Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism.
Kabrhel C, Van Hylckama Vlieg A, Muzikanski A, Singer A, Fermann GJ, Francis S, Limkakeng A, Chang AM, Giordano N, Parry B. | Acad Emerg Med. 2018 Sep;25(9):987-994
DOI: https://doi.org/10.1111/acem.13417
Keywords: Aucun

Original Contribution

Introduction : It may be possible to safely rule out pulmonary embolism (PE) in patients with low pretest probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which include three questions from the Wells PE score to identify low-PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States.

Méthode : This study was a prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: "Does the patient have clinical signs or symptoms of DVT?" "Does the patient have hemoptysis?" "Are alternative diagnoses less likely than PE?" with YEARS (+) being any "yes" response. A negative D-dimer was <1000 mg/dL for YEARS (-) patients and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE "missed."

Résultats : Of 1,789 patients, 84 (4%) had PE, 1,134 (63%) were female, 1,038 (58%) were white, and mean (±SD) age was 48 (±16) years. Using the standard D-dimer threshold, 940 (53%) would not have had imaging, with two (0.2%, 95% confidence interval [CI] = 0.02%-0.60%) missed PE. Using YEARS adjustment, 1,204 (67%, 95% CI = 65%-69%) would not have been referred for imaging, with six (0.5%, 95% CI = 0.18%-1.1%) missed PE, and using "alternative diagnoses less likely than PE" adjustment, 1,237 (69%, 95% CI = 67%-71%) would not have had imaging with six (0.49%, 95% CI = 0.18%-1.05%) missed PE. Sensitivity was 97.6% (95% CI = 91.7%-99.7%) for the standard threshold and 92.9% (95% CI = 85%-97%) for both adjusted thresholds. Negative predictive value (NPV) was nearly 100% for all approaches.

Conclusion : D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.

Conclusion (proposition de traduction) : Un ajustement des D-dimères basé sur la probabilité pré-test peut entraîner une réduction du besoin d'imagerie pour évaluer une éventuelle embolie pulmonaire, avec quelques embolies pulmonaires manquées mais sans diminution de la VPN.

Emergency Department Discharge of Pulmonary Embolus Patients.
Frank Peacock W, Coleman CI, Diercks DB, Francis S, Kabrhel C, Keay C, Kline JA, Manteuffel J, Wildgoose P, Xiang J, Singer AJ. | Acad Emerg Med. 2018 Sep;25(9):995-1003
DOI: https://doi.org/10.1111/acem.13451  | Télécharger l'article au format  
Keywords: Aucun

Oirginal contributions

Introduction : Hospitalization for low-risk pulmonary embolism (PE) is common, expensive, and of questionable benefit.
OBJECTIVE: The objective was to determine if low-risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC).

Méthode : Multicenter, open-label randomized trial in low-risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Primary outcome was total number of initial hospital hours, plus hours of hospitalization for bleeding or venous thromboembolism (VTE), 30 days after randomization. A 90-day composite safety endpoint was defined as major bleeding, clinically relevant nonmajor bleeding, and mortality.

Résultats : Of 114 randomized subjects, 51 were early discharge and 63 were SOC. Of 112 (98.2%) receiving at least one dose of study drug, 99 (86.8%) completed the study. Initial hospital LOS was 4.8 hours versus 33.6 hours, with a mean difference of -28.8 hours (95% confidence interval [CI] = -42.55 to -15.12 hours) for early discharge versus SOC, respectively. At 90 days, mean total hospital days (for any reason) were less for early discharge than SOC, 19.2 hours versus 43.2 hours, with a mean difference of 26.4 hours (95% CI = -46.97 to -3.34 hours). At 90 days, there were no bleeding events, recurrent VTE, or deaths. The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = -0.18 to 0.19). Total costs were $1,496 for early discharge and $4,234 for SOC, with a median difference of $2,496 (95% CI = -$2,999 to -$2,151).

Conclusion : Low-risk ED PE patients receiving early discharge on rivaroxaban have similar outcomes to SOC, but fewer total hospital days and lower costs over 30 days.

Conclusion (proposition de traduction) : Les patients présentant une embolie pulmonaire à faible risque qui sortent des urgences avec un traitement par rivaroxaban (Xarelto®) ont des résultats similaires à ceux qui reçoivent des soins standards, mais avec moins de jours d'hospitalisation et des coûts inférieurs, de plus de 30 jours.

Preprocedural Ultrasound for Infant Lumbar Puncture: A Randomized Clinical Trial.
Kessler D, Pahalyants V, Kriger J, Behr G, Dayan P. | Acad Emerg Med. 2018 Sep;25(9):1027-1034
DOI: https://doi.org/10.1111/acem.13429
Keywords: Aucun

Original Contribution

Introduction : Our purpose was to determine the potential effect of preprocedural ultrasound (US) to increase lumbar puncture (LP) success compared with standard palpation method. Further, we assessed feasibility of and clinician satisfaction with a standardized US protocol.

Méthode : This prospective, two-arm, parallel-group randomized trial was conducted in a single-center pediatric emergency department. We compared preprocedural US versus palpation method on success with infant LPs. Infants less than 3 months of age requiring LP were enrolled. Sixteen pediatric emergency medicine physicians with varied US experience were trained to conduct the USs to mark interspace locations. Primary outcome was successful LP, defined as obtaining a cerebrospinal fluid (CSF) sample on first attempt with < 1,000 red blood cells per high-powered field (clear CSF). Secondary outcomes included clear CSF on any attempt, any CSF on the first attempt, traumatic LP proportion, and LP attempt frequency. Feasibility was assessed by comparing provider number attempting the LP and procedure duration. Clinician satisfaction and sonographer perceptions of US acceptability and impact were assessed.

Résultats : Eighty-one patients consented and 80 were analyzed (99%): 40 per group. No statistical difference was seen for the primary outcome (p > 0.05) between intervention and control groups (difference 3%; 95% confidence interval = -19% to 24%). There were no statistical differences between intervention and controls groups for secondary outcomes including the rate of traumatic LPs, number of attempts, and the duration of LP procedure. Most sonographers (84%) strongly agreed or agreed that the US protocol was technically easy to perform, well tolerated by the patient (94%), well accepted by the family (100%), and well accepted by the LP procedural clinicians (99%). In the US group, the majority of clinicians who performed the LPs (68.4%) noted that the preprocedural US influenced their behavior, most commonly helping with overall visualization at the selected interspace (28.9%) or prompting a change in interspace (26.3% higher, 5.3% lower). Seventy-seven percent agreed or strongly agreed that they would like to use the technique again for their next LP. The mean US duration was 4.6 minutes.

Conclusion : Preprocedural US by did not improve the rates of first-attempt success when compared with palpation method. Our results suggest that US is feasible and well accepted, with a perceptible impact on care.

Conclusion (proposition de traduction) : L'échographie pré-procédurale de n'améliorait pas les taux de réussite à la première tentative par rapport à la méthode de palpation. Nos résultats suggèrent que l'échographie est réalisable et bien acceptée, avec un impact perceptible sur les soins.

Bedside Sonography Performed by Emergency Physicians to Detect Appendicitis in Children.
Nicole M, Desjardins MP, Gravel J. | Acad Emerg Med. 2018 Sep;25(9):1035-1041
DOI: https://doi.org/10.1111/acem.13445
Keywords: Aucun

Original contribution

Introduction : The aim of this study was to evaluate the ability of emergency physicians with various levels of point-of-care ultrasound (POCUS) experience to detect appendicitis with POCUS among children visiting a pediatric emergency department (ED).

Méthode : A prospective cohort study was conducted in an urban, tertiary care pediatric ED. Children aged 2 to 18 years old who presented with acute abdominal pain suggesting appendicitis were included. Patients were excluded if they had a history of appendectomy or hemodynamic instability requiring resuscitation or were transferred with proven diagnosis of appendicitis. Participating physicians had various levels of POCUS experience. Four of the 22 physicians were experienced in bowel sonography while the others had basic experience in abdominal POCUS. All the participating physicians received a 1-hour didactic and practical training session on appendix ultrasound. The treating physician performed POCUS following initial physical examination, before further radiologic evaluation. POCUS examinations were recorded as positive for appendicitis, normal, or inconclusive, with normal or inconclusive studies considered negative. Final outcomes were determined by pathology and/or operative reports for surgical cases and telephone follow-up at 3 weeks for those who did not have surgery. The primary analysis was a simple proportion for sensitivity and specificity for POCUS. Expecting a sensitivity of 80% based on previous studies, we calculated that a sample size of 50 cases would provide a 95% confidence interval (CI) ranging from 66% to 90%.

Résultats : Of the 140 approached patients, 121 accepted to participate and were recruited. After four patients were excluded for missing POCUS data, 117 patients were included in the primary analysis, of whom 51 (44%) had appendicitis. Twenty-two physicians performed between one and 20 POCUS procedures. The POCUS was positive in 39, negative in nine, and inconclusive in 69 patients. POCUS was interpreted as positive in 27 of 51 appendicitis for a sensitivity of 0.53 (95% CI = 0.40-0.66). A negative or inconclusive POCUS was reported for 54 of 66 patients without appendicitis (specificity = 0.82; 95% CI = 0.71-0.89).

Conclusion : This study shows limited sensitivity and specificity of POCUS for appendicitis in children, with a high proportion of inconclusive examinations, when performed by emergency physicians with various level of experience in POCUS.

Conclusion (proposition de traduction) : Cette étude montre une sensibilité et une spécificité limitées de l'échographie au chevet du patient pour le diagnostic de l'appendicite chez l'enfant, avec une forte proportion d'examens non concluants, lorsqu'ils sont effectués par des urgentistes ayant différents niveaux d'expérience de l'échographie au chevet du patient.

Slow Infusion of Low‐dose Ketamine Reduces Bothersome Side Effects Compared to Intravenous Push: A Double‐blind, Double‐dummy, Randomized Controlled Trial.
Clattenburg EJ, Hailozian C, Haro D, Yoo T, Flores S, Louie D, Herring AA. | Acad Emerg Med. 2018 Sep;25(9):1048-1052
DOI: https://doi.org/10.1111/acem.13428
Keywords: Aucun

Brief Report

Introduction : We compared the analgesic efficacy and incidence of side effects when low-dose (0.3 mg/kg) ketamine (LDK) is administered as a slow infusion (SI) over 15 minutes versus an intravenous push (IVP) over 1 minute.

Méthode : This was a prospective, randomized, double-blind, double-dummy, placebo-controlled trial of adult ED patients presenting with moderate to severe pain (numerical rating scale [NRS] score ≥ 5). Patients received 0.3 mg/kg ketamine administered either as a SI or a IVP. Our primary outcome was the proportion of patients experiencing any psychoperceptual side effect over 60 minutes. A secondary outcome was incidence of moderate or greater psychoperceptual side effects. Additional outcomes included reduction in pain NRS scores at 60 minutes and percent maximum summed pain intensity difference (%SPID).

Résultats : Fifty-nine participants completed the study. A total of 86.2% of the IVP arm and 70.0% of the SI arm experienced any side effect (difference = 16.2%, 95% confidence interval [CI] = -5.4 to 37.8). We found a large reduction in moderate or greater psychoperceptual side effects with SI administration-75.9% reported moderate or greater side effects versus 43.4% in the SI arm (difference = 32.5%, 95% CI = 7.9 to 57.1). Additionally, the IVP arm experienced more hallucinations (n = 8, 27.6%) than the SI arm (SI n = 2, 6.7%, difference = 20.9%, 95% CI = 1.8 to 43.4). We found no significant differences in analgesic efficacy. At 60 minutes, the mean %SPID values in the IVP and SI arms were 39.9 and 33.5%, respectively, with a difference of 6.5% (95% CI = -5.8 to 18.7).

Conclusion : Most patients who are administered LDK experience a psychoperceptual side effect regardless of administration via SI or IVP. However, patients receiving LDK as a SI reported significantly fewer moderate or greater psychoperceptual side effects and hallucinations with equivalent analgesia.

Conclusion (proposition de traduction) : La plupart des patients qui reçoivent de la kétamine présentent un effet secondaire psychodysleptique indépendamment de l'administration par perfusion lente ou injection intraveineuse. Cependant, les patients recevant de la kétamine sous forme de perfusion lente ont signalé beaucoup moins d'effets secondaires psychodysleptiques modérés ou plus importants et d'hallucinations avec une analgésie équivalente.

