC) curve analysis. An integer-based risk score was developed using multivariate logistic regression. The risk score was evaluated using ROC analysis.
Résultats : There were 33 926 ED attendances: 57.5% (n=19 517) had an ED LOS more than 4 h. The area under ROC for age, usual accommodation, triage category, arrival by ambulance, arrival overnight, imaging, laboratory investigations, overcrowding, time to be seen by doctor, ED visits with admission and access block relating to ED LOS more than 4 h was 0.796, indicating good performance. In the validation set, area under ROC was 0.80, P-value was 0.36 and prediction mean square error was 0.18, indicating good calibration. The risk score value attributed to each risk factor ranged from 2 to 68 points. The clinical prediction rule stratified patients into five levels of risk on the basis of the total risk score.
Conclusion : Objective identification of older people at intermediate and high risk of an ED LOS more than 4 h early in ED care enables targeted approaches to streamline the patient journey, decrease ED LOS and optimize emergency care for older people.
Conclusion (proposition de traduction) : L'identification objective des personnes âgées à risque moyen et élevé d'une durée de séjour à l'urgence de plus de 4 h au début des soins d'urgence permet des approches ciblées pour rationaliser le parcours du patient, réduire la durée de séjour aux urgences et optimiser les soins d'urgence pour les personnes âgées.
Which indicators to include in a crowding scale in an emergency department? A national French Delphi study.
Noel G, Drigues C, Viudes G; Fedoru Crowding Working Group. | Eur J Emerg Med. 2018 Aug;25(4):257-263
Introduction : Emergency department (ED) crowding is a serious international public health issue with a negative impact on quality of care. Despite two decades of research, there is no consensus on the indicators used to quantify crowding. The aim of our study was to select the most valid ED crowding indicators.
Méthode : The Delphi method was used. Selected indicators originated from a literature review and propositions from FEDORU (National Emergency Department Observatory Network) workgroup. Selected national experts were emergency physicians with a special interest in ED crowding. They had to assess each indicator in terms of validity out of a Likert scale from 1 to 9. Indicators withdrawal criteria after each round (consensus) were over 70% of answers of at least 7 with interquartile range less than 3 (positive consensus) or over 70% of answers of at least 4 and interquartile range less than 3 (negative consensus). The decision to stop the delphi procedure was based on the stability of answers between the rounds.
Résultats : 41 (89.13%) experts answered the first round and 37 (80.43%) answered the second round. Among the 57 indicators included, 15 reached consensus: four input indicators, six throughput and five output ones. For those three categories of at least 7 answers rates were, respectively, 80.9, 76.9 and 75.0%. Five indicators were deducible from the mandatory Emergency Department Discharge Summary. They obtained 80.2% of at least 7 answers.
Conclusion : Our study results enable the construction and validation of a crowding measuring tool from indicators approved by experts. It is necessary to further reflect about ED crowding as a concept and what is expected from a complex score.
Conclusion (proposition de traduction) : Les résultats de notre étude permettent la construction et la validation d'un outil de mesure de l'encombrement à partir d'indicateurs approuvés par des experts. Il est nécessaire d'approfondir la réflexion sur le concept de surpeuplement des urgences et sur ce que l'on attend d'un score complexe.
Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study.
Jaconelli T, Eragat M, Crane S. | Eur J Emerg Med. 2018 Aug;25(4):288-294
Introduction : Patients suspected of having venous thromboembolism (VTE), with a low pretest probability, undergo D-dimer testing. A negative D-dimer, in a low-risk patient rules out VTE with a high degree of certainty because of its high sensitivity. It is, however, a poorly specific test, and the absolute value increases with age. The aim of this study was to establish whether an age-adjusted D-dimer could be safely used instead of a standard cut-off level in low-risk patients over the age of 50 years.
Méthode : This was a retrospective review of 1649 patients with suspected VTE whose D-dimer levels were analysed. In low-risk patients (defined as 'VTE unlikely' using the dichotomized Wells' scores), the outcomes in terms of confirmed VTE diagnosis, hospital admission and investigations using an age-adjusted D-dimer level (measured in D-dimer units) of 5× the age for patients over 50 years of age and 250 ng/ml for patients younger than 50 years of age, was compared with the cut-off standard level (230 ng/ml in all patients).
Résultats : Of the total group of patients in the VTE unlikely group, the proportion of patients with a negative D-dimer when using the standard cut-off was 64.9% (859/1324). A further 130 patients had a negative D-dimer when the age-adjusted cut-off was used, increasing the proportion of all patients in whom VTE could be excluded without imaging to 74.7% (989/1324).For those patients of 75 years or older, the proportion of patients in whom VTE could be excluded without imaging increased from only 91/242 (37.6%) when using the standard D-dimer cut-off to 154/242 (63.6%) when the age-adjusted cut-off was used.These changes occurred without any additional false-negative findings.
Conclusion : For patients over the age of 50 years suspected of having VTE with a low pretest probability, increasing the D-dimer cut-off level to 5× the age increases the proportion of patients in whom VTE can safely be excluded without radiological imaging.
Conclusion (proposition de traduction) : Pour les patients âgés de plus de 50 ans suspectés d'avoir une thrombophlébite veineuse avec une faible probabilité pré-test, le fait d'augmenter le seuil des taux de D-dimères par « 5 × l'âge » augmente la proportion de patients chez qui une thrombophlébite veineuse peut être exclue sans risque, sans imagerie radiologique.
Severity of button batteries ingestions: data from French Poison Control Centres between 1999 and 2015.
Labadie M, O'Mahony E, Capaldo L, Courtois A, Lamireau T, Nisse P, Blanc-Brisset I, Puskarczyk E. | Eur J Emerg Med. 2018 Aug;25(4):e1-e8
Introduction : Although the ingestion of button batteries is an infrequent situation, it leads to a significant risk of causing serious damage.
OBJECTIVE: This study was carried out to describe all the cases of button battery ingestion recorded by the French Poison Control Centers over 16 years.
Méthode : All the cases of button battery ingestion were recorded from 1 January 1999 to the end of June 2015, analysed (age, sex, number of ingested button batteries, clinical signs and treatments) and graded for severity according to the poisoning severity score.
Résultats : he incidence of button batteries ingestions was constant over the 16-year period, with an average of 266±98.5 cases per year and a total of 4030 cases. Nevertheless, 21 cases were severe and two deaths occurred. Interestingly, for the two patients who died, the battery was stuck in the oesophagus and they presented anorexia and/or dysphagia, abdominal pain and fever and in one case, a melena 3 weeks after ingestion. Importantly, these symptoms were observed even if the battery was expelled in one fatal case.
Conclusion : Ingestions of button batteries still occur and may cause serious damage, especially in children, and if the button battery is stuck in the oesophagus as it might cause severe symptoms. Patients who have ingested a button battery must be directed to the emergency department for medical evaluation, even if the button battery has been expelled from the body and even more if gastrointestinal symptoms are present.
Conclusion (proposition de traduction) : L'ingestion de piles bouton peut encore se produire et peut causer de graves dommages, en particulier chez les enfants, et si la pile bouton est coincée dans l'œsophage, car elle peut causer des symptômes graves. Les patients qui ont ingéré une pile bouton doivent être dirigés vers le service d'urgence pour une évaluation médicale, même si la pile bouton a été expulsée du corps et encore plus si des symptômes gastro-intestinaux sont présents.
Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study).
Bernhard M, Döll S, Hartwig T, Ramshorn-Zimmer A, Yahiaoui-Doktor M, Weidhase L, Petros S, Gries A. | Eur J Emerg Med. 2018 Aug;25(4):e9-e17
Introduction : Management of critically ill nontrauma (CINT) patients in the resuscitation room (RR) of the emergency department (ED) is very challenging. Detailed data describing the characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the RR.
Méthode : From September 2014 to August 2015, data were collected prospectively on adult CINT patients admitted to the RR of a single German University ED. Patient characteristics, out-of-hospital/in-hospital treatment, admission-related diseases, time intervals for diagnostics and interventions plus outcome were recorded using a self-developed questionnaire.
Résultats : A total of 34 303 patients were admitted to the ED; of these 21 074 patients were admitted for nontrauma emergencies and because of acute life-threatening problems. Five hundred and thirty-two CINT patients were admitted to the RR (median age: 71 years, 58.3% men). The main problems on admission were obstructed airway (3.8%, A), respiratory insufficiency (26.5%, B), shock (35.5%, C), unconsciousness (33.3%, D) or other (0.9%, E). Out-of-hospital and in-hospital management included intravenous access (96.8 vs. 76.9%), 12-lead ECG (50.0 vs. 86.5%), invasive airway management (30.1 vs. 27.1%), noninvasive and invasive ventilation (7.0 vs. 16.4% and 30.1 vs. 57.2%), catecholamines (16.2 vs. 24.1%), arterial line (0.2 vs. 58.1%) and cardiopulmonary resuscitation (18.4 vs. 12.2%). The mean length of stay was 34±24 min. At day 30, all-cause mortality was 34.2% (patients with and without cardiopulmonary resuscitation: 72.7 vs. 24.0%, P<0.001).
Conclusion : Observation of critically ill patients in the resuscitation room of the Emergency Department shows the challenge of care for CINT patients in the ED. With high levels of mortality, there is an urgent need for structured ED management guidelines.
Conclusion (proposition de traduction) : L'observation des patients gravement malades dans la salle de réanimation du service des urgences montre le défi que représente la prise en charge des patients gravement malades non traumatiques dans le service des urgences. Compte tenu des taux de mortalité élevés, il est urgent d'établir des lignes directrices structurées pour la gestion des services d'urgence.
Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes.
Matz O, Heckelmann J, Zechbauer S, Litmathe J, Brokmann JC, Willmes K, Schulz JB, Dafotakis M. | Intern Emerg Med. 2018 Aug;13(5):749-755
Keywords: Creatine kinase (CK); Diagnostic marker; Lactate; Seizure; Syncope
EM - original
Introduction : Concentrations of serum creatine kinase (CK) and serum lactate are frequently measured to help differentiate between generalized tonic-clonic seizures (GTCS) and syncope.
Méthode : The aim of this prospective cohort study was to systematically compare these two markers. The primary outcome is the measurement of serum lactate and CK in blood samples drawn within 2 h of the event in patients admitted with either a GTCS (n = 49) or a syncope (n = 36). Furthermore, the specificity and sensitivity of serum lactate and CK are determined as diagnostic markers in distinguishing between GTCS and syncope. GTCS patients have significantly higher serum lactate levels compared to syncope patients (p < 0.001).
Résultats : In contrast, CK does not differ between groups at admission. Regarding the first hour after the seizure, we identify a cut-off for serum lactate of 2.45 mmol/l for diagnosing GTCS as the cause of an impairment of consciousness with a sensitivity of 0.94 and a specificity of 0.93 (AUC: 0.97; 95% CI 0.94-1.0). In the second hour after the event, the ROC analysis yields similar results (AUC: 0.94; 95% CI 0.85-1.0).
Conclusion : Serum lactate is a sensitive and specific diagnostic marker to discriminate GTCS from syncope and is superior to CK early after admission to the emergency department.
Conclusion (proposition de traduction) : Le lactate sérique est un marqueur diagnostique sensible et spécifique pour distinguer les crises tonico-cloniques généralisées de la syncope et est supérieur à la CK tôt après l'admission à l'urgence.
Evaluation of the impact of a nationwide massive online open course on the appropriate use of antimicrobials.
Pérez-Moreno MA, Peñalva-Moreno G, Praena J, González-González A, Martínez-Cañavate MT, Rodríguez-Baño J, Cisneros JM. | J Antimicrob Chemother. 2018 Aug 1;73(8):2231-2235
Introduction : To evaluate the impact of a massive online open course (MOOC) design on the appropriate use of antimicrobial agents, to determine specific study areas with better learning outcomes and to identify weak points.
Méthode : A pre- and post-intervention study in the context of a training course on infectious diseases aimed at health professionals. We designed a questionnaire with 30 questions related to the management of infectious diseases in different clinical situations. Participants had to answer the questions based on their competencies and training for these situations. We analysed the scores obtained before and after the course and the resulting progress. In addition, an open response section was provided to enable a qualitative evaluation.