Can Echocardiography Be Used to Diagnose Pulmonary Embolism at the Bedside?.
Ehrman RR, Favot MJ. | Ann Emerg Med. 2018 Sep;72(3):310-311
DOI: https://doi.org/10.1016/j.annemergmed.2017.09.018
Keywords: Aucun

Imaging

Méthode : DATA SOURCES: EMBASE, CINAHL, and PubMed were searched from January 1980 to November 2016. Reference lists of included studies were also searched.
STUDY SELECTION: Studies of adults with suspected pulmonary embolism who had an echocardiogram as part of the diagnostic pathway were included. The suitability of each study for inclusion was assessed by 2 reviewers. Multiple confirmatory tests were used in the included studies (ie, computed tomography [CT], pulmonary angiogram, high-probability ventilation/perfusion scan, intermediate-probability ventilation/perfusion scan with any other confirmatory study, and surgery or autopsy).
DATA EXTRACTION AND SYNTHESIS: Two authors independently extracted data and assessed study quality with the Quality Assessment of Diagnostic Accuracy Studies Assessment tool; disagreements were resolved by consensus of 4 reviewers. Summary estimates of sensitivity and specificity of ultrasonography were calculated for various signs of right ventricular dysfunction. Pooled test characteristics were also calculated for studies conducted in the emergency department (ED) only and when ultrasonographic examinations were performed by physicians.

Résultats : The search strategy yielded 5,905 potential references, of which 24 full-text articles were included in the final analysis; pulmonary embolism prevalence was 40.8%. Study design was prospective in 17 studies and retrospective in 7. Risk of bias was low in 7 studies, high in 4, and unclear in the remaining 13. Echocardiograms were performed by physicians in 9 studies (3 by emergency physicians, 5 by cardiologists, and 1 unclear) and at the point of care in 7 studies; 7 studies were conducted solely in the ED.
The authors identified 9 unique echocardiographic signs of pulmo- nary embolism, as well as the undefined finding of “right-sided heart strain.” Overall, the signs of pulmonary embolism were moderately specific (range 61% to 99%) but poorly sensitive (range 5% to 80%). Test characteristics were slightly improved when echocardiograms were performed by physicians. In the pooled and subgroup analyses, McConnell’s sign, paradoxic septal motion, and presence of a right-sided heart thrombus had specificities greater than or equal to 95%; right ventricular hypokinesis performed well in the subgroup analyses, with a specificity greater than or equal to 98%. Normal right ventricular end-diastolic diameter was the only sign with a sensitivity greater than 80%. McConnell’s sign had the best positive likelihood ratio, at 8.5; the best negative likelihood ratio was normal right ventricular end-diastolic diameter, at 0.3.

Discussion : Systematic reviews are limited by the heterogeneity of the included articles, and this systematic review had a great degree of heterogeneity. Only 6 of 24 included studies specifically evaluated physician-performed point-of-care ultrasonography, and of these 6 studies, 4 enrolled convenience samples. ED patients undergoing point-of-care ultrasonography represent approximately 30% of the patients included in the review. Considering these and other sources of heterogeneity within the studies, and given that sonographer experience was not assessed in this review, echocardiographic-based treatment decisions in the ED should be made by clinicians with significant experience and comfort with their ultrasonographic skills.

Conclusion : When pretest probability for pulmonary embolism is high, abnormalities in right ventricular function detected on echocardiogram strongly support the diagnosis; however, a normal echocardiogram cannot be used to rule out pulmonary embolism.

Conclusion (proposition de traduction) : Lorsque la probabilité pré-test pour une embolie pulmonaire est élevée, les anomalies de la fonction ventriculaire droite détectées sur l'échocardiographie appuient fortement le diagnostic ; cependant, une échocardiographie normale ne peut être utilisée pour exclure une embolie pulmonaire.

Platelet indices and outcome after cardiac arrest.
Cotoia A, Franchi F, De Fazio C, Vincent JL, Creteur J, Taccone FS. | BMC Emerg Med. 2018 Sep 25;18(1):31
DOI: https://doi.org/10.1186/s12873-018-0183-4  | Télécharger l'article au format  
Keywords: Cardiac arrest; Hypothermia; Platelet distribution width; Platelet indices

Research article

Introduction : Platelet variables, including platelet distribution width (PDW) and mean platelet volume (MPV), have been associated with outcome in critically ill patients. We evaluated these variables in patients after cardiac arrest (CA).

Méthode : All adult CA patients admitted to the intensive care unit (ICU) over an 8-year period (2006-2014) and treated with targeted temperature management were included. We retrieved all data concerning CA characteristics as well as platelet count, PDW and MPV on the first 2 days of admission. Unfavorable 3-month neurological outcome was defined as a cerebral performance category score of 3-5.

Résultats : We included 384 patients (age 62 [52-75] years; 270/384 male): 231 patients (60%) died within 30-days and 246 patients (64%) had an unfavorable 3-month neurological outcome. On admission, platelet count, PDW and MPV were 87 [126-261] *103cells/mm3, 17 [16.3-17.3]% and 8.3 [7.6-9.2] μm3, respectively. Platelet count decreased significantly over the first 2 days, whereas PDW and MPV did not change significantly. There were no significant differences between the values on admission or time-courses of platelet count, PDW or MPV between survivors and non-survivors or between patients with unfavorable and favorable neurological outcome.

Conclusion : In our cohort of post-CA patients, PDW and MPV were not associated with outcome.

Conclusion (proposition de traduction) : Dans notre cohorte de patients post-arrêt cardiaque, la largeur de la distribution plaquettaire et le volume plaquettaire moyen n'étaient pas associés aux résultats.

Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data.
Senior K, Burles K, Wang D, Grigat D, Innes GD, Andruchow JE, Lang ES, McRae AD. | CJEM. 2018 Sep;20(5):725-731
DOI: https://doi.org/10.1017/cem.2018.389
Keywords: administrative data; pulmonary embolism; venous thromboembolism

Original Research

Editorial : What is known about the topic? Age-adjusted D-dimer thresholds have been proposed to improve specificity of diagnostic testing for thromboembolism in patients ages 50 and over. What did this study ask? What is the diagnostic accuracy of an age-adjusted D-dimer threshold in a population of patients undergoing investigations for suspected pulmonary embolism (PE)? What did this study find? Age-adjusted D-dimer cut-offs improved specificity but at the expense of a slightly higher risk of missed PE. Why does this study matter to clinicians? Use of age adjusted D-dimer thresholds, in combination with validated risk scores, may reduce CT utilization in older patients.

Conclusion : An age-adjusted D-dimer cut-off used in conjunction with formal risk stratification prior to testing has the potential to substantially reduce the use of CT imaging among older patients with suspected PE. However, in this administrative data set representing real-world practice, we observed an unacceptable loss of diag- nostic sensitivity. Consequently, we encourage further evaluation of age-adjusted D-dimer strategies in routine clinical practice to determine whether similar losses in sensitivity are commonplace.

Conclusion (proposition de traduction) : Un seuil de D-dimères ajusté selon l'âge, utilisé conjointement avec une stratification formelle du risque avant le test, pourrait potentiellement réduire considérablement l'utilisation de la tomodensitométrie chez les patients plus âgés, chez qui on suspecte une embolie pulmonaire.
Cependant, dans cet ensemble de données administratives représentant la pratique du monde réel, nous avons observé une perte inacceptable de sensibilité diagnostique. Par conséquent, nous encourageons une évaluation plus poussée des stratégies concernant les D-dimères ajustés en fonction de l'âge dans la pratique clinique de routine, afin de déterminer si des pertes de sensibilité similaires sont courantes.

Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department..
MacLellan J, Smith T, Baserman J, Dowling S. | CJEM. 2018 Sep;20(5):746-752
DOI: https://doi.org/10.1017/cem.2017.399  | Télécharger l'article au format  
Keywords: Ottawa Ankle Rules; accuracy; non-physician provider; nurse; pediatric; sensitivity

Original Research

Introduction : The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Limited data support its use by other health care workers in children. Our objective was to determine the accuracy of the OAR when applied by non-physician providers (NPP).

Méthode : Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Phase 1 captured baseline data on x-ray use in 106 patients. NPPs were then educated on the usage of the OAR and completed an OAR learning module. In phase 2, NPPs applied the OAR to 184 included patients.

Résultats : The sensitivity of the foot rule, as applied by NPP's, was 100% (56-100% CI) and the specificity was 17% (9-29% CI) for clinically significant fractures. The sensitivity of the ankle portion of the rule, as applied by NPP's, was 88% (47-99 CI) and the specificity was 31% (23-40% CI) for clinically significant fractures. The only clinically significant fracture missed by NPP's was detected on physician assessment. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.49 for the foot rule.

Conclusion : The sensitivity of the OAR when applied by NPP's was very good. More training and practice using the OAR would likely improve NPP's inter-observer reliability. Our data suggest the OAR may be a useful tool for NPP's to apply prior to physician assessment.

Conclusion (proposition de traduction) : La sensibilité des règles d’Ottawa dans les traumatismes de la cheville lorsqu’elles étaient appliquées par des intervenants autres que des médecins était très bonne. Davantage de formation et de pratique sur l'utilisation des règles d’Ottawa dans les traumatismes de la cheville améliorerait probablement la fiabilité entre observateurs des intervenants autres que les médecins.
Nos données suggèrent que les règles d’Ottawa dans les traumatismes de la cheville pourraient être un outil utile pour les intervenants autres que les médecins, à appliquer avant l’évaluation du médecin.

Apneic oxygenation provides incremental benefit during intubation of patients in the emergency medicine and critical care settings.
Ting DK, Lang ES. | CJEM. 2018 Sep;20(5):770-773
DOI: https://doi.org/10.1017/cem.2018.29
Keywords: critical care; emergency medicine; intubation; meta-analysis

Knowledge to Practice: Journal Club

Editorial : Clinical questionShould I use apneic oxygenation when intubating patients in the emergency department to increase peri-intubation oxygen saturation and first-pass success?Article chosenOliveira JE, Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis.

Méthode : The purpose of this study was to synthesize and appraise the apneic oxygenation literature for its effect on peri-intubation outcomes.

Conclusion : The use of apneic oxygenation may provide incremental benefit to intubation in the ED. Apneic oxygenation does not replace basics in airway management, such as preoxygenation or technical skill. Further studies may help define which patient groups benefit from apneic oxyge- nation and be powered to examine potential adverse effects.

Conclusion (proposition de traduction) : L'utilisation de l'oxygénation de l'apnée peut apporter des avantages supplémentaires pour l'intubation en urgence. L'oxygénation de l'apnée ne remplace pas les bases de la gestion des voies respiratoires, telles que la préoxygénation ou les compétences techniques. Des études ultérieures peuvent aider à définir les groupes de patients qui bénéficient de l'oxygénation apnéique et qui ont le pouvoir d'analyser les effets indésirables potentiels.

Topical tranexamic acid for the treatment of epistaxis in patients using antiplatelet agents.
Sanderson M, Powell J, Lang E. | CJEM. 2018 Sep;20(5):774-776
DOI: https://doi.org/10.1017/cem.2018.422
Keywords: Anterior Nasal Packing; Anti-platelet; Tranexamic acid; Epistaxis

CJEM Journal Club

Editorial : Clinical question: Does the addition of topical tranexamic acid to anterior nasal packing decrease bleeding in patients with epistaxis who are taking antiplatelet medications?Article chosenZahed R, Jayazeri M, Naderi A, et al. Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial.

Méthode : The primary outcome of this randomized controlled trial was the percentage of patients whose epistaxis had stopped at 10 minutes from the time of intervention. Secondary outcomes included the frequency of epistaxis recurrence at both 24 hours and 7 days, emergency department length of stay, and patient satisfaction.

Conclusion (proposition de traduction) : Il s’agit d’un essai comparatif avec répartition aléatoire; l’objectif principal était le pourcentage de patients chez qui un arrêt de l’épistaxis a été observé 10 minutes après le début de l’intervention. Les objectifs secondaires comprenaient la fréquence des nouvelles épistaxis au bout de 24 heures et au bout de 7 jours, la durée de séjour au service des urgences et le degré de satisfaction des patients.

Commentaire : Voir l'article :
Birmingham AR, Mah ND, Ran R, Hansen M. Topical tranexamic acid for the treatment of acute epistaxis in theemergency department. Am J Emerg Med. 2018 Jul;36(7):1242-1245  .

Intra-season Waning of Influenza Vaccine Effectiveness.
Ray GT, Lewis N, Klein NP, Daley MF, Wang SV, Kulldorff M, Fireman B. | Clin Infect Dis. 2018 Sep 10, ciy770
DOI: https://doi.org/10.1093/cid/ciy770
Keywords: Aucun

Original

Introduction : In the United States it is recommended that health care providers offer influenza vaccination by October, if possible. However, if the vaccine's effectiveness soon begins to wane, the optimal time for vaccination may be somewhat later. We examined whether the effectiveness of influenza vaccine wanes during the influenza season with increasing time since vaccination.

Méthode : We identified persons who were vaccinated with inactivated influenza vaccine from September 1, 2010 to March 31, 2017 and who were subsequently tested for influenza and respiratory syncytial virus (RSV) by a polymerase chain reaction test. Test-confirmed influenza was the primary outcome and days-since-vaccination was the predictor of interest in conditional logistic regression. Models were adjusted for age and conditioned on calendar day and geographic area. RSV was used as a negative control outcome.

Résultats : Compared with persons vaccinated 14 to 41 days prior to being tested, persons vaccinated 42 to 69 days prior to being tested had 1.32 (95% Confidence Interval (CI): 1.11 to 1.55) times the odds of testing positive for any influenza. The odds ratio (OR) increased in linear fashion by approximately 16% for each additional 28 days since vaccination; the OR was 2.06 (95% CI: 1.69 to 2.51) for persons vaccinated 154 or more days prior to being tested. No evidence of waning was found for RSV.

Conclusion : Our results suggest that effectiveness of inactivated influenza vaccine wanes during the course of a single season. These results may lead to reconsideration of the optimal timing of seasonal influenza vaccination.

Conclusion (proposition de traduction) : Nos résultats suggèrent que l'efficacité du vaccin antigrippal inactivé diminue au cours d'une seule saison. Ces résultats peuvent conduire à reconsidérer le moment optimal pour la vaccination contre la grippe saisonnière.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : La campagne de vaccination grippe débute en octobre. Si l’épidémie est tardive le vaccin est-il aussi efficace, en d’autres termes l’efficacité vaccinale diminue-t-elle avec le temps au cours d’une saison ?  . Rédigé par le Dr Jacques Gaillat.

Effect of outpatient antibiotics for urinary tract infections on antimicrobial resistance among commensal Enterobacteriaceae: a multinational prospective cohort study.
Stewardson AJ, Vervoort J, Adriaenssens N, Coenen S, Godycki-Cwirko M, Kowalczyk A, Huttner BD, Lammens C, Malhotra-Kumar S, Goossens H, Harbarth S; SATURN WP1 Study Group; SATURN WP3 Study Group. | Clin Microbiol Infect. 2018 Sep;24(9):972-979
DOI: https://doi.org/10.1016/j.cmi.2017.12.026
Keywords: Antimicrobial resistance; Collateral damage; Enterobacteriaceae; Extended-spectrum β-lactamase; Fluoroquinolone; Microbiota; Nitrofuran; Urinary tract infection

Original article

Introduction : We quantified the impact of antibiotics prescribed in primary care for urinary tract infections (UTIs) on intestinal colonization by ciprofloxacin-resistant (CIP-RE) and extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), while accounting for household clustering.

Méthode : Prospective cohort study from January 2011 to August 2013 at primary care sites in Belgium, Poland and Switzerland. We recruited outpatients requiring antibiotics for suspected UTIs or asymptomatic bacteriuria (exposed patients), outpatients not requiring antibiotics (non-exposed patients), and one to three household contacts for each patient. Faecal samples were tested for CIP-RE, ESBL-PE, nitrofurantoin-resistant Enterobacteriaceae (NIT-RE) and any Enterobacteriaceae at baseline (S1), end of antibiotics (S2) and 28 days after S2 (S3).

Résultats : We included 300 households (205 exposed, 95 non-exposed) with 716 participants. Most exposed patients received nitrofurans (86; 42%) or fluoroquinolones (76; 37%). CIP-RE were identified in 16% (328/2033) of samples from 202 (28%) participants. Fluoroquinolone treatment caused transient suppression of Enterobacteriaceae (S2) and subsequent two-fold increase in CIP-RE prevalence at S3 (adjusted prevalence ratio (aPR) 2.0, 95% CI 1.2-3.4), with corresponding number-needed-to-harm of 12. Nitrofurans had no impact on CIP-RE (aPR 1.0, 95% CI 0.5-1.8) or NIT-RE. ESBL-PE were identified in 5% (107/2058) of samples from 71 (10%) participants, with colonization not associated with antibiotic exposure. Household exposure to CIP-RE or ESBL-PE was associated with increased individual risk of colonization: aPR 1.8 (95% CI 1.3-2.5) and 3.4 (95% CI 1.3-9.0), respectively.

Conclusion : These findings support avoidance of fluoroquinolones for first-line UTI therapy in primary care, and suggest potential for interventions that interrupt household circulation of resistant Enterobacteriaceae.

Conclusion (proposition de traduction) : Ces résultats plaident en faveur de l'utilisation des alternatives aux fluoroquinolones pour le traitement de première intention des infections urinaires, dans les soins de santé primaires et suggèrent des interventions susceptibles d’interrompre la circulation domestique des entérobactéries résistantes.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Impact du traitement des Infections Urinaires sur la colonisation par des bactéries résistantes chez les patients traités et leurs contacts familiaux  . Rédigé par le Dr Jean-Pierre Bru.

Ultrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein.
Pandurangadu AV, Tucker J, Brackney AR, Bahl A. | Emerg Med J. 2018 Sep;35(9):550-555
DOI: https://doi.org/10.1136/emermed-2017-206803
Keywords: ultrasound

Original article

Introduction : Ultrasound (US)-guided peripheral IVs have a high failure rate. We explore the relationship between the quantity of catheter residing within the vein and the functionality of the catheter over time.

Méthode : This was a prospective, observational single-site study. Adult ED patients with US-guided IVs had the catheter visualised under ultrasound post-placement. IV placement time and catheter length residing in the vein was obtained. Exclusions included catheter not visualised, patient discharged from ED unless IV failed, <24 hour hospitalisation unless IV failed or patient self-removed IV.Inpatient follow-up occurred within 24, 48 and 72 hours from the IV placement time. Catheter functionality was noted. If the catheter failed, the time and reason for failure was documented.

Résultats : 113 patients were enrolled; 27 were excluded. Of the 86 study subjects, 29 (33.7%) patients' IVs failed and 57 (66.3%) remained functional. Median time to IV failure was 15.6 hours. 100% of IVs failed when <30% of the catheter was in the vein; 32.4% of IVs failed when 30%-64% of the catheter was in the vein; no IVs failed when ≥65% of the catheter was in the vein (p<0.0002). The HR was 0.71 (95% CI 0.60 to 0.83), and for every 5% increase of catheter in vein, the hazard of the IV failing decreases by 29% (p<0.0001).

Conclusion : The quantity of catheter residing in the vein is a key predictor of long-term functionality of US-guided IVs and is strongly associated with the hazard of failure within 72 hours. Catheter failure is high when <30% of the catheter resided in the vein. Optimum catheter survival occurs when ≥65% of the catheter is placed in the vein.

Conclusion (proposition de traduction) : La longueur de cathéter introduit dans la veine est un facteur prédictif clé de la fonctionnalité à long terme des cathéters veineux posés par échographie et est fortement associée au risque de retrait dans les 72 heures. Les retraits de cathéter sont élevés lorsque moins de 30 % du cathéter est introduit dans la veine. Le maintien en place optimal d'un cathéter est assuré quand plus de 6 5% du cathéter est introduit dans la veine.

Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department.
Um SW, Ohle R, Perry JJ. | Emerg Med J. 2018 Sep;35(9):556-558
DOI: https://doi.org/10.1136/emermed-2018-207499
Keywords: emergency department

Short report

Introduction : Interarm systolic BP differential is a classic sign of acute aortic dissection (AAD). All previous studies looking at the association of BP differential with AAD combine systolic BP differential >20 mm Hg with pulse deficit. Our aim was to assess the association of systolic BP differential with AAD, and its role in predicting AAD in the context of other signs and symptoms.

Méthode : Historical matched case-control study using patient data collected between 2002 and 2014: participants were adults >18 years old with a bilateral BP measurement presenting to two tertiary care EDs or one regional cardiac referral centre in Canada. Cases were patients with diagnosed AAD; controls were those with a triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:1 ratio by sex and age. Bilateral BP differential and pulse deficit were compared between groups.

Résultats : A total of 222 patients (111 cases and 111 controls) were analysed. On univariate analysis systolic BP differential >20 mm Hg (OR 2.7, 95% CI 1.39 to 5.25) was significantly associated with AAD. Pulse deficit (diagnostic OR (DOR) 28.9) in isolation had better diagnostic accuracy than systolic BP differential >20 mm Hg in isolation (DOR 2.71) or combined with systolic BP differential >20 mm Hg (DOR 4.2).

Conclusion : Bilateral systolic BP differentials >20 mm Hg are associated with non-traumatic AAD. However, the poor diagnostic accuracy and potential variability in measurement limits its clinical usefulness.

Conclusion (proposition de traduction) : Les différences de pression artérielle systolique aux deux bras de plus de 20 mmHg sont associées à une dissection aortique aiguë non traumatique.
Cependant, la faible précision diagnostique et la variabilité potentielle des mesures limitent son utilité clinique.

Tayaa S, Berrut G, de Decker L, Chevalet P. | Geriatr Psychol Neuropsychiatr Vieil. 2018 Septembre;16(3):229-40
DOI: https://doi.org/10.1684/pnv.2018.0746
Keywords: Aucun

Gériatrie et gérontologie. Synthèse

Editorial : La fibrillation atriale est le trouble du rythme le plus fréquent dans la population âgée. Le risque d’accident vasculaire cérébral et le risque hémorragique sous traitement anticoagulant sont les plus élevés dans cette population. Les anti-vitamine K ont été jusqu’à présent le traitement anticoagulant de référence et ont démontré un bénéfice net, y compris chez les patients âgés. L’arrivée des anticoagulants oraux directs qui ne nécessitent pas de surveillance biologique a simplifié le traitement anticoagulant. Toutefois, les données concernant l’utilisation de ces molécules dans la population âgée restent limitées.

Conclusion (proposition de traduction) : La balance bénéfice-risque doit être évaluée, non pas pour la classe thérapeutique dans son ensemble, mais pour chacune des molécules et selon le profil du patient.

Dijon J, Sarazin M, Augusto V, Franck T, Gonthier R, Célarier T. | Geriatr Psychol Neuropsychiatr Vieil. 2018 Septembre;16(3):255-62
DOI: https://doi.org/10.1684/pnv.2018.0743
Keywords: Aucun

Gériatrie et gérontologie. Articles originaux

Introduction : Les hospitalisations via les services d’accueil des urgences des personnes âgées représentent en moyenne 41 % des séjours. Les médecins de ville sont conscients des effets délétères du recours aux urgences et savent que leur utilisation intensive contribue à une désorganisation de ces services. La mise à disposition d’une ligne téléphonique (hotline) permettant aux médecins de ville un accès direct à un médecin gériatre est un nouveau dispositif facilitant si nécessaire une hospitalisation directe en gériatrie mais son intérêt est encore mal évalué.

Méthode : Du 1er juin 2015 au 1er juin 2016, nous avons comparé le parcours de soin des patients hospitalisés directement en court séjour de gériatrie grâce à la hotline (groupe hotline) versus le parcours de ceux passés par les urgences (groupe SAU).

Résultats : 520 patients ont été inclus dans l’étude. Les durées moyennes de séjour sont significativement moins longues lors d’une hospitalisation via la hotline, 11,6 [intervalle de confiance à 95 % (IC 95%), 10,8-12,3] jours, lors d’une hospitalisation directe versus 14,1 [IC 95%, 13,5-14,7] jours lors d’un passage par les urgences (p < 0,05). Les patients entrés en court séjour par les urgences sont plus rapidement réhospitalisés. Chez les 170 patients réhospitalisés, on note une durée moyenne avant réhospitalisation de 29,5 [IC 95%, 23,6-35,4] jours chez les patients hospitalisés via la hotline, alors que ceux entrés par les urgences sont hospitalisés dans les 24,1 [IC 95%, 20,4-27,8] jours (p < 0,05).

Conclusion (proposition de traduction) : Cette analyse suggère que le parcours intrahospitalier des patients gériatriques directement adressés en court séjour de gériatrie grâce à une admission directe est plus court et plus efficace que le parcours par une étape intermédiaire aux urgences. Il paraît important de discuter la généralisation du dispositif de type hotline pour le fonctionnement de la filière gériatrique.

Clinical spectrum and short-term outcome of adult patients with purpura fulminans: a French multicenter retrospective cohort study.
Contou D, Sonneville R, Canoui-Poitrine F, Colin G, Coudroy R, Pène F, Tadié JM, Cour M, Béduneau G, Marchalot A, Guérin L, Jochmans S, Ehrmann S, Terzi N, Préau S, Barbier F, Schnell G, Roux D, Leroy O, Pichereau C, Gélisse E, Zafrani L, Layese R, Brun-Buisson C, Mekontso Dessap A, de Prost N; Hopeful Study Group. | Intensive Care Med. 2018 Sep;44(9):1502-1511
DOI: https://doi.org/10.1007/s00134-018-5341-3
Keywords: Limb amputation; Neisseria meningitidis; Purpura fulminans; Sepsis; Septic shock; Streptococcus pneumoniae

Original

Introduction : Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality.

Méthode : A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up).

Résultats : Among the 306 included patients, 126 (41.2%; 95% CI 35.6-46.9) died and 180 (58.8%; 95% CI 53.3-64.3) survived during the follow-up period [13 (3-24) days], including 51/180 patients (28.3%, 95% CI 21.9-35.5) who eventually required limb amputations, with a median number of 3 (1-4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02-1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69-0.99); p = 0.034] and platelet counts [HR 0.77 (0.60-0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68-4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28-0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06-3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis.