Résultats : Two thousand one hundred and forty-eight health professionals were enrolled in the course. The questionnaire was completed before and after the course by 606 participants, mainly physicians (81.2%) and pharmacists (15.4%). The mean overall scores for the pre- and post-course questionnaires were 6.2 (SD 1.38) and 7.9 (SD 0.88), respectively (overall score increase = 1.8, SD 1.21, P < 0.001). A significant increase in self-assessment was detected (P < 0.001) for all the questions. Qualitative assessments were provided by 218 participants with 225 comments, most of which were very positive.
Conclusion : The course with a MOOC design showed a great teaching capacity in the infectious diseases area for all the clinical situations analysed, notably in the management of severe infections with higher mortality. For future editions of this training activity, the need to include other infectious diseases, especially infections in primary care, was highlighted.
Conclusion (proposition de traduction) : Le cours sous la forme de MOOC a montré une grande capacité d’enseignement dans le domaine des maladies infectieuses pour toutes les situations cliniques analysées, notamment dans la prise en charge des infections sévères avec une mortalité plus élevée. Pour les éditions futures de cette activité de formation, la nécessité d'inclure d'autres maladies infectieuses, en particulier les infections dans les soins primaires, a été soulignée.
Commentaire : Voir l'analyse de l'article sur info-atbvac : Apprentissage par MOOC : un impact positif sur le bon usage des antibiotiques .
Improving antibiotic prescribing skills in medical students: the effect of e-learning after 6 months.
Sikkens JJ, Caris MG, Schutte T, Kramer MHH, Tichelaar J, van Agtmael MA. | J Antimicrob Chemother. 2018 Aug 1;73(8):2243-2246
Introduction : Antimicrobial prescribing behaviour is first established during medical study, but teachers often cite lack of time as an important problem in the implementation of antimicrobial stewardship in the medical curriculum. The use of electronic learning (e-learning) is a potentially time-efficient solution, but its effectiveness in changing long-term prescribing behaviour in medical students is as yet unknown.
Méthode : We performed a prospective controlled intervention study of the long-term effects of a short interactive e-learning course among fourth year medical students in a Dutch university. The e-learning was temporarily implemented as a non-compulsory course during a 6 week period. Six months later, all students underwent an infectious disease-based objective structured clinical examination (OSCE) aimed at simulating postgraduate prescribing. If they passed, each student did the OSCE only once. We created a control group of students from a period when the e-learning was not implemented. Main outcomes were the OSCE pass percentage and knowledge, drug choice and overall scores. We used propensity scores to create equal comparisons.
Résultats : We included 71 students in the intervention group and 285 students in the control group. E-learning participation in the intervention group was 81%. The OSCE pass percentage was 86% in the control group versus 97% in the intervention group (+11%, OR 5.9, 95% CI 1.7-20.0). OSCE overall, knowledge and drug choice grades (1-10) were also significantly higher in the intervention group (differences +0.31, +0.31 and +0.51, respectively).
Conclusion : E-learning during a limited period can significantly improve medical students' performance of an antimicrobial therapeutic consultation in a situation simulating clinical practice 6 months later.
Conclusion (proposition de traduction) : L'apprentissage en ligne pendant une période limitée peut améliorer de manière significative la performance d'une consultation thérapeutique antimicrobienne par un étudiant en médecine dans une situation simulant la pratique clinique six mois plus tard.
Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : e-learning : des étudiants en médecine plus performants ? . Rédigé par le Dr Philippe Lesprit.
Balanced crystalloids versus isotonic saline in critically ill patients: systematic review and meta-analysis.
Zayed YZM, Aburahma1 AMY, Barbarawi MO, Hamid K, Banifadel MRN, Rashdan L, Bachuwa GI. | J Intensive Care. 2018 Aug;6:51
DOI: https://doi.org/10.1186/s40560-018-0320-x | Télécharger l'article au format
Keywords: Balanced crystalloids; Isotonic saline; Critically ill patients; Fluid therapy; meta-analysis
Introduction : Intravenous fluids are one of the most used medical therapy for patients, especially critically ill patients. We conducted a meta-analysis comparing between balanced crystalloids and normal saline in critically ill patients and its effect on various clinical outcomes.
Design: Meta-analysis and systematic review of randomized clinical trials (RCTs).
Méthode : Electronic search was performed using PubMed, Cochrane library, and clinical trials. gov from inception through March 1, 2018, with inclusion of prospective studies that investigated one of the primary outcomes which were acute kidney injury (AKI) and in-hospital mortality while secondary outcomes were intensive care unit (ICU) mortality and new renal replacement therapy (RRT).
Résultats : Six RCTs were included. Total of 19,332 patients were included in the final analysis. There was no significant difference in in-hospital mortality (11.5% vs 12.2%; OR 0.92; 95% CI 0.85–1.01; P = 0.09; I2 = 0%), incidence of AKI (12% vs 12.7%, OR 0.92; 95% CI 0.84–1.01; P = 0.1; I2 = 0), overall ICU mortality (OR 0.9, 95% CI 0.81–1.01, P = 0.08, I2 = 0%), or need for new RRT (OR 0.92, 95% CI 0.67–1.28, P = 0.65, I2 = 38%) between balanced crystalloids and isotonic saline in critically ill patients.
Conclusion : Balanced crystalloids and isotonic saline have no difference on various clinical outcomes including in-hospital mortality, AKI, overall ICU mortality, and new RRT. Further powerful clinical trials are required to determine the relationship between crystalloid fluid type and clinical outcomes.
Conclusion (proposition de traduction) : Les cristalloïdes balancés et les solutions salines isotoniques n'ont aucune différence quant aux divers résultats cliniques, y compris la mortalité à l'hôpital, les lésions rénales aiguës, la mortalité globale à l'USI et la nouvelle thérapie de remplacement rénal. D'autres essais cliniques puissants sont nécessaires pour déterminer la relation entre le type de fluide cristalloïde et les résultats cliniques.
Difficult tracheal intubation in critically ill.
Ahmed A, Azim A. | J Intensive Care. 2018 Aug;6:49
DOI: https://doi.org/10.1186/s40560-018-0318-4 | Télécharger l'article au format
Keywords: Critically ill; Intubation; Physiologically difficult airway
Introduction : Endotracheal intubation in critically ill is a high-risk procedure requiring significant expertise in airway handling as well as understanding of pathophysiology of the disease process.
Discussion : Critically ill patients are prone for hypotension and hypoxemia in the immediate post-intubation phase due to blunting of compensatory sympathetic response. Preoxygenation without NIV is frequently suboptimal, as alveolar flooding cause loss of alveolar capillary interface in many of these patients. All these factors, along with relative fluid deficit, neuromuscular fatigue and coexistent organ dysfunction lead to physiologically difficult airway. Airway in ICU can be classified as anatomically difficult, physiologically difficult and anatomically as well as physiologically difficult. Though rapid sequence intubation is the recommended method for securing airway in these patients, other methods like delayed sequence intubation awake intubation and double setup approach can be used in specific subgroups. Further research is needed in this field to set guidelines and fine tune airway management for patients with specific organ failure or dysfunction.
Conclusion : Airway in ICU should be managed according to the physiological as well as the anatomical abnormalities.
Conclusion (proposition de traduction) : Les voies respiratoires en soins intensifs doivent être prises en charge en fonction des anomalies physiologiques et anatomiques.
Acute Decompensated Heart Failure.
Hammond DA, Smith MN, Lee KC, Honein D, Quidley AM. | J Intensive Care Med. 2018 Aug;33(8):456-466
Keywords: acute decompensated heart failure; diuretic; heart failure; inotrope; vasodilator
Review of a Large Clinical Series
Editorial : Heart failure (HF) is a societal burden due to its high prevalence, frequent admissions for acute decompensated heart failure (ADHF), and the economic impact of direct and indirect costs associated with HF and ADHF. Common etiologies of ADHF include medication and diet noncompliance, arrhythmias, deterioration in renal function, poorly controlled hypertension, myocardial infarction, and infections. Appropriate medical management of ADHF in patients is guided by the identification of signs and symptoms of fluid overload or low cardiac output and utilization of evidence-based practices. In patients with fluid overload, various strategies for diuresis or ultrafiltration may be considered. Depending on hemodynamics and patient characteristics, vasodilator, inotropic, or vasopressor therapies may be of benefit. Upon ADHF resolution, patients should be medically optimized, have lifestyle modifications discussed and implemented, and medication concierge service considered. After discharge, a multidisciplinary HF team should follow up with the patient to ensure a safe transition of care. This review article evaluates the management options and considerations when treating a patient with ADHF.
Conclusion : The management of ADHF is quite complex and requires a systematic and multidisciplinary approach. Accurate patient assessment to determine fluid status and hemodynamics is a key to determining optimal treatment for a particular patient. Therapies commonly used in management include diuretics, vasodilators, and, in selected patients, inotropes. Additionally, patient education and management of concomitant disease states can optimize therapy and successfully reduce readmis- sions and minimize morbidity and mortality.
Conclusion (proposition de traduction) : La prise en charge de l'insuffisance cardiaque décompensée aiguë est assez complexe et nécessite une approche systématique et multidisciplinaire. Une évaluation précise du patient pour déterminer le statut liquidien et l'hémodynamique sont essentiels pour déterminer le traitement optimal pour un patient particulier. Les thérapeutiques couramment utilisées dans la prise en charge comprennent les diurétiques, les vasodilatateurs et, chez certains patients, les inotropes. De plus, l'éducation des patients et la gestion des états pathologiques concomitants peuvent optimiser la thérapeutique et réduire avec succès les réadmissions et minimiser la morbidité et la mortalité.
Defining No Pain, Mild, Moderate, and Severe Pain Based on the Faces Pain Scale-Revised and Color Analog Scale in Children With Acute Pain.
Tsze DS, Hirschfeld G, Dayan PS, Bulloch B, von Baeyer CL. | Pediatr Emerg Care. 2018 Aug;34(8):537-544
Introduction : The aims of this study were to define the Faces Pain Scale-Revised (FPS-R) and Color Analog Scale (CAS) scores associated with no pain, mild pain, moderate pain, and severe pain in children with acute pain, and to identify differences based on age, sex, and ethnicity.
Méthode : We conducted a prospective observational study in 2 pediatric emergency departments of children aged 4 to 17 years with painful and nonpainful conditions. We assessed their pain intensity using the FPS-R, CAS, and qualitative measures. Pain score cut points that best differentiated adjacent categories of pain were identified using a receiver operating characteristic-based method. Cut points were compared within subgroups based on age, sex, and ethnicity.
Résultats : We enrolled 620 patients, of whom 314 had painful conditions. The mean age was 9.2 years; 315 (50.8%) were in the younger age group (aged 4-7 years); 291 (46.8%) were female; and 341 (55%) were Hispanic. The scores best representing categories of pain for the FPS-R were as follows: no pain, 0 and 2; mild pain, 4; moderate pain, 6; and severe pain, 8 and 10. For the CAS, these were 0 to 1, 1.25 to 2.75, 3 to 5.75, and 6 to 10, respectively. Children with no pain frequently reported nonzero pain scores. There was considerable overlap of scores associated with mild and moderate pain. There were no clinically meaningful differences of scores representing each category of pain based on age, ethnicity, and race.
Conclusion : We defined pain scores for the FPS-R and CAS associated with categories of pain intensity in children with acute pain that are generalizable across subgroups based on patient characteristics. There were minor but potentially important differences in pain scores used to delineate categories of pain intensity compared to prior convention.
Conclusion (proposition de traduction) : Nous avons défini les scores de douleur pour l'échelle de la douleur de la face révisée et l'échelle de l'analogie de couleur associée aux catégories d'intensité de la douleur chez les enfants souffrant de douleur aiguë, généralisables en fonction des caractéristiques des patients. Il y avait des différences mineures mais potentiellement importantes dans les scores de douleur utilisés pour délimiter les catégories d'intensité de la douleur par rapport aux conventions antérieures.
Measuring Anxiety in the Pediatric Emergency Department.
Rochat CP, Gaucher N, Bailey B. | Pediatr Emerg Care. 2018 Aug;34(8):558-563
Introduction : The objective of this study was to evaluate the agreement between the State Trait Anxiety Inventory (STAI) and other anxiety scales to determine whether these shorter to administer scales could replace the STAI.
Méthode : This was a prospective cohort study on a convenience sample of children, aged 9 to 17 years, presenting to a pediatric emergency department. Patients were divided into 2 groups: preteens (PT) (aged 9-12 years) completed the pediatric STAI and teens (T) (aged 13-17 years) completed the adult STAI. Participants also completed a visual analog scale (0-100 mm), a Likert scale (1-5), and a short version of the STAI. Intraclass correlation (2-way mixed model, average measures) was used to evaluate agreement between the STAI and the other scales. A sample size of 100 patients per group was estimated as sufficient.
Résultats : The median (interquartile range) STAI state anxiety scores were 33 (28.25-36.75) and 37.5 (32-44), in the PT (n = 100) and T (n = 100) groups, respectively. The median (interquartile range) STAI trait anxiety scores were 33.5 (28-38.75) and 36 (31-44), in the PT and T groups, respectively. Agreements between the STAI and the other scales were poor for all scales. At best, the intraclass correlation was 0.71 for the agreement between the STAI and the short version of the STAI.
Conclusion : There appears to be poor agreement between the STAI and the other scales designed to measure anxiety in children 9 to 17 years presenting to the pediatric emergency department.
Conclusion (proposition de traduction) : Il semble y avoir une faible concordance entre le score « Inventaire de l'anxiété de l'établissement des traits » (State Trait Anxiety Inventory [STAI]) et les autres échelles conçues pour mesurer l'anxiété chez les enfants de 9 à 17 ans se présentant au service des urgences pédiatriques.
What is the Optimal Age for Students to Receive Cardiopulmonary Resuscitation Training?.
He DX, Huang KS, Yang YI, Jiang W, Yang NL, Yang H. | Prehosp Disaster Med. 2018 Aug;33(4):394-398
Keywords: AHA American Heart Association; CPR cardiopulmonary resuscitation; East Asian students; age; cardiopulmonary resuscitation; training
Introduction : Training students has been proven to be the optimal way to deliver cardiopulmonary resuscitation (CPR) skills. However, it is somehow unknown whether or not the current recommendations appropriate for Caucasian students are also suitable for East Asian students. The purpose of this study is to explore the best age for East Asian students to receive CPR training.
Méthode : Students were recruited from six schools. Students participated in a standard CPR training program provided by tutors. Each student attended a 60-minute training session with a manikin. After being trained, within one hour, the student's compression quality was assessed.
Résultats : A total of 360 students who constituted 12 continuous grades were recruited for this study. Adequate compression depth and satisfactory compression rate with correct hand position could be achieved since the age of 12. However, successful compression rate and complete release could be achieved since the younger age of six.
Conclusion : Current recommendations for Caucasian students to cultivate a full-capacity CPR rescuer at the age of 12 are also appropriate for East Asian students. However, the optimal age for students to receive CPR training should be decided based on evidence and importance assessment of CPR.
Conclusion (proposition de traduction) : Les recommandations actuelles pour les étudiants de race blanche à apprendre à réaliser une CPR à pleine capacité à l'âge de 12 ans sont également appropriées pour les étudiants de l'Asie de l'Est. Cependant, l'âge optimal pour que les étudiants reçoivent une formation sur la RCP devrait être déterminé en fonction de l'évaluation des preuves et de l'importance de la RCP.
Quality And Feasibility of Sonographic Measurement of the Optic Nerve Sheath Diameter to Estimate the Risk of Raised Intracranial Pressure After Traumatic Brain Injury in Prehospital Setting.
Houzé-Cerfon CH, Bounes V, Guemon J, Le Gourrierec T, Geeraerts T. | Prehosp Emerg Care. 2018 Aug;27:1-7
Keywords: prehospital; sonographic; traumatic brain injury
Introduction : In patients with traumatic brain injury (TBI), early detection and subsequent prompt treatment of elevated intracranial pressure (ICP) is a challenge in the prehospital setting, because physical examination is limited in comatose patients and invasive device placement is not possible. The aim of this study was to evaluate the quality and feasibility of optic nerve sheath diameter (ONSD) measurements obtained during the prehospital management of patients with TBI.
Méthode : This study was a prospective, observational study of 23 patients with moderate and severe TBI during prehospital medical care. The primary endpoint was the quality of ONSD measurements expressed as the percentage of ONSD validated by the experts. Secondary endpoints included the feasibility of ONSD measurements as the percentage of ONSD performed and assessment by operators of ease and duration to perform.
Résultats : Ultrasound ONSD was performed in 19 (82%) patients and 80% of ONSD measurements were validated by the experts. The ONSD measurements were possible in 15 (79%) cases. The physicians have assessed the ease of use at 8 (interquartile range [IQR] = 2.5-8) on 10 for and the median time to obtain ONSD measurement was 4 min (IQR = 3-5). ONSD measurement was performed in 12 (63%) cases during the transport and in 7 (37%) cases on scene, with 58% (n = 7) and 71% (n = 5) validated ONSD, respectively. The success rate in the helicopter was 43% compared to 80% in the ambulance.
Conclusion : This study shows that it is feasible to obtain high-quality ONSD measurements in the management of patients with TBI in a prehospital setting. A randomized study evaluating the usefulness of ONSD to guide management of TBI in the prehospital phase may be of great interest.
Conclusion (proposition de traduction) : Cette étude montre qu'il est possible d'obtenir des mesures de haute qualité du diamètre de la gaine du nerf optique dans la prise en charge des patients souffrant d'un traumatisme crânien en milieu préhospitalier. Une étude randomisée évaluant l'utilité du diamètre de la gaine du nerf optique pour guider la prise en charge des traumatismes cérébraux dans la phase préhospitalière peut être d'un grand intérêt.
Prehospital Antibiotic Prophylaxis for Open Fractures: Practicality and Safety.
Lack W, Seymour R, Bickers A, Studnek J, Karunakar M. | Prehosp Emerg Care. 2018 Aug;24:1-10
Keywords: Antibiotic prophylaxis; open fractures; practicality; pre-hospital; safety
Introduction : Early antibiotic administration has been associated with a significant decrease in infection following open fractures. However, antibiotics are most effective at a time when many patients are still being transported for care. There is very limited evidence that antibiotics may be safely administered for open fractures when being transported by life-flight personnel. No such data exists for ground ambulance transport of patients with open fractures. The purpose of the study was to assess the safety and feasibility of prophylactic antibiotic delivery in the prehospital setting.
Méthode : We performed a prospective observational study between 1/1/2014-5/31/205 of all trauma patients being transferred to a level 1 trauma center by a single affiliated ground ambulance transport service. If open fracture was suspected, the patient was indicated for antibiotic prophylaxis with 2g IV Cefazolin. Exclusion criteria included penicillin allergy, higher priority patient care tasks and remaining transport time insufficient for administration of antibiotics. The administration of antibiotics were recorded. Patient demographics, associated injuries, priority level (1 = life threatening injury, 2 = potentially life threatening injury, 3 = non-life threatening injury), and timing of transport and antibiotic administration were recorded as well.
Résultats : EMTs identified 70 patients during the study period for whom they suspected an open fracture. Eight reported penicillin allergy and were not eligible for prophylaxis. The patient's clinical status and transport time allowed for administration of antibiotic prophylaxis for 32 patients (51.6%). Total pre-hospital time was the only variable assessed that had a significant impact on administration of prehospital antibiotics (<30 minutes = 29% vs >30 minutes = 66%; p < 0.001). There were no allergic reactions among patients, and no needle sticks or other injuries to EMT personnel related to antibiotic administration.
Conclusion : EMT personnel were able to administer pre-hospital antibiotic prophylaxis for a substantial portion of the identified patients without any complications for patients or providers. Given the limited training provided to EMTs prior to implementation of the antibiotic prophylaxis protocol, it is likely that further development of this initial training will lead to even higher rates of pre-hospital antibiotic administration for open fractures.
Conclusion (proposition de traduction) : Le paramédic a pu administrer une prophylaxie antibiotique préhospitalière à une partie importante des patients identifiés sans aucune complication pour les patients ou les prestataires. Compte tenu de la formation limitée dispensée aux paramédic avant la mise en œuvre du protocole de prophylaxie antibiotique, il est probable que le développement ultérieur de cette formation initiale conduira à des taux encore plus élevés d'administration d'antibiotiques pré-hospitaliers pour les fractures ouvertes.
Self-Assessment Feedback Form Improves Quality of Out-of-Hospital CPR.
Weston BW, Jasti J, Mena M, Unteriner J, Tillotson K, Yin Z, Colella MR, Aufderheide TP. | Prehosp Emerg Care. 2018 Aug;17:1-8
Keywords: CPR; cardiac arrest; continuous quality improvement; emergency medical services; out-of-hospital
Introduction : Various continuous quality improvement (CQI) approaches have been used to improve quality of cardiopulmonary resuscitation (CPR) delivered at the scene of out-of-hospital cardiac arrest. We evaluated a post-event, self-assessment, CQI feedback form to determine its impact on delivery of CPR quality metrics.
Méthode : This before/after retrospective review evaluated data from a CQI program in a midsized urban emergency medical services (EMS) system using CPR quality metrics captured by Zoll Medical Inc. X-series defibrillator ECG files in adult patients (≥18 years old) with non-traumatic out-of-hospital cardiac arrest. Two 9-month periods, one before and one after implementation of the feedback form on December 31, 2013 were evaluated. Metrics included the mean and percentage of goal achievement for chest compression depth (goal: >5 centimeters [cm]; >90%/episode), rate (goal: 100-120 compressions/minute [min]), chest compression fraction (goal: ≥75%), and preshock pause (goal: <10 seconds [sec]). The feedback form was distributed to all EMS providers involved in the resuscitation within 72 hours for self-review.
Résultats : A total of 439 encounters before and 621 encounters after were evaluated including basic life support (BLS) and advanced life support (ALS) providers. The Before Group consisted of 408 patients with an average age of 61 ± 17 years, 61.8% male. The After Group consisted of 556 patients with an average age of 61 ± 17 years, 58.3% male. Overall, combining BLS and ALS encounters, the mean CPR metric values before and after were: chest compression depth (5.0 cm vs. 5.5 cm; p < 0.001), rate (109.6/min vs 114.8/min; p < 0.001), fraction (79.2% vs. 86.4%; p < 0.001), and preshock pause (18.8 sec vs. 11.8 sec; p < 0.001), respectively. Overall, the percent goal achievement before and after were: chest compression depth (48.5% vs. 66.6%; p < 0.001), rate (71.8% vs. 71.7%, p = 0.78), fraction (68.1% vs. 91.0%; p < 0.001), and preshock pause (24.1% vs. 59.5%; p < 0.001), respectively. The BLS encounters and ALS encounters had similar statistically significant improvements seen in all metrics.
Conclusion : This post-event, self-assessment CQI feedback form was associated with significant improvement in delivery of out-of-hospital CPR depth, fraction and preshock pause time.
Conclusion (proposition de traduction) : Cette forme de rétroaction continue d'amélioration de la qualité de l'auto-évaluation post-événement a été associée à une amélioration significative de la réalisation de la RCP extrahospitalière en ce qui concerne la profondeur du massage cardiaque, de la fraction et du temps de pause avant un choc électrique.
Can We Define Termination Of Resuscitation Criteria In Out-Of-Hospital Hanging?.
Escutnaire J, Ducrocq F, Singier A, Baert V, Babykina E, Dumont C, Vilhelm C, Marc JB, Segal N, Wiel E, Mols P, Hubert H; GR-RéAC. | Prehosp Emerg Care. 2018 Aug 17:1-8
Keywords: cardiac arrest; hanging; registry; survival; termination of resuscitation
Focus on Cardiac Arrest
Introduction : Survival rate of cardiac arrest due to hanging (H-CA) victims is low. Hence, this leads to the question of the utility of resuscitation in these patients. The objective was to investigate whether there are predictive criteria for survival with a good neurological outcome or predictive criteria for non-survival or survival with a poor neurological outcome enabling us to define the termination of resuscitation rules in these patients.
Méthode : Between July 1, 2011 and January 1, 2016, we included 1,689 out-of-hospital cardiac arrests due to hanging. We compared the characteristics of survivors with a good neurological outcome at day 30 with the others.