Conclusion : Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation.

Conclusion (proposition de traduction) : La mortalité et la morbidité du purpura fulminans de l’adulte demeurent élevées. L’étiologie pneumococcique est associée avec un risque accru d’amputation.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Purpura fulminans de l’adulte : son pronostic apparaît toujours aussi sombre  . Rédigé par le Dr Olivier Leroy.

Corticosteroid treatment in critically ill patients with severe influenza pneumonia: a propensity score matching study.
Moreno G, Rodríguez A, Reyes LF, Gomez J, Sole-Violan J, Díaz E, Bodí M, Trefler S, Guardiola J, Yébenes JC, Soriano A, Garnacho-Montero J10, Socias L, Del Valle Ortíz M, Correig E, Marín-Corral J, Vallverdú-Vidal M, Restrepo MI, Torres A, Martín-Loeches I; GETGAG Study Group. | Intensive Care Med. 2018 Sep;44(9):1470-1482
DOI: https://doi.org/10.1007/s00134-018-5332-4
Keywords: Corticosteroids; ICU; Influenza; Mortality; Pneumonia

Original

Introduction : To determine clinical predictors associated with corticosteroid administration and its association with ICU mortality in critically ill patients with severe influenza pneumonia.

Méthode : Secondary analysis of a prospective cohort study of critically ill patients with confirmed influenza pneumonia admitted to 148 ICUs in Spain between June 2009 and April 2014. Patients who received corticosteroid treatment for causes other than viral pneumonia (e.g., refractory septic shock and asthma or chronic obstructive pulmonary disease [COPD] exacerbation) were excluded. Patients with corticosteroid therapy were compared with those without corticosteroid therapy. We use a propensity score (PS) matching analysis to reduce confounding factors. The primary outcome was ICU mortality. Cox proportional hazards and competing risks analysis was performed to assess the impact of corticosteroids on ICU mortality.

Résultats : A total of 1846 patients with primary influenza pneumonia were enrolled. Corticosteroids were administered in 604 (32.7%) patients, with methylprednisolone the most frequently used corticosteroid (578/604 [95.7%]). The median daily dose was equivalent to 80 mg of methylprednisolone (IQR 60-120) for a median duration of 7 days (IQR 5-10). Asthma, COPD, hematological disease, and the need for mechanical ventilation were independently associated with corticosteroid use. Crude ICU mortality was higher in patients who received corticosteroids (27.5%) than in patients who did not receive corticosteroids (18.8%, p < 0.001). After PS matching, corticosteroid use was associated with ICU mortality in the Cox (HR = 1.32 [95% CI 1.08-1.60], p < 0.006) and competing risks analysis (SHR = 1.37 [95% CI 1.12-1.68], p = 0.001).

Conclusion : Administration of corticosteroids in patients with severe influenza pneumonia is associated with increased ICU mortality, and these agents should not be used as co-adjuvant therapy.

Conclusion (proposition de traduction) : L'administration de corticostéroïdes chez les patients atteints de pneumonie grippale sévère est associée à une mortalité accrue en USI, et ces agents ne doivent pas être utilisés en traitement co-adjuvant.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Il faut vraiment éviter la corticothérapie au cours de grippes sévères  . Rédigé par le Dr Olivier Leroy.

Lactate determination in pleural and abdominal effusions: a quick diagnostic marker of exudate-a pilot study.
Porta G, Numis FG, Rosato V, Pagano A, Masarone M, Bosso G, Serra C, Rinaldi L, Fascione MC, Amelia A, Paladino F, Schiraldi F. | Intern Emerg Med. 2018 Sep;13(6):901-906
DOI: https://doi.org/10.1007/s11739-017-1757-y
Keywords: Abdominal effusion; Bacterial peritonitis; Delta lactate; Diagnostic marker; Exudate; Infection; Lactate; Lactate ratio; Light’s criteria; Paracentesis; Pleural effusion; Pneumonia; Sepsis; Thoracentesis; Transudate

EM Original

Introduction : Pleural or abdominal effusions are frequent findings in ICU and Internal Medicine patients. Diagnostic gold standard to distinguish between transudate and exudate is represented by "Light's Criteria," but, unfortunately, the chemical-physical examination for their calculation is not a rapid test. Pursuing an acid-base assessment of the fluid by a blood-gas analyzer, an increase of lactate beyond the normal serum range is reported in the exudative effusions. The advantages of this test are that it is a very fast bed-side test, executable directly by the physician. The aim of this study is to evaluate whether the increase in lactate in pleural and abdominal effusions might be used as a criterion for the differential diagnosis of the nature of the fluid. Sixty-nine patients with pleural or abdominal effusions and clinical indication for thoracentesis or paracentesis were enrolled. Acid-base assessment with lactate, total protein, and LDH dosage on the serum, and acid-base assessment with lactate, total protein, and LDH dosage, cytology, and bacterial culture on the fluid were performed to each patient. Fluid-blood lactate difference (ΔLacFB) and fluid-blood lactate ratio (LacFB ratio) were calculated. A statistical analysis was carried out for fluid lactate (LacF), ΔLacFB, and LacFB ratio, performing ROC curves to find the cut-off values with best sensitivity (Sn) and specificity (Sp) predicting an exudate diagnosis: LacF: cut-off value: 2.4 mmol/L; AU-ROC 0.854 95% CI 0.756-0.952; Sn 0.77; Sp 0.84. ΔLacFB: cut-off value: 0.95 mmol/L; Au-ROC 0.876 95% CI 0.785-0.966; Sn 0.80; Sp 0.92. LacFB ratio: cut-off value: 2 mmol/L; Au-ROC 0.730 95% CI 0.609-0.851; Sn 0.74; Sp 0.65. Lactate dosage by blood-gas analyzer on pleural and abdominal effusions seems to be a promising tool to predict a diagnosis of exudate.

Conclusion : The determination of lactic acid levels by a blood-gas analyzer in both pleural and abdominal effusions might be considered a very useful test to perform a very rapid differential diagnosis between exudate and transudate. In particular, the calculation of the ΔLacFB with a 0.95 mmol/L cutoff shows an excellent diagnostic accuracy, which is non-inferior to LC, the current gold standard. Furthermore, the shorter time to obtain the results makes such test a very useful bed-side method in critically ill patients, in which the time to diagnosis represents one of the most important keys of a good outcome.

Conclusion (proposition de traduction) : La recherche des taux d'acide lactique par un analyseur de gaz sanguin dans les épanchements pleuraux et abdominaux peut être considérée comme un test très utile pour effectuer un diagnostic différentiel très rapide entre exsudat et transsudat. En particulier, le calcul de la différence entre le lactate sanguin et le lactate avec un seuil de significativité de 0,95 mmol/L montre une excellente précision diagnostique, qui n'est pas inférieure aux « critères de Light », l'étalon or actuel. De plus, le temps plus court pour obtenir les résultats fait de ce test une méthode très utile au lit des malades gravement malades, dans laquelle le temps de diagnostic représente l'une des clés les plus importantes d'un bon résultat.

Non-urgent use of emergency departments: populations most likely to overestimate illness severity.
Andrews H, Kass L. | Intern Emerg Med. 2018 Sep;13(6):893-900
DOI: https://doi.org/10.1007/s11739-018-1792-3
Keywords: Emergency department; Illness severity; Non-urgent; Overcrowding

EM Original

Editorial : Patients' overestimation of their illness severity appears to contribute to the national epidemic of emergency department (ED) overcrowding. This study aims to elucidate which patient populations are more likely to have a higher estimation of illness severity (EIS). The investigator surveyed demographic factors of all non-urgent patients at an academic ED. The patients and physicians were asked to estimate the patients' illness severity using a 1-10 scale with anchors. The difference of these values was taken and compared across patient demographic subgroups using a 2-sample t-test. One hundred and seventeen patients were surveyed. The mean patient EIS was 5.22 (IQR 4), while the mean physician EIS was less severe at 7.57 (IQR 3), a difference of 2.35 (p < 0.0001). Patient subgroups with the highest EIS compared to the physicians' EIS include those who were self-referred (difference of 2.65, p = 0.042), with income ≤ $25,000 (difference of 2.96, p = 0.004), with less than a college education (difference of 2.83, p = 0.018), and with acute-on-chronic musculoskeletal pain (difference of 4.17, p = 0.001). If we assume the physicians' EIS is closer to the true illness severity, patients with lower socioeconomic status, lower education status, who were self-referred, and who suffered from acute-on-chronic musculoskeletal pain are more likely to overestimate their illness severity and may contribute to non-urgent use of the ED. They may benefit from further education or resources for care to prevent ED misuse. The large difference of acute-on-chronic musculoskeletal pain may reflect a physician's bias to underestimate the severity of a patients' illness in this particular population.

Conclusion : Patients with lower socioeconomic status or lower education status, who are self-referred, and those who suffer from acute–chronic musculoskeletal pain are more likely to overestimate their illness severity compared to a physician-determined baseline. These patients may contribute to non-urgent use and overcrowding of the emergency department and may benefit from further education to prevent ED overuse.

Conclusion (proposition de traduction) : Les patients dont le statut socioéconomique ou le niveau de scolarité est inférieur, qui se déclarent eux-mêmes et ceux qui souffrent de douleurs musculo-squelettiques chroniques aiguës sont plus susceptibles de surestimer la gravité de leur maladie par rapport à un niveau de référence déterminé par le médecin. Ces patients peuvent contribuer à une utilisation non urgente et au surpeuplement du service des urgences et peuvent également bénéficier d'une formation supplémentaire pour prévenir la surutilisation des services d'urgence.

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool.
Hasemann W, Grossmann FF, Stadler R, Bingisser R, Breil D, Hafner M, Kressig RW, Nickel CH. | Intern Emerg Med. 2018 Sep;13(6):915-922
DOI: https://doi.org/10.1007/s11739-017-1781-y
Keywords: Algorithms; Attention; Delirium; Dementia; Emergency medicine; Performance; Prevalence

EM Original

Editorial : Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1 = 72.15; Q3 = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

Conclusion : The mCAM-ED is able to rule out delirium as well as to identify delirium quickly. Its application is efficient even in patients with dementia and may lead to lower screening and assessment burden for the patient. Validation studies in other ED settings are needed.

Conclusion (proposition de traduction) : La mCAM-ED est en mesure d'exclure le délire ainsi que de l'identifier rapidement. Son application est efficace même chez les patients atteints de démence et peut entraîner une réduction des mesures de dépistage et d'évaluation pour le patient. Des études de validation dans d'autres services d'urgence sont nécessaires.

Trends in Visits to Acute Care Venues for Treatment of Low-Acuity Conditions in the United States From 2008 to 2015.
Poon SJ, Schuur JD, Mehrotra A. | JAMA Intern Med. 2018 Sep;4
DOI: https://doi.org/10.1001/jamainternmed.2018.3205
Keywords: Aucun

Original Investigation

Introduction : Over the past 2 decades, a variety of new care options have emerged for acute care, including urgent care centers, retail clinics, and telemedicine. Trends in the utilization of these newer care venues and the emergency department (ED) have not been characterized.
OBJECTIVE: To describe trends in visits to different acute care venues, including urgent care centers, retail clinics, telemedicine, and EDs, with a focus on visits for treatment of low-acuity conditions.

Méthode : This cohort study used deidentified health plan claims data from Aetna, a large, national, commercial health plan, from January 1, 2008, to December 31, 2015, with approximately 20 million insured members per study year. Descriptive analysis was performed for health plan members younger than 65 years. Data analysis was performed from December 28, 2016, to February 20, 2018.
MAIN OUTCOMES AND MEASURES: Utilization, inflation-adjusted price, and spending associated with visits for treatment of low-acuity conditions. Low-acuity conditions were identified using diagnosis codes and included acute respiratory infections, urinary tract infections, rashes, and musculoskeletal strains.

Résultats : This study included 20.6 million acute care visits for treatment of low-acuity conditions over the 8-year period. Visits to the ED for the treatment of low-acuity conditions decreased by 36% (from 89 visits per 1000 members in 2008 to 57 visits per 1000 members in 2015), whereas use of non-ED venues increased by 140% (from 54 visits per 1000 members in 2008 to 131 visits per 1000 members in 2015). There was an increase in visits to all non-ED venues: urgent care centers (119% increase, from 47 visits per 1000 members in 2008 to 103 visits per 1000 members in 2015), retail clinics (214% increase, from 7 visits per 1000 members in 2008 to 22 visits per 1000 members in 2015), and telemedicine (from 0 visits in 2008 to 6 visits per 1000 members in 2015). Utilization and spending per person per year for low-acuity conditions had net increases of 31% (from 143 visits per 1000 members in 2008 to 188 visits per 1000 members in 2015) and 14% ($70 per member in 2008 to $80 per member in 2015), respectively. The increase in spending was primarily driven by a 79% increase in price per ED visit for treatment of low-acuity conditions (from $914 per visit in 2008 to $1637 per visit in 2015).