Résultats : The study population was mainly composed of males with a median age of 48 [37-60]. The overall survival was 2.1%, among which 48.6% had a good neurological outcome. Survivors benefited more often from immediate basic life support than the rest of the subjects, which was corroborated by the shorter no-flow durations. We did not record any difference in terms of advanced cardiac life support initiation frequency and technique between survivors with a good neurological outcome and the rest. Nevertheless, ACLS duration was longer in survivors with a good neurological outcome than in others.
Conclusion : Basic life support (BLS) was the decisive criterion for 15/17 survivors. However, a detailed analysis showed 2 survivors presenting no BLS before the arrival of mobile medical teams and non-shockable rhythms who survived at day 30 with a good neurological outcome. These results lead us to consider that mobile medical team intervention and ACLS attempt are not futile, and the benefit justifies the cost. Thus, we cannot define any rule for the termination of resuscitation.
Conclusion (proposition de traduction) : Le maintien des fonctions vitales de base (BLS) a été le critère décisif pour 15/17 survivants. Cependant, une analyse détaillée a montré que 2 survivants qui n'avait pas bénéficié d'une BLS avant l'arrivée des équipes médicales mobiles et qui présentaient des rythmes non choquables, ont survécu à J30 avec un bon résultat neurologique. Ces résultats nous amènent à considérer que l'intervention d'une équipe médicale mobile et la tentative de réanimation spécialisée (ACLS) ne sont pas futiles et que le bénéfice justifie le coût.
Par conséquent, nous ne pouvons définir aucune règle pour l'interruption de la réanimation.
A Novel Infant Chest Compression Assist Device Using a Palm Rather Than Fingers: A Randomized Crossover Trial.
Park JW, Jung JY, Kim J, Kwak YH, Kim DK, Lee JC, Ham EM, Hwang S, Kwon H. | Prehosp Emerg Care. 2018 Aug 17:1-9
Keywords: cardiopulmonary resuscitation; infant; manikins
Focus on Cardiac Arrest
Introduction : We developed a novel compression assist device (palm presser) to perform chest compressions using a palm in infant cardiopulmonary resuscitation (CPR). We hypothesized that the palm presser will increase compression depth without increasing hands-off time and will reduce rescuer fatigue compared with the two-finger technique (TFT).
Méthode : In this randomized crossover manikin trial, participants performed two minutes of CPR with a 30:2 compression:ventilation ratio using the palm presser and the TFT in randomized sequence on an infant manikin. CPR parameters, including compression depth and hands-off time, were collected to compare CPR quality between the palm presser and the TFT. The linear mixed-effect model was used to control the carryover effect of a crossover design in the analysis of CPR parameters. To evaluate rescuer fatigue, we compared changes in compression depth over time and calculated the odds of sufficiently deep compressions over time between the two groups.
Résultats : The palm presser resulted in greater mean compression depth (41.5 ± 1.6 mm vs. 36.8 ± 5.5 mm, p < 0.001), greater sufficiently deep compressions (80.9 ± 27.8% vs. 42.4 ± 35.4%, p < 0.001), and better correct hand position (99.9 ± 0.5% vs. 83.9 ± 25.3%, p = 0.013) than the TFT. Total compressions, compression rate, total ventilations, volume of ventilations, and hands-off time were not significantly different between the two groups. The mean change in compression depth over time was greater with the TFT than with the palm presser (regression coefficient: -0.024 [95% CI -0.030 to -0.018] vs. -0.004 [95% CI -0.006 to -0.002]). The odds of a compression depth greater than 40 mm increased 2.8 times (95% CI 2.2 to 3.4) with the TFT during the first minute compared with the last minute, whereas the corresponding odds ratio when using the palm presser was not significantly different in the first and last minutes (OR: 1.2 [95% CI 0.9 to 1.5]).
Conclusion : Compression with palm pressers resulted in greater compression depth without increasing hands-off time and reduced rescuer fatigue compared with compression with the TFT in simulated infant CPR with manikins.
Conclusion (proposition de traduction) : La compression à l'aide de la paume de la main a permis d'obtenir une plus grande profondeur de compression sans augmenter le temps d'immobilisation et de réduire la fatigue du secouriste par rapport à la compression à l'aide de la technique des deux doigts dans la RCP simulée sur mannequin.
Editorial : En novembre 2017, de nombreuses sociétés de discipline médicale américaines ont publié de nouvelles lignes directrices relatives au diagnostic et au traitement de l’hypertension artérielle. Dans ces nouvelles lignes directrices, l’hypertension artérielle a été définie par une valeur ≥130/80 mm Hg. Du jour au lendemain, les Etats-Unis comptaient alors 32 millions de personnes atteintes d’hypertension artérielle de plus, ce qui a suscité des discussions parfois virulentes dans le monde entier. Les nouvelles lignes directrices européennes relatives au diagnostic et au traitement de l’hypertension artérielle ont été attendues avec d’autant plus d’impatience.
Conclusion (proposition de traduction) : Le critère de décision pour l’initiation du traitement reste une pression artérielle ≥ 140/90 mmHg chez les adultes ; chez les patients âgés de ≥ 80 ans, la valeur seuil est de ≥ 160/90 mmHg. Les modifications du style de vie restent également la base du traitement antihypertenseur.
Toutefois, les lignes directrices soulignent expressément que leur implémentation ne doit pas retarder l’initiation du traitement antihypertenseur médicamenteux en cas de risque cardiovasculaire correspondant. Les nouvelles valeurs cibles de pression artérielle recommandées sont de < 130/80 mmHg en cas d’hypertension non compliquée et de 130 à < 140 mmHg chez les patients âgés.
Une étape assurément déterminante, qui devrait avoir des conséquences majeures pour la prise en charge des patients atteints d’hypertension artérielle, est la recommandation conseillant de débuter si possible le traitement hypertenseur en suivant une stratégie single-pill et en employant une association de deux substances. L’association initiale idéale recommandée est l’association d’un inhibiteur de l’ECA ou d’un sartan avec un antagoniste calcique ou un diurétique.
Patient–physician gender concordance and increased mortality among female heart attack patients.
Greenwood BN, Carnahan S, Huang L. | Proc Natl Acad Sci U S A. 2018 Aug 6. pii: 201800097
Keywords: gender disparity; heart attacks; mortality; patient advocacy; patient–physician gender concordance
Social Sciences - Economic Sciences
Editorial : We examine patient gender disparities in survival rates following acute myocardial infarctions (i.e., heart attacks) based on the gender of the treating physician. Using a census of heart attack patients admitted to Florida hospitals between 1991 and 2010, we find higher mortality among female patients who are treated by male physicians. Male patients and female patients experience similar outcomes when treated by female physicians, suggesting that unique challenges arise when male physicians treat female patients. We further find that male physicians with more exposure to female patients and female physicians have more success treating female patients.
Conclusion : A large body of medical research suggests that women are less likely than men to survive traumatic health episodes like acute myocardial infarctions. In this work, we posit that these diffi- culties may be partially explained, or exacerbated, by the gender match between the patient and the physician. Findings suggest that gender concordance increases a patient’s proba- bility of survival and that the effect is driven by increased mortality when male physicians treat female patients. Empiri- cal extensions indicate that mortality rates decrease when male physicians practice with more female colleagues or have treated more female patients in the past.
Conclusion (proposition de traduction) : Un grand nombre de recherches médicales suggèrent que les femmes ont moins de chances que les hommes de survivre à des épisodes traumatisants comme les infarctus aigu du myocarde. Dans ce travail, nous posons comme postulat que ces différences peuvent être partiellement expliquées, ou exacerbées, par l'adéquation entre le sexe du patient et celui du médecin. Les résultats suggèrent que la concordance entre les sexes augmente la probabilité de survie d'un patient et que l'effet est dû à l'augmentation de la mortalité lorsque les médecins masculins traitent des patientes. Les extensions empiriques indiquent que les taux de mortalité diminuent lorsque les médecins masculins pratiquent avec plus de collègues féminins ou ont traité plus de patientes dans le passé.
Commentaire : Lire le commentaire de l'article sur Medscape : Arrêt cardiaque : meilleure survie chez les femmes prises en charge par des médecins femmes - Medscape - 17 août 2018 .
Comparison of presumed cardiac and respiratory causes of out-of-hospital cardiac arrest.
Orban JC, Truc M, Kerever S, Novain M, Cattet F, Plattier R, Nefzaoui M, Hyvernat H, Raguin O, Kaidomar M, Mongardon N, Ichai C.. | Resuscitation. 2018 Aug;129:24-28
Keywords: Cause of cardiac arrest; Out-of-hospital cardiac arrest; Outcome
Introduction : Most interventional and observational studies include cardiac arrest from cardiac origin. However, an increasing proportion of cardiac arrest results from an extra-cardiac origin, mainly respiratory. The aim of our study was to compare the characteristics and outcome of cardiac arrest patients according to the presumed cardiac or respiratory causes.
Méthode : This retrospective multicenter observational study included out-of-hospital cardiac arrest patients from presumed cardiac and respiratory origin treated with therapeutic hypothermia. Demographic data (age, sex, initial rhythm as shockable or non-shockable, durations of no-flow and low-flow), clinical evolution in ICU, lactate and outcome (CPC scale at ICU discharge) were compared between patients according to the presumed cardiac or respiratory origin of the cardiac arrest.
Résultats : Two hundred and fifty-one cardiac arrest patients were included, 156 from presumed cardiac origin (62%) and 95 from presumed respiratory origin (38%). Patients with presumed cardiac cause presented more frequently a shockable rhythm (68% vs. 5%, p < 0.001), received more defibrillations attempts (2 [1-5] vs. 0 [0-0], <0.001) and needed less adrenaline (3 mg [0-5] vs. 4 mg [2-7], p = 0.01). The arterial lactate concentration on admission was higher in patients with presumed respiratory causes (6.3 mmol/L [4.2-9.8] vs. 3.2 mmol/L [1.6-5.0], p < 0.001). The proportion of patients presenting a favorable outcome was higher in the population with presumed cardiac causes, compared to its respiratory counterpart (42% vs. 19%, p < 0.001).
Conclusion : Compared to presumed cardiac origin, a worse outcome and a different mode of death are associated with the presumed respiratory origin, resulting from a greater insult preceding cardiac arrest. The presumed cause of cardiac arrest could be integrated in the multimodal prognostication process.
Conclusion (proposition de traduction) : Par rapport aux suspicions d'étiologie cardiaques, si une étiologie respiratoire est retenue, elle est associée à une évolution plus grave et à un mode de décès différent, résultant d’une atteinte plus importante précédant l’arrêt cardiaque. La cause présumée de l’arrêt cardiaque pourrait être intégrée au processus de pronostic multimodal.
Effect of detection time interval for out-of-hospital cardiac arrest on outcomes in dispatcher-assisted cardiopulmonary resuscitation: A nationwide observational study.
Ko SY, Shin SD, Ro YS, Song KJ, Hong KJ, Park JH, Lee SC. | Resuscitation. 2018 Aug;129:61-69
Keywords: Detection time; Dispatch-assisted cardiopulmonary resuscitation; Out-of-hospital cardiac arrest; Outcomes; Urbanization
Introduction : The association between the detection time interval (DTI) from the call for ambulance to the detection of out-of-hospital cardiac arrest (OHCA) by the dispatcher and the neurological outcome in dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is unclear.
Méthode : Adults who sustained OHCA with cardiac etiology received DA-CPR between 2013 and 2016 were analyzed. The main predictor was DTI defined as the time interval from the beginning of the emergency call to identification of OHCA by the dispatcher. The primary outcomes were the good cerebral performance category (CPC) 1 or 2. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for outcomes, adjusting for potential confounders, by the 10- and 30-s DTI delay and three DTI groups; Short (0-90 s), Middle (91-180 s), and Long (181-1,200 s) groups. Interaction analysis for DTI and urbanization level (megacity with 10 million or more population in urban region, metropolis with 1 to 5 million population in urban region, and Rural province with less than 2 million population in urban, suburban, and rural region) was performed to compare the effect size of DTI group according to urbanization level.