Conclusion : From 2008 to 2015, total acute care utilization for the treatment of low-acuity conditions and associated spending per member increased, and utilization of non-ED acute care venues increased rapidly. These findings suggest that patients are more likely to visit urgent care centers than EDs for the treatment of low-acuity conditions.

Conclusion (proposition de traduction) : De 2008 à 2015, l'utilisation totale des centres de consultation et soins d’urgence (Urgent Care, Retail clinic, télémédecine où des examens simples d’imagerie et de laboratoire sont possibles) pour traiter les pathologies peu graves et les dépenses connexes par personne ont augmenté, et l'utilisation des centres de consultation et soins d’urgence autres que les urgences a augmenté rapidement.
Ces résultats suggèrent que les patients sont plus susceptibles de visiter des centres de soins d'urgence que des services d'urgences pour le traitement des pathologies peu graves.

Commentaire : Voir l'analyse de l'étude par Medscape : Proposer des structures alternatives pour les « urgences » peu graves : quel impact ? - Medscape - 12 sept 2018 
  

Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial.
Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. | JAMA. 2018 Sep 25;320(12):1259-1265
DOI: https://doi.org/10.1001/jama.2018.13201
Keywords: Aucun

Original Investigation

Introduction : Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis, but long-term outcomes are not known.
OBJECTIVE: To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis.

Méthode : Five-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotic therapy, in which 530 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were randomized to undergo an appendectomy (n = 273) or receive antibiotic therapy (n = 257). The initial trial was conducted from November 2009 to June 2012 in Finland; last follow-up was September 6, 2017. This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone.
INTERVENTIONS: Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.
MAIN OUTCOMES AND MEASURES: In this analysis, prespecified secondary end points reported at 5-year follow-up included late (after 1 year) appendicitis recurrence after antibiotic treatment, complications, length of hospital stay, and sick leave.

Résultats : Of the 530 patients (201 women; 329 men) enrolled in the trial, 273 patients (median age, 35 years [IQR, 27-46]) were randomized to undergo appendectomy, and 257 (median age, 33 years, [IQR, 26-47]) were randomized to receive antibiotic therapy. In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%]; 70/256), 30 additional antibiotic-treated patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) underwent appendectomy between 1 and 5 years. The cumulative incidence of appendicitis recurrence was 34.0% (95% CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI, 33.1%-45.3%; 100/256) at 5 years. Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, 2 had complicated appendicitis, and 7 did not have appendicitis. At 5 years, the overall complication rate (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) was 24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI, 3.8%-10.4%) (n = 16/246) in antibiotic group (P < .001), which calculates to 17.9 percentage points (95% CI, 11.7-24.1) higher after surgery. There was no difference between groups for length of hospital stay, but there was a significant difference in sick leave (11 days more for the appendectomy group).

Conclusion : Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 years was 39.1%. This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.

Conclusion (proposition de traduction) : Parmi les patients initialement traités par antibiotiques pour une appendicite aiguë non compliquée, la probabilité de récidive tardive dans les 5nbsp;ans était de 39,1 %. Ce suivi à long terme confirme la faisabilité d'un traitement antibiotique seul en tant qu'alternative à la chirurgie pour une appendicite aiguë non compliquée.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Appendicite aiguë non compliquée : des données à 5 ans favorables à l’antibiothérapie  . Rédigé par le Dr Vincent Richeux.

Beyls C, Huette P, Mahjoub Y. | Prat Anesth Reanim. 2018 2018;22(4):210-217
DOI: https://doi.org/10.1016/j.pratan.2018.06.005
Keywords: Ventricular coupling; Tamponade; Pericardiocentesis; Echocardiography

Mise au point

Editorial : Le péricarde est un double feuillet entourant le cœur et participant à l’interdépendance VD-VG. Un épanchement péricardique, au-delà d’un certain volume, va augmenter la pression intra-péricardique, augmenter le couplage VD-VG et provoquer une chute du retour veineux. Le diagnostic de tamponnade est aussi bien clinique qu’échocardiographie. La visualisation en mode bidimensionnel du collapsus des cavités droites, et l’augmentation des variations respiratoires des flux gauches et droits est essentielle au diagnostic. Le traitement est la péricardiocentèse associé au maintien d’une pression de perfusion. Le drainage peut être chirurgical dans certains cas.

Conclusion (proposition de traduction) : L’épanchement péricardique représente une pathologie cli- nique relativement fréquente. Il peut être isolé ou associé à une pathologie péricardique sous-jacente. L’étiologie est variée et peut être infectieuse ou non infec- tieuse (cancer, maladies inflammatoires systémiques). Sa prise en charge est essentiellement guidée par l’effet hémodynamique (présence ou non d’une tamponnade péri- cardique), la présence d’une péricardite concomitante ou d’une maladie sous-jacente, ainsi que sa taille et son délai d’installation. L’échocardiographie est incontournable dans ce contexte. Le diagnostic de tamponnade reste difficile et nécessite une bonne maîtrise de l’échographie couplée à un examen clinique rigoureux. Des situations particulières comme l’épanchement post chirurgie cardiaque nécessitent une pris en charge spécifique.

Treatment with normobaric or hyperbaric oxygen and its effect on neuropsychometric dysfunction after carbon monoxide poisoning: A systematic review and meta-analysis of randomized controlled trials.
Lin CH, Su WH, Chen YC, Feng PH, Shen WC, Ong JR, Wu MY, Wong CS. | Medicine (Baltimore). 2018 Sep;97(39):e12456
DOI: https://doi.org/10.1097/MD.0000000000012456  | Télécharger l'article au format  
Keywords: Aucun

Systematic Review and Meta-Analysis

Introduction : Carbon monoxide (CO) poisoning may result in acute neurological sequelae, cognitive sequelae, and delay neurological sequelae. The administration of hyperbaric oxygen (HBO) to prevent the development of delayed neurological sequelae in CO poisoning have extensively investigated but conflicting results have been reported. We performed a systematic literature review and meta-analysis of randomized controlled trials (RCTs) evaluating HBO treatment and its effect on neuropsychometric dysfunction after CO poisoning.

Méthode : We searched Medline, Embase, Pubmed, and the Cochrane Register of Controlled Trials from inception to December 2017. Eligible studies compared HBO therapy with normobaric oxygen (NBO) in patients with CO poisoning.

Résultats : Six studies compared HBO with NBO in CO poisoning patients. Compared with patients treated with NBO, a lower percentage of patients treated with HBO reported headache (16.2% vs 16.5%, relative risk [RR] = 0.83, 95% CI = 0.38-1.80), memory impairment (18.2% vs 23.8%, RR = 0.80, 95% CI = 0.43-1.49), difficulty concentrating (15.0% vs 18.4%, RR = 0.86, 95% CI = 0.55-1.34), and disturbed sleep (14.7% vs 16.2%, RR = 0.91, 95% CI = 0.59-1.39). Two sessions of HBO treatment exhibited no advantage over one session.

Conclusion : The meta-analysis indicated that compared with CO poisoning patients treated with NBO, HBO treated patients have a lower incidence of neuropsychological sequelae, including headache, memory impairment, difficulty concentrating, disturbed sleep, and delayed neurological sequelae. Taking into consideration the cost-effectiveness of one session of HBO, one session of HBO treatment could be an economical option for patients with CO poisoning with high severity.

Conclusion (proposition de traduction) : La méta-analyse a mis en évidence que, par rapport aux patients intoxiqués au CO traités par l'oxygène normobare, les patients bénéficiant d'une oxygénothérapie hyperbare ont une incidence plus faible de séquelles neuropsychologiques, notamment des maux de tête, des troubles de la mémoire, des difficultés de concentration, des troubles du sommeil et des séquelles neurologiques à long terme. Compte tenu du rapport coût-efficacité d'une séance l'oxygénothérapie hyperbare, une séance de traitement à l'oxygène hyperbare pourrait être une option économique pour les patients présentant une intoxication au CO de sévérité élevée.

Randomized Trial of Intranasal Fentanyl Versus Intravenous Morphine for Abscess Incision and Drainage.
Fenster DB, Dayan PS, Babineau J, Aponte-Patel L, Tsze DS. | Pediatr Emerg Care. 2018 Sep;34(9):607-612
DOI: https://doi.org/10.1097/PEC.0000000000000810
Keywords: Aucun

Original Articles

Introduction : Abscess incision and drainage (I&D) are painful and distressing procedures in children. Intranasal (IN) fentanyl is an effective analgesic for reducing symptomatic pain associated with fractures and burns but has not been studied for reducing procedural pain during abscess I&D. Our objective was to compare the analgesic efficacy of IN fentanyl with intravenous (IV) morphine for abscess I&D in children.

Méthode : We performed a randomized noninferiority trial in children aged 4 to 18 years undergoing abscess I&D in a pediatric emergency department. Patients received IN fentanyl (2 μg/kg; maximum, 100 μg) or IV morphine (0.1 mg/kg; maximum, 8 mg). The primary outcome, determined independently by blinded assessors, was the Observational Scale of Behavioral Distress-Revised (OSBD-R). The prestated margin of noninferiority (Δ) was 1.80. Secondary outcomes included self-reported pain, treatment failure, and patient and parental satisfaction.

Résultats : We enrolled 20 children (median age, 15.4 years), 10 in each group. The difference between total OSBD-R scores was -13.45 (95% confidence interval, -24.24 to -2.67), favoring IN fentanyl.There was less self-reported pain in patients who received IN fentanyl immediately after the procedure. Four patients (40%) receiving IV morphine had treatment failures and required moderate sedation or had the procedure terminated. More patients who received IN fentanyl were satisfied with the analgesic administered compared with those who received IV morphine.

Conclusion : In a small sample of children aged 4 to 18 years undergoing abscess I&D, IN fentanyl was noninferior, and potentially superior, to IV morphine for reducing procedural pain and distress.

Conclusion (proposition de traduction) : Sur un petit échantillon d'enfants âgés de 4 à 18 ans subissant une incision et un drainage d'abcès, le fentanyl intranasal était non inférieur, et potentiellement supérieur à la morphine IV pour réduire la douleur et la détresse lors de la procédure.

Performance of Bedside Lung Ultrasound by a Pediatric Resident: A Useful Diagnostic Tool in Children With Suspected Pneumonia.
Zhan C, Grundtvig N2, Klug BH. | Pediatr Emerg Care22. 2018 Sep;34(9):618-622
DOI: https://doi.org/10.1097/PEC.0000000000000888
Keywords: Aucun

Original Articles

Introduction : Recent studies suggest that lung ultrasound is a good, radiation-free alternative to chest radiography in children with pneumonia. We investigated how bedside lung ultrasound performed by a pediatric resident compared with chest radiography in children with suspected pneumonia.

Méthode : This was a prospective study comparing bedside lung ultrasound to chest radiography as the reference standard. Children aged 0 to 15 years with suspected pneumonia at a pediatric emergency department were included and underwent chest radiography and lung ultrasound. A pediatric resident with minimal practical ultrasound experience and with no access to supervision performed the bedside lung ultrasound and was blinded to the patients' medical evaluation.

Résultats : A total of 82 children underwent both chest radiography and lung ultrasound (57% boys; median [interquartile range] age, 1.5 [1.1-2.5] years). The lung ultrasound took 7 to 20 minutes to perform, and 10% were of suboptimal quality due to an uneasy child. The prevalence of consolidations by chest radiography was 50%. Lung ultrasound had a sensitivity of 40% (95% confidence interval [CI], 30%-51%), specificity of 91% (95% CI, 83%-96%), positive likelihood ratio of 4.71 (95% CI, 2.21-10.04), and negative likelihood ratio of 0.65 (95% CI, 0.54-0.79).

Conclusion : Bedside lung ultrasound is a useful tool, with a good specificity, to find lung consolidations in children even when the sonologist has minimal practical ultrasound experience and no access to supervision. We suggest the use of bedside lung ultrasound as a diagnostic tool in children with suspected pneumonia.

Conclusion (proposition de traduction) : L'échographie pulmonaire au lit du malade est un outil utile, avec une bonne spécificité, pour rechercher des consolidations pulmonaires chez les enfants, même lorsque l'échographiste a une expérience minimale en échographie et n'a pas accès à une supervision.
Nous recommandons l'utilisation de l'échographie pulmonaire au lit du malade comme outil de diagnostic chez les enfants suspects de pneumopathie.

Efficacy and safety of mechanical versus manual compression in cardiac arrest - A Bayesian network meta-analysis.
Khan SU, Lone AN, Talluri S, Khan MZ, Khan MU, Kaluski E. | Resuscitation. 2018 Sep;130:182-188
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.005
Keywords: Cardiac arrest; Compression devices; Network meta-analysis

Reviews

Introduction : To compare relative efficacy and safety of mechanical compression devices (AutoPulse and LUCAS) with manual compression in patients with cardiac arrest undergoing cardiopulmonary resuscitation (CPR).