Résultats : Of 116,374 adults with an OHCA, 11,833 were finally analyzed. Overall, the number (%) of survival to discharge was 1380 (11.4%), and the good CPC was 945 (8.0%). For good cerebral performance category, the AOR (95% CIs) for good CPC was 0.99 (0.98-1.00) by 10-s DTI delay and 0.97 (0.95-0.99) by 30-s DTI delay. The AORs (95% CIs) for good CPC were 0.84 (0.71-1.00) for the Middle and 0.79 (0.66-0.96) for the Long DTI groups compared with Short DTI. The AORs (95% Cl) for good CPC compared with Short DTI group were 0.93 (0.68-1.27) by Middle DTI and 0.84 (0.59-1.20) by Long DTI in megacity, 0.60 (0.44-0.81) by Middle DTI and 0.60 (0.44-0.82) by Long DTI in metropolis, and 0.43 (0.31-0.60) by Middle DTI and 0.38 (0.26-0.56) by Long DTI in Rural province, respectively.
Conclusion : A longer DTI in DA-CPR showed significantly lower good neurological recovery in adult patients with witnessed OHCA. A 30 s delay in DTI was associated with a 3% decrease of a good CPC score. The DTI effect on good CPC was significant in metropolis and Rural province while not in megacity region.
Conclusion (proposition de traduction) : Un intervalle de temps plus long mis par une assistant de régulation pour la détection d'un arrêt cardiaque extra-hospitalier a montré une récupération neurologique satisfaisante significativement plus faible chez les patients adultes. Un intervalle de temps de détection de 30 secondes était associé à une diminution de 3 % sur les bons résultats du score de CPC. L'effet de l'intervalle de temps de détection sur les bons résultats du score de CPC était significatif dans la métropole et la province rurale, mais pas dans la mégapole.
Adherence to advanced cardiovascular life support (ACLS) guidelines during in-hospital cardiac arrest is associated with improved outcomes.
Honarmand K, Mepham C, Ainsworth C, Khalid Z. | Resuscitation. 2018 Aug;129:76-81
Keywords: Advanced cardiac life support; Cardiopulmonary resuscitation; In-hospital cardiac arrest
Introduction : Identifying modifiable factors associated with survival following in-hospital cardiac arrest is crucial. The purpose of this study was to determine the extent to which adherence to the 2010 American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines in their entirety affects patient outcomes. In addition, we explored the role of code leader training level on patient outcomes.
Méthode : We conducted a retrospective review of records for cardiac arrests that occurred on hospital wards and were run by the hospital code team, at three tertiary care centres over 2 to 4 years. Deviations from the ACLS guidelines were quantified using a standardized checklist. Primary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge.
Résultats : Of 160 resuscitation events, ROSC was achieved in 75 events (46.9%) and survival to hospital discharge in 20 patients (13.1%). On average, there were 2.3 deviations from ACLS guidelines during events that led to ROSC and 3.9 deviations during events that did not lead to ROSC (p < 0.0001). There were fewer deviations during events that led to survival to hospital discharge (2.1) compared to those where the patient did not survive to hospital discharge (3.1; p = 0.016). Code leader training level was not associated with patient outcomes. Multivariable logistic regression analysis confirmed an association between deviations from ACLS guidelines and ROSC, but not for survival to hospital discharge. The latter finding may reflect a very low survival rate.
Conclusion : We found that higher numbers of deviations from ACLS guidelines were associated with a lower likelihood of ROSC and survival to hospital discharge. These findings emphasize the importance of adherence to ACLS guidelines and the need for training healthcare personnel in resuscitation guidelines in order to improve outcomes for victims of in-hospital cardiac arrest.
Conclusion (proposition de traduction) : Nous avons constaté qu'un nombre plus élevé d'écarts par rapport aux lignes recommandation de l'ACLS était associé à une probabilité plus faible de RACS et de survie après la sortie de l'hôpital. Ces résultats soulignent l’importance du respect des recommandation de l'ACLS et de la nécessité de former le personnel de santé aux recommandations de réanimation afin d’améliorer les résultats pour les victimes d’arrêt cardiaque à l’hôpital.
Comparison of right and left ventricular enhancement times using a microbubble contrast agent between proximal humeral intraosseous access and brachial intravenous access during cardiopulmonary resuscitation in adults.
Cho Y, You Y, Park JS, Min JH, Yoo I, Jeong W, Ryu S, Lee J, Kim S, Cho SU, Oh SK, Lee J, Ahn HJ. | Resuscitation. 2018 Aug;129:90-93
Keywords: Cardiac arrest; Intraosseous; Intravenous
Introduction : The present study aimed to compare the ventricular enhancement time between humeral intraosseous access (HIO) and brachial intravenous access (BIV) during cardiopulmonary resuscitation (CPR) in adult humans. To our knowledge, this is the first such study during CPR in adult humans.
Méthode : This prospective single-centre observational cohort study assessed the medical records of patients who underwent CPR between January 2018 and March 2018. The primary endpoints were the left and right ventricular enhancement (LVE and RVE, respectively) times after administration of a microbubble contrast agent via HIO or BIV. Continuous variables are reported as means and standard deviations depending on normal distribution, while categorical variables are reported as frequencies and percentages. The paired t-test and analysis of variance were used to compare HIO and BIV. Differences were considered significant at a P-value <0.05.
Résultats : The study included 10 patients. The HIO time (15.60 ± 6.45 s) was significantly lower than the BIV time (20.80 ± 7.05 s; P = 0.009). The RVE time was significantly lower with HIO (5.60 ± 1.71 s) than with BIV (15.40 ± 3.24 s; P < 0.001). Additionally, the LVE time was significantly lower with HIO (120.20 ± 4.18 s) than with BIV (132.00 ± 3.09 s; P < 0.001).
Conclusion : Our results indicated that the arrival times of a drug at the right and left ventricles are significantly lower with HIO than with BIV in an adult cardiac arrest model.
Conclusion (proposition de traduction) : Nos résultats montrent que les temps d'arrivée d'un médicament dans les ventricules droit et gauche sont significativement plus courts avec un accès intraosseux huméral (15,60 ± 6,5 sec ) qu'avec un accès veineux brachial (20,80 ± 7,0 sec) dans un modèle en arrêt cardiaque chez l'adulte.
Cerebral saturation in cardiac arrest patients measured with near-infrared technology during pre-hospital advanced life support. Results from Copernicus I cohort study.
Genbrugge C, De Deyne C, Eertmans W, Anseeuw K, Voet D, Mertens I, Sabbe M, Stroobants J, Bruckers L, Mesotten D, Jans F, Boer W, Dens J. | Resuscitation. 2018 Aug;129:107-113
Keywords: Advanced life support; Cardiac arrest; Cerebral oximetry; Cerebral saturation; Out-of hospital cardiac arrest; Pre-hospital
Introduction : To date, monitoring options during pre-hospital advanced life support (ALS) are limited. Regional cerebral saturation (rSO2) may provide more information concerning the brain during ALS. We hypothesized that an increase in rSO2 during ALS in out-of hospital cardiac arrest (OHCA) patients is associated with return of spontaneous circulation (ROSC).
Méthode : A prospective, non-randomized multicenter study was conducted in the pre-hospital setting of six hospitals in Belgium. Cerebral saturation was measured during pre-hospital ALS by a medical emergency team in OHCA patients. Cerebral saturation was continuously measured until ALS efforts were terminated or until the patient with sustained ROSC (>20 min) arrived at the emergency department. To take the longitudinal nature of the data into account, a linear mixed model was used. The correlation between the repeated measures of a patient was handled by means of a random intercept and a random slope. Our primary analysis tested the association of rSO2 with ROSC.
Résultats : Of the 329 patients 110 (33%) achieved ROSC. First measured rSO2 was 30% ± 18 in the ROSC group and 24% ± 15 in the no-ROSC group (p = .004; mean ± SD). Higher mean rSO2 values were observed in the ROSC group compared to the no-ROSC group (41% ± 13 versus 33% ± 13 respectively; p < 0.001). The median increase in rSO2, measured from start until two minutes before ROSC, was higher in the ROSC group (ROSC group 17% (IQR 6-29)) than in the no-ROSC group (8% (IQR 2-13); p < 0.001). An increase in rSO2 above 15% was associated with ROSC (OR 4.5; 95%CI 2.747-7.415; p < 0.001).
Conclusion : Regional cerebral saturation measurements can be used during pre-hospital ALS as an additional marker to predict ROSC. An increase of at least 15% in rSO2 during ALS is associated with a higher probability of ROSC.
Conclusion (proposition de traduction) : Les mesures régionales de saturation cérébrale peuvent être utilisées lors de la réanimation avancée pré-hospitalière en tant que marqueur supplémentaire pour prédire la RACS. Une augmentation d'au moins 15 % de la saturation cérébrale régionale pendant la réanimation cardiopulmonaire spécialisée est associée à une probabilité plus élevée de RACS.
Cerebral tissue oximetry levels during prehospital management of cardiac arrest - A prospective observational study.
Prosen G, Strnad M, Doniger SJ, Markota A, Stožer A, Borovnik-Lesjak V, Mekiš D. | Resuscitation. 2018 Aug;129:141-145
Keywords: Cerebral oximetry; Dynamics; EMS; NIRS; OHCA; Out-of-hospital cardiac arrest; Prehospital emergency medicine, cardiac arrest, survival; ROSC; rSO(2)
Introduction : Near-infrared spectroscopy (NIRS) enables continuous monitoring of regional oximetry (rSO2). The aim of this study was to describe dynamics of regional cerebral oximetry levels during out of hospital cardiac arrest (OHCA) resuscitation, specifically around the time of restoration of spontaneous circulation (ROSC).
Méthode : This prospective observational study was performed in the prehospital setting during cardio-pulmonary resuscitation (CPR) of OHCA patients. In the three-year study period, two-hundred eighty OHCA's were responded to; rSO2 was continuously measured throughout CPR and after attaining ROSC.
Résultats : Final data analysis included 53 patients. Continuous rSO2dynamics were described and data was compared amongst ROSC (22 cases) and no-ROSC (31 cases) groups. Initial rSO2levels were below 15% (not detectable) in both groups. With ongoing CPR, rSO2levels were higher in the ROSC group (median 22% vs. 14% in no-ROSC group, p = 0.030). Until ROSC, rSO2levels were higher throughout CPR before ROSC (mean maximal value 47% at ROSC vs. 31% no-ROSC, p < 0.01). Furthermore, we found a pattern of significant, rapid and sustained rise in rSO2levels minutes prior to ROSC and normalization thereafter.
Conclusion : Initial rSO2 levels during OHCA are generally undetectable by the time EMS teams initiate CPR. With CPR, rSO2 levels rise and are higher during CPR in patients who later achieve ROSC. Patients who achieve ROSC exhibit significant, rapid, and sustained rise in rSO2 minutes prior to attaining ROSC, and normalization of rSO2 levels thereafter. Persistently low levels of rSO2 during CPR likely portend poor neurologic outcomes.
Conclusion (proposition de traduction) : Les taux d’oxymétrie cérébraux initiaux lors d’un arrêt cardiaque extrahospitalier sont généralement indétectables au moment où les équipes de soins d'urgence initient la RCP. Avec la RCP, les niveaux d'oxymétrie régionaux augmentent et sont plus élevés pendant la RCP chez les patients qui présenteront plus tard une RACS. Chez les patients qui présenteront une RACS on observe une augmentation significative, rapide et soutenue du nombre de minutes d'oxymétrie cérébrale régionale normale avant d'obtenir la RACS et une normalisation des niveaux d'oxymétrie cérébrale normale par la suite. De faibles niveaux persistants d'oxymétrie cérébraux pendant la RCP laissent présager des résultats neurologiques médiocres.
Clinical Prediction Rules to Classify Types of Stroke at Prehospital Stage.
Uchida K, Yoshimura S, Hiyama N, Oki Y, Matsumoto T, Tokuda R, Yamaura I, Saito S, Takeuchi M, Shigeta K, Araki H, Morimoto T. | Stroke. 2018 August;49:1820-1827
DOI: https://doi.org/10.1161/STROKEAHA.118.021794 | Télécharger l'article au format
Introduction : Endovascular therapy is effective against acute cerebral large vessel occlusion (LVO). However, many patients do not receive such interventions because of the lack of timely identification of the type of stroke. If the types of stroke (any stroke, LVO, intracranial hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) were to be predicted at the prehospital stage, better access to appropriate interventions would be possible. Japan Urgent Stroke Triage (JUST) score was clinical prediction rule to classify suspected patients of acute stroke into different types at the prehospital stage.