Méthode : For this Bayesian network meta-analysis, seven randomized controlled trials (RCTs) were selected using PubMed/Medline, EMBASE, and CENTRAL (Inception- 31 October 2017). For all the outcomes, median estimate of odds ratio (OR) from the posterior distribution with corresponding 95% credible interval (Cr I) was calculated. Markov chain Monte Carlo (MCMC) modeling was used to estimate the relative ranking probability of each intervention based on surface under the cumulative ranking curve (SUCRA).

Résultats : In analysis of 12, 908 patients with cardiac arrest [AutoPulse (2, 608 patients); LUCAS (3, 308 patients) and manual compression (6, 992 patients)], manual compression improved survival at 30 days or hospital discharge (OR, 1.40, 95% Cr I, 1.09-1.94), and neurological recovery (OR, 1.51, 95% Cr I, 1.06-2.39) compared to AutoPulse. There were no differences between LUCAS and AutoPulse with regards to survival to hospital admission, neurological recovery or return of spontaneous circulation (ROSC). Manual compression reduced the risk of pneumothorax (OR, 0.56, 95% Cr I, 0.33-0.97); while, both manual compression (OR, 0.15, 95% Cr I, 0.01-0.73) and LUCAS (OR, 0.07, 95% Cr I, 0.00-0.43) reduced the risk of hematoma formation compared to AutoPulse. Probability analysis ranked manual compression as the most effective treatment for improving survival at 30 days or hospital discharge (SUCRA, 84%).

Conclusion : Manual compression is more effective than AutoPulse and comparable to LUCAS in improving survival at 30 days or hospital discharge and neurological recovery. Manual compression had lesser risk of pneumothorax or hematoma formation compared to AutoPulse.

Conclusion (proposition de traduction) : La compression manuelle est plus efficace que l'AutoPulse et comparable au LUCAS pour améliorer la survie à 30 jours ou la sortie de l'hôpital et la récupération neurologique. La compression manuelle avait moins de risque de causer un pneumothorax ou un hématome par rapport à l'AutoPulse.

Commentaire : ndlr : Les comparaisons indirectes - Méthodes et validité. HAS Juillet 2009. « Méta-analyses bayésiennes en réseau » p27
  

Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center.
Stream S, Nolan A, Kwon S, Constable C. | Resuscitation. 2018 Sep;130:1-5
DOI: https://doi.org/10.1016/j.resuscitation.2018.06.020  | Télécharger l'article au format  
Keywords: Advance directives; Code status; Do-not-intubate (DNI); Do-not-resuscitate (DNR); Goals of care; Medical ethics

Clinical Papers

Introduction : In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders.
Objective: To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders.

Méthode : Retrospective chart review.
Setting/subjects: Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period.
Measurements: Logistic regression was used to identify demographic and medical data associated with code status.

Résultats : Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00).

Conclusion : Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.

Conclusion (proposition de traduction) : Comparées aux consignes de non-réanimation, les consignes combinées de non-réanimation/non-intubation sont plus étroitement associées à bon nombre des mêmes facteurs qui ont été associés aux consignes de non-réanimation. Il est nécessaire de savoir à quel point les deux directives peuvent être confondues lors des discussions sur l'état du code afin de promouvoir l'application de ces interventions centrée sur le patient.

Out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study.
Yates EJ, Schmidbauer S, Smyth AM, Ward M, Dorrian S, Siriwardena AN, Friberg H, Perkins GD. | Resuscitation. 2018 Sep;130:21-27
DOI: https://doi.org/10.1016/j.resuscitation.2018.06.021
Keywords: CPR; Cardiac arrest; Cardiopulmonary resuscitation; Decision support techniques; OHCA; Ongoing CPR, observational; Out-of-hospital cardiac arrest; ROSC; Return of spontaneous circulation; Survival to discharge; TOR; Termination of resuscitation; UK; Universal prehospital termination of resuscitation rule; West Midlands

Clinical papers

Introduction : Termination of resuscitation guidelines for out-of-hospital cardiac arrest can identify patients in whom continuing resuscitation has little chance of success. This study examined the outcomes of patients transferred to hospital with ongoing CPR. It assessed outcomes for those who would have met the universal prehospital termination of resuscitation criteria (no shocks administered, unwitnessed by emergency medical services, no return of spontaneous circulation).

Méthode : A retrospective cohort study of consecutive adult patients who were transported to hospital with ongoing CPR was conducted at three hospitals in the West Midlands, UK between September 2016 and November 2017. Patient characteristics, interventions and response to treatment (ROSC, survival to discharge) were identified.

Résultats : 227 (median age 69 years, 67.8% male) patients were identified. 89 (39.2%) met the universal prehospital termination of resuscitation criteria. Seven (3.1%) were identified with a potentially reversible cause of cardiac arrest. After hospital arrival, patients received few specialist interventions that were not available in the prehospital setting. Most (n = 210, 92.5%) died in the emergency department. 17 were admitted (14 to intensive care), of which 3 (1.3%) survived to hospital discharge. There were no survivors (0%) in those who met the criteria for universal prehospital termination of resuscitation.

Conclusion : Overall survival amongst patients transported to hospital with ongoing CPR was very poor. Application of the universal prehospital termination of resuscitation rule, in patients without obvious reversible causes of cardiac arrest, would have allowed resuscitation to have been discontinued at the scene for 39.2% of patients who did not survive.

Conclusion (proposition de traduction) : La survie globale des patients transportés à l'hôpital avec une RCP en cours était très faible. L’application de la règle de l’interruption universelle de la réanimation préhospitalière, chez des patients sans causes évidentes et irréversibles d’arrêt cardiaque, aurait permis d’interrompre la réanimation sur les lieux pour 39,2 % des patients qui n’ont pas survécu.

Commentaire : Yates EJ, Smyth MA, Perkins GD. Reply to: Letter to the Editor re out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study. Resuscitation. 2018 Dec;133:e10  .

A potential termination of resuscitation rule for EMS to implement in the field for out-of-hospital cardiac arrest: An observational cohort study.
Shibahashi K, Sugiyama K2, Hamabe Y. | Resuscitation. 2018 Sep;130:28-32
DOI: https://doi.org/10.1016/j.resuscitation.2018.06.026
Keywords: Out-of-hospital cardiac arrest; Prehospital care; Termination of resuscitation rule

Clinical papers

Introduction : Despite international guidelines recommending termination of resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA), their implementation remains low. We aimed to develop and validate a new TOR rule that could allow emergency medical service (EMS) personnel to immediately and objectively decide whether to withhold further resuscitation attempts after their arrival.

Méthode : This observational study evaluated data from OHCA cases in a prospectively collected nationwide Utstein-style Japanese database (2008-2012). Patients were divided into a development cohort (2008-2010, n = 342,055) and a validation cohort (2011-2012, n = 247,283). A new TOR was developed based on multivariable logistic regression analysis of factors that were associated with unfavourable neurological outcomes. Validation was performed based on specificity, the positive predictive value (PPV), and the area under the receiver operating characteristic curve (AUC).

Résultats : Three factors were strongly associated with unfavourable neurological outcomes at one month after OHCA: unshockable initial rhythm (adjusted odds ratio [aOR]: 6.09, 95% confidence interval [CI]: 5.81-6.38), unwitnessed by bystanders (aOR: 5.27, 95% CI: 4.99-5.57), and age of ≥73 years (adjusted OR: 2.34, 95% CI: 2.24-2.45). In the validation cohort, the new TOR rule provided specificity of 0.955 (95% CI: 0.950-0.959), a PPV of 0.996 (95% CI: 0.996-0.997), and an AUC of 0.828 (95% CI: 0.824-0.833).

Conclusion : Based on three objective variables: unshockable initial rhythm, unwitnessed by bystanders, and age ≥73 years, which can be collected immediately after the arrival of EMS personnel at the scene, a new TOR can be developed. Our potential new TOR rule provided an excellent PPV (>99%) for unfavourable neurological outcomes at one month after OHCA.

Conclusion (proposition de traduction) : Sur la base de trois variables objectives : un rythme initial non choquable, l'absence de témoins et un âge supérieur ou égal à 73 ans, qui peuvent être recueillis immédiatement après l'arrivée du personnel des services de secours d'urgence sur les lieux, une nouvelle règle d'arrêt de la réanimation peut être élaborée. Notre nouvelle règle a montré une excellente VPP (valeur prédictive positive > 99 %) pour les résultats neurologiques défavorables à un mois après un arrêt cardiaque préhospitalier.

Early ECPR for out-of-hospital cardiac arrest: Best practice in 2018.
Hutin A, Abu-Habsa M, Burns B, Bernard S, Bellezzo J, Shinar Z, Torres EC, Gueugniaud PY, Carli P, Lamhaut L. | Resuscitation. 2018 Sep;130:44-48
DOI: https://doi.org/10.1016/j.resuscitation.2018.05.004
Keywords: Cardiac arrest; ECMO; ECPR; Refractory cardiac arrest

Clinical papers

Editorial : Extracorporeal CPR is a second line treatment for refractory cardiac arrest, as written in the latest International Guidelines. Optimal timing, patient selection, location and method of implementation vary across the world. The objective here is to present an international consensus on the pillars of an ECPR program. The major aspect the group agrees on in that ECPR should be implemented within 60 minutes of collapse. With this in mind, the program should be built according to local resources knowing that the optimal team will require pre-established specific roles with personnel dedicated to resuscitation and others to ECPR.

Conclusion : ECPR may offer salvage therapy for temporizing management of refractory cardiac arrest with numerous studies now showing a survival benefit that can no longer be ignored. Providing patients with access to ECPR in a timely manner requires a system-wide approach and engagement, whether implemented in-hospital or in the out-of-hospital setting. We present a multi-centre perspective on challenges encountered and a pragmatic framework that can be adapted to multiple settings. Ongoing randomized controlled trials on ECPR will hopefully bring additional clarifications to harmonize practices and increase international consensus. The major part of these studies compares an ECPR group to standard care. But some others compare some different strategies to compare ECPR to angioplasty under CA or prehospital insertion in hospital insertion.

Conclusion (proposition de traduction) : L'ECPR peut proposer une thérapeutique de sauvetage pour la gestion temporaire d'un arrêt cardiaque réfractaire. De nombreuses études montrent maintenant un bénéfice de survie qui ne peut plus être ignoré.
Fournir aux patients un accès rapide à l'ECPR nécessite une approche et un engagement à l'échelle d'une organisation, qu'ils soient mis en œuvre à l'hôpital ou en dehors du milieu hospitalier. Nous présentons une perspective multicentrique des défis rencontrés et un cadre pragmatique pouvant être adapté à de multiples contextes.
Il est à espérer que les essais contrôlés randomisés en cours sur l'ECPR apporteront des clarifications supplémentaires pour harmoniser les pratiques et augmenter le consensus international. La majeure partie de ces études compare un groupe ECPR aux soins standard. Mais d'autres comparent différentes stratégies pour comparer l'ECPR à l'angioplastie dans arrêt cardiaque ou la canulation en préhospitalière ou intra-hospitalière.

Defining the plateau point: When are further attempts futile in out-of-hospital advanced airway management?.
Jarvis JL, Barton D, Wang H. | Resuscitation. 2018 Sep;130:57-60
DOI: https://doi.org/10.1016/j.resuscitation.2018.07.002
Keywords: Advanced airway management; Out-of-hospital care

Clinical papers

Introduction : We sought to characterize the number of attempts required to achieve advanced airway management (AAM) success.

Méthode : Using 4 years of data from a national EMS electronic health record system, we examined the following subsets of attempted AAM: 1) cardiac arrest intubation (CA-ETI), 2) non-arrest medical intubation (MED-ETI), 3) non-arrest trauma intubation (TRA-ETI), 4) rapid-sequence intubation (RSI), 5) sedation-assisted ETI (SAI), and 6) supraglottic airway (SGA). We determined the first pass and overall success rates, as well as the point of additional attempt futility ("plateau point").

Résultats : Among 57,209 patients there were 64,291 AAM. CA-ETI performance was: first-pass success (FPS) 71.4% (95% CI: 70.9-71.9%), 4 attempts to reach 91.5% (91.2-91.9%) success plateau. MED-ETI performance was: FPS 66.0% (95% CI: 65.1-67.0%), 3 attempts to reach 79.2% (78.4-80.0%) success plateau. TRA-ETI performance was: FPS 61.6% (95% CI: 59.3-63.9%), 3 attempts to reach 75.8% (73.7-77.8%) success plateau. RSI performance was: FPS 76.1% (95% CI: 75.1-77.1%), 5 attempts to reach 95.8% (95.3-96.2%) success plateau. SAI performance was: FPS 66.9% (95% CI: 65.1-68.6%), 3 attempts to 85.3% (83.9-86.6%) success plateau. SGA performance was: FPS 88.7% (95% CI: 88.0-89.3%), 5 attempts to reach 92.8% (92.3-93.4%) success plateau.

Conclusion : Multiple attempts are often needed to accomplish successful AAM. The number of attempts needed to accomplish AAM varies with AAM technique. These results may guide AAM practices.