Méthode : We obtained information for signs and symptoms and medical history of consecutive suspected patients of acute stroke at prehospital stage from paramedics and final diagnosis from the receiving hospital. We constructed derivation cohort in the historical multicenter cohort study from June 2015 to March 2016 and validation cohort in the prospective multicenter cohort study from August 2016 to July 2017. The derivation and the validation cohorts included 1229 and 1007 patients, respectively. We constructed multivariate logistic regression models with 21 variables to develop clinical prediction rules, which distinguish between different types of stroke: any stroke, LVO, ICH, and SAH.
Résultats : Among the 1229 patients (median age, 72 years; 55% men) in the derivation cohort, 533 stroke, 104 LVO, 169 ICH, and 57 SAH cases were observed. The developed rules showed that the areas under the receiver operating curves were 0.88 for any stroke, 0.92 for LVO, 0.84 for ICH, and 0.89 for SAH. The validation cohort of 1007 patients (median age, 75 years; 56% men) showed that the areas under the curves of any stroke, LVO, ICH, and SAH were 0.80, 0.85, 0.77, and 0.94, respectively.
Conclusion : These clinical prediction rules can help paramedics classify the suspected patients of stroke into any stroke, LVO, ICH, and SAH groups with excellent accuracy.
Conclusion (proposition de traduction) : Ces règles de prédiction clinique peuvent aider les ambulanciers paramédicaux à classer les patients soupçonnés d'accident vasculaire cérébral (AVC) dans chaque catégorie d'accident cérébral non traumatique, un accident vasculaire ischémique, une hémorragie intracrânienne ou une hémorragie sous-arachnoïdienne avec une excellente précision.
Recanalization in Cerebral Venous Thrombosis: A Systematic Review and Meta-Analysis.
Aguiar de Sousa D, Lucas Neto L, Canhão P, Ferro JM. | Stroke. 2018 August;49:1828–1835
DOI: https://doi.org/10.1161/STROKEAHA.118.022129 | Télécharger l'article au format
Keywords: adult; follow-up studies; humans; meta-analysis; neuroimaging; prognosis; sinus thrombosis, intracranial
Introduction : The role of recanalization of the occluded dural sinus or vein in the outcome of patients with cerebral venous thrombosis (CVT) is not established. We aimed to systematically review, in patients with CVT, (1) the recanalization rate and its association with (2) clinical outcome and (3) CVT recurrence.
Méthode : Systematic search in MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane Library, and clinicaltrials.gov (inception to September 2017). We considered cohort studies reporting the recanalization rate in adult patients with CVT treated with anticoagulation. Reported rates of venous recanalization at the last follow-up, functional outcome defined using the modified Rankin Scale at last follow-up dichotomized for favorable (0-1) and unfavorable (2-6) outcome, and recurrence rate of CVT according to recanalization status were extracted independently by 2 authors. Meta-analyses of proportions were performed using Freeman-Tukey double arcsine transformation. Functional outcomes according to the recanalization status were compared using meta-analysis and ordinal logistic regression. We conducted sensitivity analyses for time to assessment of recanalization and study quality.
Résultats : Four hundred sixty-eight studies were identified, and 19 studies were included. (1) We found report of 694 patients with recanalization in the follow-up among 818 cases of CVT. The overall pooled proportion of patients achieving recanalization was 85% (95% confidence interval, 80-89; I2=58%). In studies with higher methodological quality, the recanalization rate was 77% (95% confidence interval, 70-82; I2=0%). (2) There was a significant increase in the chance of favorable outcome (modified Rankin Scale, 0-1) in patients with recanalization with a pooled odds ratio of 3.3 (95% confidence interval, 1.2-8.9; I2=32%) in the random effects meta-analysis and a common odds ratio of 3.3 (95% confidence interval, 1.7-6.3) in the ordinal logistic regression. (3) Data on CVT recurrence according to recanalization was scarce.
Conclusion : The overall rate of recanalization in patients receiving anticoagulation was 85%, but exclusion of severe patients from follow-up imaging is a plausible source of bias. Lack of venous recanalization was associated with worse clinical outcome.
Conclusion (proposition de traduction) : Le taux global de recanalisation chez les patients recevant une anticoagulation était de 85 %, mais l'exclusion des patients sévères de l'imagerie de suivi est une source plausible de biais. Le manque de recanalisation veineuse était associé à un résultat clinique moins favorable.
Age Threshold for Ischemic Stroke Risk in Atrial Fibrillation: Cohort Data Covering the Entire Korean Population.
Kim TH, Yang PS, Yu HT, Jang E, Uhm JS, Kim JY, Pak HN, Lee MH, Joung B, Lip GYH. | Stroke. 2018 August;49:1872-1879
DOI: https://doi.org/10.1161/STROKEAHA.118.021047 | Télécharger l'article au format
Keywords: age threshold; atrial fibrillation; risk factor; stroke
Introduction : Although older age is one of the most important risk factor for stroke in atrial fibrillation (AF), the appropriate age threshold (eg, CHA2DS2-VASc score [congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65-74 years, female], 1 point for age 65-74 years, 2 points for age ≥75 years) for increased risk is controversial because actual age thresholds may differ between countries and ethnic groups. We investigated the age threshold for ischemic stroke risk among Asian AF patients.
Méthode : Using National Health Insurance Service database, including 426 650 oral anticoagulant-naive nonvalvular AF patients from 2005 to 2015, with ≤2 nongender-related CHA2DS2-VASc risk scores (CHA2DS2-VASc score 0-2 in males, 1-3 in females), we assessed the risk of ischemic stroke in AF patients according to the age.
Résultats : Patients who fulfill the age risk criterion (age, 65-74 years) without other risk factors showed a significantly higher risk of stroke (4.76 per 100 person-years [100PY]; adjusted hazard ratio, 2.25; 95% confidence interval [CI], 2.17-2.36) compared with patients with 1 risk score other than age (1.87/100PY). Patients aged 55 to 59 years with no risk factors showed similar risk of stroke (1.94/100PY; adjusted hazard ratio, 0.95; 95% confidence interval, 0.90-1.00) than patients with 1 risk score (2.06/100PY). Patients aged 65 to 69 years and no other risk factors had similar stroke risk (4.08/100PY; adjusted hazard ratio, 0.93; 95% confidence interval, 0.90-0.97) than patients with 2 nongender-related risk scores (4.42/100PY).
Conclusion : Older age is the most important predictor of ischemic stroke in AF, particularly for patients with low to intermediate risk of stroke. These nationwide data suggest lowering the current age threshold (age, ≥65 years) in the CHA2DS2-VASc score to age ≥55 years might be appropriate among Asian patients with AF.
Conclusion (proposition de traduction) : L'âge avancé est le facteur prédictif le plus important de l'AVC ischémique dans la FA, en particulier chez les patients présentant un risque d'AVC faible à intermédiaire.
Ces données nationales suggèrent que l'abaissement du seuil d'âge actuel (âge ≥ 65 ans) du score CHA2DS2-VASc à l'âge ≥ 55 ans pourrait être approprié chez les patients asiatiques atteints de FA.
Hemostatic Therapies For Acute Spontaneous Intracerebral Hemorrhage.
Law ZK, Al-Shahi Salman R1, Bath PM, Steiner T, Sprigg N. | Stroke. 2018 Aug;49:e271–e272
DOI: https://doi.org/10.1161/STROKEAHA.118.022071 | Télécharger l'article au format
Introduction : Outcome after spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume; up to one-third of ICHs enlarge within 24 hours of onset. Early haemostatic therapy might improve outcome by limiting haematoma growth. This is an update of a Cochrane Review first published in 2006, and last updated in 2009.
OBJECTIVES: To examine 1) the effectiveness and safety of individual classes of haemostatic therapies, compared against placebo or open control, in adults with acute spontaneous intracerebral haemorrhage, and 2) the effects of each class of haemostatic therapy according to the type of antithrombotic drug taken immediately before ICH onset (i.e. anticoagulant, antiplatelet, or none).
Méthode : We searched the Cochrane Stroke Trials Register, CENTRAL; 2017, Issue 11, MEDLINE Ovid, and Embase Ovid on 27 November 2017. In an effort to identify further published, ongoing, and unpublished randomised controlled trials (RCT), we scanned bibliographies of relevant articles and searched international registers of RCTs in November 2017.
SELECTION CRITERIA: We sought randomised controlled trials (RCTs) of any haemostatic intervention (i.e. pro-coagulant treatments such as coagulation factors, antifibrinolytic drugs, or platelet transfusion) for acute spontaneous ICH, compared with placebo, open control, or an active comparator, reporting relevant clinical outcome measures.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data, assessed risk of bias, and contacted corresponding authors of eligible RCTs for specific data if they were not provided in the published report of an RCT.
Résultats : We included 12 RCTs involving 1732 participants. There were seven RCTs of blood clotting factors versus placebo or open control involving 1480 participants, three RCTs of antifibrinolytic drugs versus placebo or open control involving 57 participants, one RCT of platelet transfusion versus open control involving 190 participants, and one RCT of blood clotting factors versus fresh frozen plasma involving five participants. We were unable to include two eligible RCTs because they presented aggregate data for adults with ICH and other types of intracranial haemorrhage. We identified 10 ongoing RCTs. Across all seven criteria in the 12 included RCTs, the risk of bias was unclear in 37 (44%), high in 16 (19%), and low in 31 (37%). Only one RCT was at low risk of bias in all criteria.In one RCT of platelet transfusion versus open control for acute spontaneous ICH associated with antiplatelet drug use, there was a significant increase in death or dependence (modified Rankin Scale score 4 to 6) at day 90 (70/97 versus 52/93; risk ratio (RR) 1.29, 95% confidence interval (CI) 1.04 to 1.61, one trial, 190 participants, moderate-quality evidence). All findings were non-significant for blood clotting factors versus placebo or open control for acute spontaneous ICH with or without surgery (moderate-quality evidence), for antifibrinolytic drugs versus placebo (moderate-quality evidence) or open control for acute spontaneous ICH (moderate-quality evidence), and for clotting factors versus fresh frozen plasma for acute spontaneous ICH associated with anticoagulant drug use (no evidence).
Conclusion : Based on moderate-quality evidence from one trial, platelet transfusion seems hazardous in comparison to standard care for adults with antiplatelet-associated ICH. We were unable to draw firm conclusions about the efficacy and safety of blood clotting factors for acute spontaneous ICH with or without surgery, antifibrinolytic drugs for acute spontaneous ICH, and clotting factors versus fresh frozen plasma for acute spontaneous ICH associated with anticoagulant drug use.Further RCTs are warranted, and we await the results of the 10 ongoing RCTs with interest.
Conclusion (proposition de traduction) : D'après des données de qualité moyenne d'une étude, la transfusion plaquettaire semble dangereuse par rapport aux soins standard pour les adultes présentant une hémorragie intracérébrale associée aux antiplaquettaires. Nous n'avons pas été en mesure de tirer des conclusions fermes sur l'efficacité et l'innocuité des facteurs de coagulation sanguine pour l'hémorragie intracérébrale spontanée aiguë avec ou sans chirurgie, des médicaments antifibrinolytiques pour l'hémorragie intracérébrale spontanée aiguë et des facteurs de coagulation par rapport au plasma frais congelé pour l'hémorragie intracérébrale spontanée aiguë associée à l'utilisation d'anticoagulants.
D'autres essais contrôlés randomisés sont justifiés et nous attendons avec intérêt les résultats des 10 essais contrôlés randomisés en cours.
Improved Stroke Prevention in Atrial Fibrillation After the Introduction of Non–Vitamin K Antagonist Oral Anticoagulants.
Forslund T, and al. | Stroke. 2018 August;49:2122-2128
DOI: https://doi.org/10.1161/ STROKEAHA.118.021990 | Télécharger l'article au format
Keywords: anticoagulants; atrial fibrillation; incidence; stroke; warfarin
Introduction : The purpose of this study was to investigate the impact of improved antithrombotic treatment in atrial fibrillation after the introduction of non–vitamin K antagonist oral anticoagulants on the incidence of stroke and bleeding in a real-life total population, including both primary and secondary care.
Méthode : All resident and alive patients with a recorded diagnosis for atrial fibrillation during the preceding 5 years in the Stockholm County Healthcare database (Vårdanalysdatabasen) were followed for clinical outcomes during 2012 (n=41 008) and 2017 (n=49 510).