Conclusion (proposition de traduction) : Plusieurs tentatives sont souvent nécessaires pour réussir la gestion avancée (ndlr : intubation) des voies aériennes. Le nombre de tentatives nécessaires pour obtenir une gestion avancée des voies respiratoires varie en fonction de la technique de gestion avancée des voies respiratoires. Ces résultats peuvent guider les pratiques avancées de gestion des voies respiratoires.

Commentaire : Le « point plateau » est défini dans l'article comme le nombre d'essai d'intubations qui n'améliore plus le taux de réussite.
Dans ce système, les performances d'intubation au premier essai allaient de 61,6 % à 76,1 % selon le motif et les conditions nécessitant une intubation (arrêt cardiaque, ISR, traumatologie, EMS, médecin...);
Les performances pour la gestion des voies aériennes par des dispositifs supraglottiques était au premier essai de 88,7 %.
En analysant les principales études publiées, la plupart des travaux ayant trait à l’intubation en situation d’urgence réalisée dans des systèmes de soins pré-hospitaliers médicalisés rapportent des taux de succès d’intubation trachéale très élevés, le plus souvent supérieur à 99 %. (Combesa X, Jabreb P. Prise en charge d’une intubation difficile en pré-hospitalier. Réanimation 2010;19:627-632  )

Associations between body size and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study.
Wang CH1, Huang CH, Chang WT, Fu CM, Wang HC, Tsai MS, Yu PH, Wu YW, Ma MH, Chen WJ. | Resuscitation. 2018 Sep;130:67-72
DOI: https://doi.org/10.1016/j.resuscitation.2018.07.006
Keywords: Cardiopulmonary resuscitation; Critical care; Heart arrest

Clinical papers

Introduction : Animal studies have demonstrated that hemodynamic-directed cardiopulmonary resuscitation (CPR) improves outcomes following cardiac arrest compared with the "one-size-fits-all" algorithm. We investigated whether body size of patients is correlated with outcomes of in-hospital cardiac arrest (IHCA).

Méthode : A retrospective study in a single centre was conducted. Adult patients experiencing IHCA between 2006 and 2015 were screened. Body mass index (BMI) was calculated using body weight and height measured at hospital admission. Thoracic anteroposterior diameter (APD) was measured by analysing computed tomography images. Multivariate logistic regression analysis was used to study the associations between independent variables and outcomes. Generalised additive models were used to identify cut-off points for continuous variables.

Résultats : A total of 766 patients were included, and 60.4% were male. Their mean age was 62.8 years. Mean BMI was 22.9 kg/m2, and the mean thoracic APD was 21.4 cm. BMI > 23.2 kg/m2 was inversely associated with a favourable neurological outcome (odds ratio [OR]: 0.30, 95% confidence interval [CI]: 0.13-0.68; p-value = 0.004), while thoracic APD was not. When the interaction term was analysed, BMI > 23.2 (kg/m2) × thoracic APD > 18.5 (cm) was inversely associated with both a favourable neurological outcome (OR: 0.33, 95% CI: 0.16-0.69; p-value = 0.003) and survival to hospital discharge (OR: 0.46, 95% CI: 0.26-0.81; p-value = 0.007).

Conclusion : Higher BMI and thoracic APD was correlated with worse outcomes following IHCA. For those patients, it might be better to perform CPR under guidance of physiological parameters rather than a "one-size-fits-all" resuscitation algorithm to improve outcomes.

Conclusion (proposition de traduction) : Un IMC et un diamètre antéropostérieur thoracique plus élevé étaient corrélés à de moins bons résultats dans l'arrêt cardiaque intrahospitalier. Pour ces patients, il serait peut-être préférable de pratiquer la RCP en fonction de paramètres physiologiques plutôt qu'en fonction d'un algorithme de réanimation « taille unique » pour améliorer les résultats.

Risk Factors for the Development of Acute Respiratory Distress Syndrome Following Hemorrhage.
Robinson BRH, Cohen MJ, Holcomb JB, Pritts TA, Gomaa D, Fox EE, Branson RD, Callcut RA, Cotton BA, Schreiber MA, Brasel KJ, Pittet JF, Inaba K, Kerby JD, Scalea TM, Wade CE, Bulger EM; PROPPR Study Group.. | Shock. 2018 Sep;50(3):258-264
DOI: https://doi.org/10.1097/SHK.0000000000001073
Keywords: Aucun

Clinical Science Aspects

Introduction : The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) study evaluated the effects of plasma and platelets on hemostasis and mortality after hemorrhage. The pulmonary consequences of resuscitation strategies that mimic whole blood, remain unknown.

Méthode : A secondary analysis of the PROPPR study was performed. Injured patients predicted to receive a massive transfusion were randomized to 1:1:1 versus 1:1:2 plasma-platelet-red blood cell ratios at 12 Level I North American trauma centers. Patients with survival >24 h, an intensive care unit (ICU) stay, and a recorded PaO2/FiO2 (P/F) ratio were included. Acute respiratory distress syndrome (ARDS) was defined as a P/F ratio < 200, with bilateral pulmonary infiltrates, and adjudicated by investigators.

Résultats : Four hundred fifty-four patients were reviewed (230 received 1:1:1, 224 1:1:2). Age, sex, injury mechanism, and regional abbreviated injury scale (AIS) scores did not differ between cohorts. Tidal volume, positive end-expiratory pressure, and lowest P/F ratio did not differ. No significant differences in ARDS rates (14.8% vs. 18.4%), ventilator-free (24 vs. 24) or ICU-free days (17.5 vs. 18), hospital length of stay (22 days vs. 18 days), or 30-day mortality were found (28% vs. 28%). ARDS was associated with blunt injury (OR 3.61 [1.53-8.81] P < 0.01) and increasing chest AIS (OR 1.40 [1.15-1.71] P < 0.01). Each 500 mL of crystalloid infused during hours 0 to 6 was associated with a 9% increase in the rate of ARDS (OR 1.09 [1.04-1.14] P < 0.01). Blood given at 0 to 6 or 7 to 24 h were not risk factors for lung injury.

Conclusion : Acute crystalloid exposure, but not blood products, is a potentially modifiable risk factor for the prevention of ARDS following hemorrhage.

Conclusion (proposition de traduction) : L'exposition aiguë aux cristalloïdes, mais pas aux produits sanguins, est un facteur de risque potentiellement modifiable pour la prévention du SDRA après une hémorragie.

Commentaire : A propos de l'étude Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) :
- Baraniuk S and al. in Injury. 2014 Sep;45(9):1287-95  . Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation.
- Yonge JD and al. in Transfusion. 2016 Apr;56 Suppl 2:S149-56  . The pragmatic randomized optimal platelet and plasma ratios trial: what does it mean for remote damage control resuscitation?

A comparison of carotid doppler ultrasonography and capnography in evaluating the efficacy of CPR.
Yilmaz G, Silcan M, Serin S, Caglar B, Erarslan Ö, Parlak. | Am J Emerg Med. 2018 Sep;36(9):1545-1549
DOI: https://doi.org/10.1016/j.ajem.2018.01.022
Keywords: Cardiopulmonary resuscitation; Carotid blood flow; End-tidal CO2. carotid doppler ultrasonography

Original Contribution

Introduction : The end-tidal carbon dioxide (ETCO2) measurement is accepted as the gold standard method for assessing cardiopulmonary resuscitation (CPR) efficacy. In recent studies, the use of Carotid Doppler Ultrasonography has become widespread in showing CPR efficacy. In the present study, the carotid blood flow measurement was compared with ETCO2 measurement and an evaluation was made of whether this method could be used as an alternative method to capnography in the assessment of CPR efficacy.

Méthode : This study was conducted on patients who presented at the Emergency Department (ED) with non-traumatic arrest or began to suffer from arrest during emergency service follow-up. The main carotid artery peak systolic velocity (PSV), end diastolic velocity (EDV) and time-dependent mean flow velocity (MNV), and ETCO2 values were measured and recorded after the 100th chest pressure of the CPR cycle and the results were statistically analyzed.

Résultats : The mean age of the patients was 54.5±12.3years and 65.6% of the patients were male. The mean values of patients measured from the carotid artery during the CPR were PSV 67.1±17.3, EDV 16.3±4.5, MNV 25.5±8.1 and ETCO2 22.2±8.1. A significant difference was found between in-hospital and out-of-hospital arrests in terms of patient outcome (return of spontaneous circulation (ROSC) and death) (p<0.05). The mean ETCO2 values of those who died were found to be lower than those of the ROSC group (p<0.05). Although there was a positive and low-level of correlation between the ETCO2 values and PSV values, and a positive and very low-level of correlation between the EDV and MNV values of all patients, these correlations were not statistically significant. (p>0.05).

Conclusion : A low correlation was found between the PSV and ETCO2 values. With effective CPR, the results close to carotid blood flow in normal healthy individuals were obtained. However, the study showed that carotid blood flow measurement results during CPR were not as valuable as ETCO2 in demonstrating CPR efficacy.

Conclusion (proposition de traduction) : Une faible corrélation a été trouvée entre la vitesse systolique maximale à l'écho-doppler et les valeurs d'ETCO₂. Avec une RCP efficace, des résultats proches du débit sanguin carotidien chez les individus en bonne santé ont été obtenus. Cependant, l'étude a montré que les résultats de la mesure du débit sanguin carotidien pendant la RCP n'étaient pas aussi utiles que l'ETCO2 pour démontrer l'efficacité de la RCP.

A mathematical model for efficient emergency transportation in a disaster situation.
Tlili T, Abidi S, Krichen S. | Am J Emerg Med. 2018 Sep;36(9):1585-1590
DOI: https://doi.org/10.1016/j.ajem.2018.01.039
Keywords: Ambulance routing problem; Emergency medical services; Genetic algorithm; Healthcare; Optimization

Original Contribution

Editorial : This work focuses on a real-life patient transportation problem derived from emergency medical services (EMS), whereby providing ambulatory service for emergency requests during disaster situations. Transportation of patients in congested traffic compounds already time sensitive treatment. An urgent situation is defined as individuals with major or minor injuries requiring EMS assistance simultaneously. Patients are either slightly injured and treated on site or are seriously injured and require transfer to points of care (PoCs). This paper will discuss enhancing the response-time of EMS providers by improving the ambulance routing problem (ARP). A genetic based algorithm is proposed to efficiently guide the ARP while simultaneously solving two scenarios.

Conclusion : This paper discussed a patient transportation problem and named ambulance routing derived from emergency medical services. The ambulance routing problem is modeled as a simple ambulance rout- ing problem and an open ambulance routing problem. The primary objective was to service more patients with the same number of resources while minimizing the total travel distance for the same number of requests. A genetic algorithm was developed with a cus- tomized recombination operator. The proposed algorithm was tested with real-world data. The comparisons of small instances demon- strate the proposed algorithm’s ability to solve them efficiently and prove that considering the ARP as an open ambulance routing problem rather than a regular ambulance routing problem is the best solution for real-world healthcare transportation services. The results for larger instances will be provided in future studies.

Conclusion (proposition de traduction) : Cet article a discuté d'un problème de transport de patient et a nommé le routage d'ambulance dérivé des services médicaux d'urgence. Le problème du routage des ambulances est modélisé sous la forme d'un simple problème de routage ambulancier et d'un problème de routage ambulancier ouvert. L'objectif principal était de desservir plus de patients avec le même nombre de ressources tout en minimisant la distance totale parcourue pour le même nombre de demandes. Un algorithme générique a été développé avec un opérateur de recombinaison personnalisé.
L'algorithme proposé a été testé avec des données réelles. Les comparaisons de petites instances démontrent la capacité de l’algorithme proposé à les résoudre efficacement et prouvent que considérer le problème du routage ambulancier comme un problème de routage ambulancier ouvert plutôt qu’un problème de routage ambulancier régulier est la meilleure solution pour les services de transport de soins de santé réels.
Les résultats pour des cas plus importants seront fournis dans des études futures.

Integration of lung ultrasound in the diagnostic reasoning in acute dyspneic patients: A prospective randomized study.
Pontis E, Pontis E, Claret PG, Markarian T, Javaudin F, Flacher A, Roger C, Muller L, de La Coussaye JE, Bobbia X. | Am J Emerg Med. 2018 Sep;36(9):1597-1602
DOI: https://doi.org/10.1016/j.ajem.2018.01.041
Keywords: Clinical decision-making; Dyspnea; Emergency medicine; Ultrasonography

Original contribution

Introduction : Misdiagnosis in acute dyspneic patients (ADP) has consequences on their outcome. Lung ultrasound (LUS) is an accurate tool to improve diagnostic performance. The main goal of this study was to assess the determinants of increased diagnostic accuracy using LUS.