Résultats : Pharmacy claims for oral anticoagulants increased from 51.6% to 73.8% (78.7% among those with CHA2DS2- VASc ≥2). Non–vitamin K antagonist oral anticoagulant claims increased from 0.4% to 34.4%. Ischemic stroke incidence rates decreased from 2.01 per 100 person-years in 2012 to 1.17 in 2017 (incidence rate ratio, 0.58; 95% CI, 0.52–0.65). The largest increases in oral anticoagulants use and decreases in ischemic strokes were seen in patients aged ≥80 years who had the highest risk of stroke and bleeding. The incidence rates for major bleeding (2.59) remained unchanged (incidence rate ratio, 1.00; 95% CI, 0.92–1.09) even in those with a high bleeding risk. Poisson regression showed that 10% of the absolute ischemic stroke reduction was associated with increased oral anticoagulants treatment, whereas 27% was related to a generally decreased risk for all stroke.
Conclusion : Increased oral anticoagulants use contributed to a marked reduction of ischemic strokes without increasing bleeding rates between 2012 and 2017. The largest stroke reduction was seen in elderly patients with the highest risks for stroke and bleeding. These findings strongly support the adoption of current guideline recommendations for stroke prevention in atrial fibrillation in both primary and secondary care.
Conclusion (proposition de traduction) : L'augmentation de l'utilisation des anticoagulants oraux a contribué à une réduction marquée des accidents ischémiques cérébraux sans augmentation des taux de saignement entre 2012 et 2017. La réduction la plus importante a été observée chez les patients âgés présentant les risques les plus élevés d'accident vasculaire cérébral et de saignement. Ces résultats appuient fortement l'adoption des recommandations des lignes directrices actuelles pour la prévention de l'AVC dans la fibrillation auriculaire dans les soins primaires et secondaires.
Should patients with complex febrile seizure be admitted for further management?.
Olson H, Rudloe T, Loddenkemper T, Harper MB, Kimia AA. | Am J Emerg Med. 2018 Aug;36(8):1386-1390
Keywords: Admission; Febrile seizures
Introduction : Children with first complex febrile seizure (CFS) are often admitted for observation. The goals of this study were 1) to assess the risk of seizure recurrence during admission, 2) to determine whether early EEG affects acute management.
Méthode : We retrospectively reviewed a cohort of children 6-60months of age admitted from a Pediatric Emergency Department for first CFS over a 15year period. We excluded children admitted for supportive care of their febrile illness. Data extraction included age, gender, seizure features, laboratory and imaging studies, EEG, further seizures during admission, and antiepileptic drugs (AEDs) given.
Résultats : One hundred eighty three children met inclusion criteria. Seven patients had seizures during the admission (7/183 or 3.8%) Since 38 children were loaded with anti-epileptic medication during their visit, the adjusted rate is 7/145 or 4.8. Increased risk of seizure recurrence during admission was observed in children presenting with multiple seizures (P=0.005). EEG was performed in 104/183 children (57%) and led to change in management in one patient (1%, 95% C.I. 0.05-6%). Six of the 7 children with seizure had an EEG. The study was normal in 3 and findings in the other 2 did not suggest/predict further seizures during the admission.
Conclusion : Children with first CFSs are at low risk for seizure recurrence during admission. Multiple seizures at presentation are associated with risk of early recurrence and may warrant an admission. EEG had limited effect on acute management and should not be an indication for admission.
Conclusion (proposition de traduction) : Les enfants qui font une première crise fébriles complexe sont à faible risque de récidive pendant l'admission. Les crises multiples lors de la présentation sont associées à un risque de récidive précoce et peuvent justifier une admission. L'EEG a eu un effet limité sur la prise en charge aiguë et ne devrait pas être une indication d'admission.
Determination of plasma lactate in the emergency department for the early detection of tissue hypoperfusion in septic patients.
Gómez-Ramos JJ, Marín-Medina A, Prieto-Miranda SE, Dávalos-Rodríguez IP, Alatorre-Jiménez MA, Esteban-Zubero E. | Am J Emerg Med. 2018 Aug;36(8):1418-1422
Keywords: Hypoxia; Infection; Lactate; Sepsis; Septic shock
Introduction : To determine the validity of plasma lactate in the emergency department for the early detection of tissue hypoperfusion in septic patients.
Méthode : Longitudinal descriptive study. Non probabilistic sampling for convenience. Plasma lactate levels were determined in patients admitted to the emergency department with systemic inflammatory response data and clinical suspicion or documented infection. Follow-up was seven days. Complications were considered if the patients presented septic shock, severe sepsis, entry to intensive care or death.
Résultats : Ninety patients were included. The mean age was 57.4±20.31. Fifty five percent (n=49) were women. 25% (n=22) of the patients showed complications. Plasma lactate levels were 1.55mmol/L in uncomplicated patients and 3.72mmol/L for complicated patients (p<0.001). The area under the ROC curve was 0.72 (95% CI, 0.575-0.829). The cutoff point that best described the relationship with the probability of complications was that set at 4.2mmol/L. The variables studied that showed a significant association with the probability of complications were edema (p=0.004), and infections of the respiratory tract (p=0.037). A model that included lactate levels, using as adjustment variables edema and the presence of low respiratory tract infection explained between 0.234 and 0.349 of the dependent variant, correctly classifying 80% of the cases.
Conclusion : Plasma lactate is useful in emergency departments as a predictive test for the early detection of patients with tissue hypoperfusion that evolve to severe sepsis, septic shock or death.
Conclusion (proposition de traduction) : Le dosage du lactate plasmatique est utile dans les services d'urgence comme test prédictif pour la détection précoce des patients atteints d'hypoperfusion tissulaire qui évoluent vers une septicémie grave, un choc septique ou la mort.
Dual defibrillation in patients with refractory ventricular fibrillation.
Hajjar K, Berbari I, El Tawil C, Bou Chebl R, Abou Dagher G. | Am J Emerg Med. 2018 Aug;36(8):1474-1479
Keywords: Cardiac arrest; Electric counter shock; Emergency medical services; Ventricular fibrillation
Editorial : In the setting of cardiac arrest, refractory ventricular fibrillation (VF) is difficult to manage, and mortality rates are high. Double sequential defibrillation (DSD) has been described in the literature as a successful means to terminate this malignant rhythm, after failure of traditional Advanced Cardiac Life Support (ACLS) measures. The authors herein present a case of refractory VF in a patient with cardiac arrest, on whom DSD was successful in reversion to sinus rhythm, and provide a thorough review of similar cases in the literature.
Conclusion : Refractory ventricular fibrillation in the setting of cardiac arrest is not uncommon. Previous published data shows promising results with the use of double sequential defibrillation. Randomized controlled trials are required to institute recommendations on its use and implementation in ACLS algorithms.
Conclusion (proposition de traduction) : La fibrillation ventriculaire réfractaire dans le cadre d'un arrêt cardiaque n'est pas rare. Les données publiées précédemment montrent des résultats prometteurs avec l'utilisation de la défibrillation séquentielle double. Des essais contrôlés randomisés sont nécessaires pour instituer des recommandations sur son utilisation et sa mise en œuvre dans les algorithmes de l'ACLS.
Biphasic anaphylaxis: A review of the literature and implications for emergency management.
Pourmand A, Robinson C, Syed W, Mazer-Amirshahi M. | Am J Emerg Med. 2018 Aug;36(8):1480-1485
Keywords: Allergic reaction; Anaphylaxis; Biphasic reaction; Corticosteroids; Epinephrine
Introduction : The biphasic reaction is a feared complication of anaphylaxis management in the emergency department (ED). The traditional recommended ED observation time is 4-6 h after complete resolution of symptoms for every anaphylaxis patient. However, there has been great controversy regarding whether this standard of care is evidence-based.
Méthode : Articles were selected using a PubMed, MEDLINE search for the keywords "biphasic anaphylaxis", yielding 155 articles. Articles were filtered by English language, and the keyword biphasic in the title. Case reports and case series were excluded, narrowing to 33 articles. Then, articles were filtered by relevance to the ED setting, and studies conducted in outpatient clinic settings were excluded, narrowing the search to 16 articles. All remaining articles were reviewed and findings were discussed.
Résultats : The reported mean time to onset between the resolution of initial anaphylaxis and biphasic reaction ranges widely by study from 1 to 72 h with the majority of studies reporting the mean time to onset >8 h. A delay between anaphylaxis symptom onset and administration of epinephrine of 60-190 min was reported to correlate with biphasic anaphylaxis in three studies. Anaphylaxis requiring >1 dose of epinephrine to achieve symptom resolution was also reported to correlate with biphasic reactions in two studies. No definitive conclusions about the role of corticosteroids in preventing biphasic reactions can be made at this time however; a couple small studies have shown that they may decrease the incidence of biphasic reactions. Additional risk factors correlated with biphasic reaction vary widely between studies and the generalizability of these risk factors is questionable.
Conclusion : There is a need for further research to identify true risk factors associated with biphasic anaphylaxis and to clearly define the role of corticosteroids in biphasic reactions. However, given the low incidence and rare mortality of biphasic reactions, patients who receive epinephrine within one hour of symptom onset and who respond to epinephrine with rapid and complete symptom resolution can probably be discharged from the ED with careful return precautions and education without the need for prolonged observation.
Conclusion (proposition de traduction) : Il est nécessaire de poursuivre les recherches afin d'identifier les véritables facteurs de risque associés à l'anaphylaxie biphasique et de définir clairement le rôle des corticostéroïdes dans les réactions biphasiques.
Toutefois, étant donné la faible incidence et la mortalité rare des réactions biphasiques, les patients qui reçoivent de l'épinéphrine dans l'heure suivant l'apparition des symptômes et qui répondent à l'épinéphrine par une résolution rapide et complète des symptômes peuvent probablement être libérés de l'urgence avec des précautions de retour et de l'éducation sans qu'il soit nécessaire de prolonger l'observation.
Using a rubber strip test to classify swollen fingers for ring removal.
Cui C, Zhang RM. | Am J Emerg Med. 2018 Aug;36(8):1509-1510
Editorial : We are very interested in techniques for removing tight rings from swollen fingers. As Asim Kalkan has summarized, many approaches have been used to remove rings, but there is no clear standard to help clinicians choose the proper method. We use a rubber strip test to cate- gorize fingers that have swollen to the point that ring removal has be- come problematic. This method categorizes swollen fingers into four types and recommends the proper approach for removing rings for each of the different types of swollen fingers.
Conclusion : We hope this approach to classify swollen fingers and ring removal methods will help in selecting the proper methodology. This is a preliminary study, which we hope to further improve in the future.
Conclusion (proposition de traduction) : Nous espérons que cette méthode de classification des doigts oedématiés et des méthodes de retrait des anneaux de doigt aidera à choisir la bonne méthodologie. Il s'agit d'une étude préliminaire que nous espérons améliorer à l'avenir.
Commentaire : Pour compléter cet article, consulter : une revue des techniques proposée par par Kalkan A and al. en 2013 dans Am J Emerg Med. 2013 Nov;31(11):1605-11 , la technique de la chenille pour enlever un anneau serré proposée par St Laurent C en 2006 dans Anesth Analg. 2006 Oct;103(4):1060-1 , la technique des deux élastiques proposée par Kingston D and al. en 2016 dans Ann R Coll Surg Engl. 2016 May;98(5):300-2 , les techniques de Penrose décrite par Chiu TF and al. en 2007 dans Am J Emerg Med. 2007 Jul;25(6):722-3 et l'anneau coupé avec un outil par Kumar A and al. en 2013 dans BMJ Case Rep. 2013 May 9;2013
Controversies in Management of Hyperkalemia.
Long B, Warix JR, Koyfman A. | J Emerg Med. 2018 Aug;55(2):192-205
Keywords: acidosis; beta-agonist; calcium; cardiac arrest; dialysis; diuresis; electrocardiogram; excretion; hyperkalemia; insulin; patiromer; sodium polystyrene sulfonate; sodium zirconium cyclosilicate
Introduction : Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately.
Méthode : This review evaluates the classic treatments of hyperkalemia and discusses controversies and new medications for management.
Résultats : Potassium (K+) plays a key role in determining the transmembrane potentials of "excitable membranes" present in nerve and muscle cells. K+ is the predominant intracellular cation, and clinical deterioration typically ensues when patients develop sufficiently marked elevation in extracellular fluid concentrations of K+ (hyperkalemia). Hyperkalemia is usually detected via serum clinical laboratory measurement. The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death. Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion. Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted. Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin. Dextrose should also be administered, as indicated by initial and serial serum glucose measurements. Dialysis is the most efficient means to enable removal of excess K+. Loop and thiazide diuretics can also be useful. Sodium polystyrene sulfonate is not efficacious. New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise.
Conclusion : Hyperkalemia can be deadly, and treatment requires specific measures including membrane stabilization, cellular shift, and excretion.
Conclusion (proposition de traduction) : L'hyperkaliémie peut être mortelle et le traitement nécessite des mesures spécifiques, notamment stabiliser la membrane cellulaire (rôle de l'ion calcium), mouvement du potassium cellulaire (rôle de l'insuline) et son excrétion (rôle des résines).
Selective Prereduction Radiography in Anterior Shoulder Dislocation: The Fresno-Quebec Rule.
Émond M, Gariepy C, Boucher V, Hendey GW. | J Emerg Med. 2018 Aug;55(2):218-225
Keywords: anterior shoulder dislocation; clinical decision rule; emergency department; prereduction radiography
Selected Topics: Emergency Radiology
Introduction : Shoulder dislocation is one of the most frequent dislocations encountered by emergency physicians. Typical emergency care usually includes performing both prereduction and postreduction radiography. However, selective radiography has the potential benefits of reducing emergency department (ED) time and radiation exposure.
OBJECTIVES: To refine and combine two existing clinical decision rules for selective radiography in the ED management of anterior shoulder dislocation, thus creating the Fresno-Quebec rule (FQR).
Méthode : Patients presenting to the ED with an anterior shoulder dislocation were enrolled in a prospective cohort study in two university-affiliated EDs. Patients with a clinically important fracture-dislocation were compared with those with an uncomplicated dislocation. We refined our new decision rule to detect all fracture-dislocations while maximizing specificity.
Résultats : A total of 207 patients were included in this study, of which 24 (11.8%) had a clinically important fracture-dislocation. The refined rule consisting of three criteria had a sensitivity of 100% (95% confidence interval [CI] 87.5-100%), specificity of 50% (95% CI 42.5-57.5%), negative predictive value of 100% (95% CI 96-100%), and a negative likelihood ratio of 0.21 (95% CI 0.14-0.30). No patient with an atraumatic, recurrent dislocation had a fracture. Patients over age 35 years had an increased risk of fracture-dislocation if they sustained blunt injury or had a first episode of dislocation. Using this rule could have reduced prereduction radiographs by 44%.
Conclusion : The refined Fresno-Quebec shoulder dislocation rule detected all clinically important prereduction fracture-dislocations and could have reduced prereduction films by 44%. Prospective validation is warranted.
Conclusion (proposition de traduction) : La règle de luxation de l'épaule de Fresno-Québec (refined Fresno-Quebec shoulder dislocation rule [FQR]) améliorée a permis de déceler sur le plan clinique toutes les fractures-luxations importantes avant réduction et de réduire de 44 % le nombre de radiographies. La validation prospective est justifiée.
Commentaire : Lire l'article de Emond M dans CJEM. 2009 Jan;11(1):36-43 . Refinement of the Quebec decision rule for radiography in shoulder dislocation
Effect of Automated Simultaneous Sternothoracic Cardiopulmonary Resuscitation Device on Hemodynamics in Out-of-Hospital Cardiac Arrest Patients.
Lee DK, Cha YS, Kim OH, Cha KC, Lee KH, Hwang SO, Kim H, Lee YH3 Chae MK. | J Emerg Med. 2018 Aug;55(2):226-234
Keywords: cardiopulmonary resuscitation; coronary circulation; heart arrest
Selected Topics: Emergency Radiology
Introduction : An automatic simultaneous sternothoracic cardiopulmonary resuscitation (SST-CPR) device is an apparatus that performs CPR by providing simultaneous cyclic compressions of the thorax with a thoracic strap and compression of the sternum with a piston.
OBJECTIVE: This study was conducted to compare the hemodynamic effects of CPR with an automatic SST-CPR device to those with standard CPR (STD-CPR) in cardiac arrest patients.
Méthode : A randomized trial was performed on victims of out-of-hospital cardiac arrest resistant to initial 20 min of CPR after emergency department (ED) arrival. Patients were instrumented with femoral arterial and internal jugular venous lines before enrollment. Informed consent was waived per protocol. Patients were randomized to SST-CPR or STD-CPR based on the day of the month. The primary outcome was a comparison of the mean estimated coronary perfusion pressure (CPP) between SST-CPR and STD-CPR. The secondary outcome was a comparison of compression arterial systolic pressure, compression arterial diastolic pressure, right atrial systolic pressure, right atrial diastolic pressure, return of spontaneous circulation rate, survival to hospital admission, survival at 30 days, favorable neurologic outcomes at 30 days, and adverse events between two groups.
Résultats : Of 62 patients with non-traumatic, adult, out-of-hospital cardiac arrest who presented to the ED, 24 received CPR with an automatic SST-CPR device (SST-CPR group), and 38 received standard CPR (STD-CPR group). Acquisition and analysis of hemodynamic data were completed in 11 (46%) patients in the SST-CPR group and 14 (37%) patients in the STD-CPR group. Compression arterial systolic pressure, right atrial systolic/diastolic pressures, and end-tidal carbon dioxide tension were not different between the two groups. Median compression arterial diastolic pressure (femoral arterial pressure during relaxation) was 20 mm Hg (mean 22 mm Hg; 95% confidence interval [CI] 5 to 38 mm Hg) and 0 mm Hg (mean -2 mm Hg; 95% CI -21 to 18 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.002), respectively. Median estimated CPP was 10 mm Hg (mean 16 mmHg; 95% CI 1 to 31 mm Hg) and 2 mm Hg (mean 4 mm Hg; 95% CI -4 to 12 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.017), respectively.
Conclusion : CPR with an automatic SST-CPR device results in higher estimated CPP compared to standard CPR in patients with non-traumatic, out-of-hospital cardiac arrest.
Conclusion (proposition de traduction) : La RCP avec une planche à masser automatique permet d'obtenir une pression de perfusion coronarienne plus élevée par rapport à la RCP standard chez les patients présentant un arrêt cardiaque non traumatique hors hôpital.
A Modified String Technique for Atraumatic Ring Removal.
Boe C, Kakar S. | J Emerg Med. 2018 Aug;55(2):240-243.
Keywords: edematous finger; hand; upper-extremity trauma
Techniques and Procedures
Introduction : We describe a modified string technique for ring removal from an edematous finger, a critical step in the initial treatment of a patient with upper-extremity trauma.
Résultats : This technique involves multiple sutures looped around the ring to provide differential tension on the ring as it is advanced distally over a lubricated digit. With the use of an assistant, the ring can be advanced in caterpillar fashion without sliding back proximal when the direct pressure is released as a result of edema.
Conclusion : This multisuture technique adds to the armamentarium of methods for ring removal in the setting of upper-extremity trauma without reverting to alternate techniques for cutting or shattering the ring.
Conclusion (proposition de traduction) : Cette technique multisuture s'ajoute à l’arsenal des méthodes de retrait des anneaux dans le cadre d’un traumatisme des membres supérieurs sans revenir à des techniques alternatives pour couper ou briser l’anneau.
Commentaire : Voir les articles sur le même sujet :
• Cui C, Zhang RM. Am J Emerg Med. 2018 ug;36(8):1509-1510 . Using a rubber strip test to classify swollen fingers for ring removal ;
• une revue des techniques proposée par par Kalkan A and al. en 2013 dans Am J Emerg Med. 2013 Nov;31(11):1605-11 ;
• la technique de la chenille pour enlever un anneau serré proposée par St Laurent C en 2006 dans Anesth Analg. 2006 Oct;103(4):1060-1 ;
• la technique des deux élastiques proposée par Kingston D and al. en 2016 dans Ann R Coll Surg Engl. 2016 May;98(5):300-2 ;
• les techniques de Penrose décrite par Chiu TF and al. en 2007 dans Am J Emerg Med. 2007 Jul;25(6):722-3 ;
• l'anneau coupé avec un outil par Kumar A and al. en 2013 dans BMJ Case Rep. 2013 May 9;2013 .
Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial.
Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. | JAMA. 2018 Aug 28;320(8):779-791
DOI: https://doi.org/10.1001/jama.2018.11597 | Télécharger l'article au format
Introduction : IMPORTANCE :
The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.
OBJECTIVE : To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.
Méthode : DESIGN, SETTING, AND PARTICIPANTS:
Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.
INTERVENTIONS : Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.
MAIN OUTCOMES AND MEASURES: The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.
Résultats : A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], -0.6% [95% CI, -1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, -0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, -1.5% to 1.8%]).
Conclusion : Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.
Conclusion (proposition de traduction) : Parmi les patients en arrêt cardiaque extra-hospitalier, la randomisation par rapport à une stratégie de gestion avancée des voies respiratoires avec un dispositif supraglottique par rapport à une intubation trachéale ne s'est pas traduite par un résultat fonctionnel favorable à 30 jours.
Artificial intelligence can predict daily trauma volume and average acuity.
Stonko DP, Dennis BM, Betzold RD, Peetz AB, Gunter OL, Guillamondegui OD. | J Trauma Acute Care Surg. 2018 Aug;85(2):393-397
Introduction : The goal of this study was to integrate temporal and weather data in order to create an artificial neural network (ANN) to predict trauma volume, the number of emergent operative cases, and average daily acuity at a Level I trauma center.
Méthode : Trauma admission data from Trauma Registry of the American College of Surgeons and weather data from the National Oceanic and Atmospheric Administration was collected for all adult trauma patients from July 2013-June 2016. The ANN was constructed using temporal (time, day of week), and weather factors (daily high, active precipitation) to predict four points of daily trauma activity: number of traumas, number of penetrating traumas, average Injury Severity Score (ISS), and number of immediate operative cases per day. We trained a two-layer feed-forward network with 10 sigmoid hidden neurons via the Levenberg-Marquardt back propagation algorithm, and performed k-fold cross validation and accuracy calculations on 100 randomly generated partitions.
Résultats : Ten thousand six hundred twelve patients over 1,096 days were identified. The ANN accurately predicted the daily trauma distribution in terms of number of traumas, number of penetrating traumas, number of OR cases, and average daily ISS (combined training correlation coefficient r = 0.9018 ± 0.002; validation r = 0.8899 ± 0.005; testing r = 0.8940 ± 0.006).
Conclusion : We were able to successfully predict trauma and emergent operative volume, and acuity using an ANN by integrating local weather and trauma admission data from a Level I center. As an example, for June 30, 2016, it predicted 9.93 traumas (actual: 10), and a mean ISS of 15.99 (actual: 13.12). This may prove useful for predicting trauma needs across the system and hospital administration when allocating limited resources.
Conclusion (proposition de traduction) : Nous avons été en mesure de prédire avec succès les traumatismes, le volume opératoire émergent et la fréquence à l'aide d'un réseau neuronal artificiel en intégrant les données météorologiques locales et les données d'admission en traumatologie d'un centre de niveau I. À titre d'exemple, pour le 30 juin 2016, il prévoyait 9,93 traumatismes (réel : 10) et une SSV moyenne de 15,99 (réel : 13,12). Cela peut s'avérer utile pour prédire les besoins en traumatologie à l'échelle du système et de l'administration de l'hôpital lorsqu'il s'agit d'allouer des ressources limitées.
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 Aug 23;379(8):711-721
DOI: https://doi.org/10.1056/NEJMoa1806842 | Télécharger l'article au format
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 l'adulte en arrêt cardiaque extra-hospitalier, l'utilisation d'adrénaline a entraîné un taux de survie à 30 jours significativement supérieur à celui du placebo, mais il n'y avait pas de différence significative entre les groupes dans le taux d'évolution neurologique favorable car plus de survivants présentaient une atteinte neurologique grave dans le groupe adrénaline.
Commentaire : Etude multicentrique prospective randomisée en double aveugle avec inclusion de 8 014 patients.