Méthode : Multicentre, prospective, randomized study including emergency physicians and critical care physicians treating ADP on a daily basis. Each participant received three difficult clinical cases of ADP: one with only clinical data (OCD), one with only LUS data (OLD), and one with both. Ultrasound video loops of A, B and C profiles were associated with the cases. Which physician received what data for which clinical case was randomized. Physicians assessed the diagnostic probability from 0 to 10 for each possible diagnosis. The number of uncertain diagnoses (NUD) was the number of diagnoses with a diagnostic probability between 3 and 7, inclusive.

Résultats : Seventy-six physicians responded to the study cases (228 clinical cases resolved). Among the respondents, 28 (37%) were female, 64 (84%) were EPs, and the mean age was 37±8 years. The mean NUDs, respectively, when physicians had OCD, OLD, and both were 2.9±1.8, 2.2±1.7, 2.2±1.8 (p = 0.02). Ultrasound data and ultrasound frequency of use were the only variables related to the NUD. Higher frequency of ultrasound use by physicians decreased the number of uncertain diagnoses in difficult clinical cases with ultrasound data (OLD or associated with clinical data).

Conclusion : LUS decreases the NUD in ADP. The ultrasound frequency of use decreased the NUD in ADP clinical cases with LUS data.

Conclusion (proposition de traduction) : L'échographie pulmonaire diminue le nombre de diagnostics incertains chez les patients dyspnéiques aigus. La fréquence d'utilisation de l'échographie a diminué le nombre de diagnostics incertains dans les cas cliniques de patients atteints de dyspnée aiguë grâce aux données de l'échographie pulmonaire.

D-Dimer and thrombus burden in acute pulmonary embolism.
Keller K, Beule J, Balzer JO, Dippold W. | Am J Emerg Med. 2018 Sep;36(9):1613-1618
DOI: https://doi.org/10.1016/j.ajem.2018.01.048
Keywords: D-Dimer; Deep venous thrombosis; Pulmonary embolism; Risk stratification; Thrombus burden

Original contribution

Introduction : Thrombus burden in pulmonary embolism (PE) is associated with higher D-Dimer-levels and poorer prognosis. We aimed to investigate i) the influence of right ventricular dysfunction (RVD), deep venous thrombosis (DVT), and high-risk PE-status on D-Dimer-levels and ii) effectiveness of D-Dimer to predict RVD in normotensive PE patients.

Méthode : Overall, 161 PE patients were analyzed retrospectively, classified in 5 subgroups of thrombus burden according to clinical indications and compared regarding D-Dimer-levels. Linear regression models were computed to investigate the association between D-Dimer and the groups. In hemodynamically stable PE patients, a ROC curve was calculated to assess the effectiveness of D-Dimer for predicting RVD.

Résultats : Overall, 161 patients (60.9% females, 54.0% aged >70 years) were included in this analysis. The D-Dimer-level was associated with group-category in a univariate linear regression model (β 0.050 (95%CI 0.002-0.099), P = .043). After adjustment for age, sex, cancer, and pneumonia in a multivariate model we observed an association between D-Dimer and group-category with borderline significance (β 0.047 (95%CI 0.002-0.096), P = .058). The Kruskal-Wallis test demonstrated that D-Dimer increased significantly with higher group-category. In 129 normotensive patients, patients with RVD had significantly higher D-Dimer values compared to those without (1.73 (1.11/3.48) vs 1.17 (0.65/2.90) mg/l, P = .049). A ROC curve showed an AUC of 0.61, gender non-specific, with calculated optimal cut-off of 1.18 mg/l. Multi-variate logistic regression model confirmed an association between D-Dimer >1.18 mg/l and RVD (OR2.721 (95%CI 1.196-6.190), P = .017).

Conclusion : Thrombus burden in PE is related to elevated D-Dimer levels, and D-Dimer values >1.18 mg/l were predictive for RVD in normotensive patients. D-Dimer levels were influenced by DVT, but not by cancer, pneumonia, age, or renal impairment.

Conclusion (proposition de traduction) : La charge thrombotique, dans les embolies pulmonaires, est liée aux taux élevés de D-dimères et les valeurs de D-dimères > 1,18 mg/l étaient prédictives pour le dysfonctionnement ventriculaire droit seulement chez les patients normotendus.
Les taux de D-dimères ont été influencés par la thrombose veineuse profonde, mais pas par le cancer, la pneumonie, l'âge ou l'insuffisance rénale.

Quantification of ventilation volumes produced by compressions during emergency department cardiopulmonary resuscitation.
McDannold R, Bobrow BJ, Chikani V, Silver A, Spaite DW, Vadeboncoeur T. | Am J Emerg Med. 2018 Sep;36(9):1640-1644
DOI: https://doi.org/10.1016/j.ajem.2018.06.057
Keywords: CPR; Cardiac output; Emergency medicine; Out-of-hospital cardiac arrest; Respiration

Original contribution

Introduction : Clinical investigations have shown improved outcomes with primary compression cardiopulmonary resuscitation strategies. It is unclear whether this is a result of passive ventilation via chest compressions, a low requirement for any ventilation during the early aspect of resuscitation or avoidance of inadvertent over-ventilation.
OBJECTIVES: To quantify whether chest compressions with guideline-compliant depth (>2 in) produce measurable and substantial ventilation volumes during emergency department resuscitation of out-of-hospital cardiac arrest.

Méthode : This was a prospective, convenience sampling of adult non-traumatic out-of-hospital cardiac arrest patients receiving on-going cardiopulmonary resuscitation in an academic emergency department from June 1, 2011 to July 30, 2013. Cardiopulmonary resuscitation quality files were analyzed using R-Series defibrillator/monitors (ZOLL Medical) and ventilation data were measured using a Non-Invasive Cardiac Output monitor (Philips/Respironics, Wallingford, CT).

Résultats : Cardiopulmonary resuscitation quality data were analyzed from 21 patients (17 males, median age 59). The median compression depth was 2.2 in (IQR = 1.9, 2.5) and the median chest compression fraction was 88.4% (IQR = 82.2, 94.1). We were able to discern 580 ventilations that occurred during compressions. The median passive tidal volume recorded during compressions was 7.5 ml (IQR 3.5, 12.6). While the highest volume recorded was 45.8 ml, 81% of the measured tidal volumes were <20 ml.

Conclusion : Ventilation volume measurements during emergency department cardiopulmonary resuscitation after out-of-hospital cardiac arrest suggest that chest compressions alone, even those meeting current guideline recommendations for depth, do not provide physiologically significant tidal volumes.

Conclusion (proposition de traduction) : Les mesures des volumes ventilatoires pendant la réanimation cardio-respiratoire dans le service des urgences après un arrêt cardiaque extrahospitalier suggèrent que les compressions thoraciques seules, même celles répondant aux recommandations actuelles en matière de profondeur, ne fournissent pas de volume courant physiologiquement significatif.

The controversial role of dual sequential defibrillation in shockable cardiac arrest.
Pourmand A, Galvis J, Yamane D. | Am J Emerg Med. 2018 Sep;36(9):1674-1679
DOI: https://doi.org/10.1016/j.ajem.2018.05.078
Keywords: Cardiac arrest; Dual sequential defibrillation; Refractory; Ventricular fibrillation

Reviews

Introduction : In the United States, over 350,000 cardiac arrests occur outside of the hospital and 209,000 occur in the hospital. Shockable rhythms such as ventricular fibrillation (VF) have a survival rate of 20-30% outside of the hospital setting. Dual Sequential Defibrillation (DSD) has demonstrated success in terminating VF that is refractory to multiple attempts using a single defibrillator.

Méthode : The PubMed, and MEDLINE databases were reviewed in February of 2018 and literature reviewed on dual sequential defibrillation. The terms "dual", "sequential", "double sequential", and "defibrillation" were added in the search builder. This search was limited to English-language articles. The results and their references were assessed for relevance to the topic and implications for dual sequential defibrillation in shockable cardiac arrest.

Résultats : Included search terms yielded 23 articles. Studies occurred in the emergency department and prehospital setting. There are two retrospective cohort studies and the majority of published studies are case reports/series. Sample size per study varied from 1 to 279 encounters.

Conclusion : Studies have shown success in using DSD to treat refractory VF. However, further studies are necessary to assess the efficacy and safety of DSD compared to the standard of care treating refractory VF.

Conclusion (proposition de traduction) : Des études ont démontré la réussite de l’utilisation de la double défibrillation séquentielle pour traiter la fibrillation ventriculaire réfractaire. Cependant, d'autres études sont nécessaires pour évaluer l'efficacité et l'innocuité de la double défibrillation séquentielle par rapport au standard de traitement de la fibrillation ventriculaire réfractaire.

Pulmonary Embolism Among Patients With Acute Exacerbation Of Chronic Obstructive Pulmonary Disease: Implications For Emergency Medicine.
Pourmand A, Robinson H, Mazer-Amirshahi M, Pines JM. | J Emerg Med. 2018 Sep;55(3):339-346
DOI: https://doi.org/10.1016/j.jemermed.2018.05.026
Keywords: COPD; chronic obstructive pulmonary disease; pulmonary embolism

Clinical Reviews

Introduction : Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Common in COPD are acute exacerbations (AE-COPD) that cause acute dyspnea, cough, and bronchospasm. Symptoms of AE-COPD mimic pulmonary embolism (PE).

Méthode : We conducted a systematic review of the literature to assess the prevalence of PE in patients admitted to the hospital with a clinical diagnosis of AE-COPD. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we queried PubMed and MEDLINE databases from 1990 to 2017. The search term "prevalence pulmonary embolism, COPD" was used, and Boolean operators were used to combine search terms. Data were extracted from each article, specifically the sample size, study setting, design, and the prevalence of PE.

Résultats : A total of 5 articles were included that demonstrated a prevalence of PE among patients with a clinical diagnosis of AE-COPD that ranged from 3.3-29.1%. Sample sizes varied from 49-197 patients. Studies occurred in both emergency department and inpatient settings, including intensive care units. Among the studies that reported patient characteristics associated with PE in AE-COPD, both obesity and immobility were important.

Conclusion : Studies reporting the prevalence of PE during AE-COPD vary considerably in their methods and results. Because of the relatively high prevalence of PE during AE-COPD, it is important for providers to be aware of this linkage between the 2 conditions and to screen patients using clinical gestalt and validated screening tools until more emergency department data are available.

Conclusion (proposition de traduction) : Les études rapportant la prévalence de l'embolie pulmonaire au cours des exacerbations aiguës de la maladie pulmonaire obstructive chronique varient considérablement dans leurs méthodes et leurs résultats.
En raison de la prévalence relativement élevée de l'embolie pulmonaire pendant les exacerbations aiguës de la maladie pulmonaire obstructive chronique, il est important que les urgentistes soient conscients de ce lien entre les deux affections et qu'ils procèdent au dépistage des patients à l'aide de la présentation clinique et d'outils de dépistage validés jusqu'à ce que davantage de données soient disponibles dans les services d'urgence.

Does Initial Temperature in the Emergency Department Predict Outcomes in Patients Admitted for Sepsis?.
Khodorkovsky B, Youssef E, Adamakos F, Cina T, Falco A, LaMura L, Marion A, Nathan S, Hahn B. | J Emerg Med. 2018 Sep;55(3):372-377
DOI: https://doi.org/10.1016/j.jemermed.2018.06.008
Keywords: hypothermia; initial temperature; mortality; sepsis; septic shock; severe sepsis

Critical Care

Introduction : Sepsis is a leading cause of morbidity and mortality in hospitalized patients. Prompt recognition and early treatment has been shown to improve mortality. Both low and high temperature are among the four elements of systemic inflammatory response required for the diagnosis of sepsis. We hypothesized that initial temperature has an effect on the identification, treatment, and outcomes of septic patients.
OBJECTIVE: Our aim was to determine the prognostic and diagnostic utility of the initial recorded body temperature in patients presenting to the emergency department (ED) with sepsis.

Méthode : This retrospective cohort study was conducted in the ED of a single facility during the study period of January 1, 2014 through December 31, 2014. Inclusion criteria were adult subjects 18 years of age and older who were admitted to the hospital from the ED with a diagnosis of sepsis.

Résultats : Hypothermia on presentation was associated with a longer time to antibiotics treatment of 338.6 min (p = 0.002), longer length of stay of 14.5 days (p < 0.001), higher rate of intensive care unit (ICU) admission of 32.7% (p = 0.003), and higher mortality rate of 30.8% (p < 0.001).

Conclusion : In this study of adult patients diagnosed in the ED with sepsis, hypothermia correlated with increased time to initial antibiotics, length of stay, rate of ICU admission, and mortality. Therefore, hypothermia in the setting of sepsis requires early and aggressive intervention to prevent adverse outcomes and delays in care.

Conclusion (proposition de traduction) : Dans cette étude de patients adultes diagnostiqués au service des urgences avec une septicémie, l'hypothermie était corrélée à une augmentation du délai du traitement initial par antibiotiques, de la durée du séjour, du taux d'admission aux soins intensifs et de la mortalité. Par conséquent, l'hypothermie dans le contexte de la septicémie nécessite une intervention précoce et agressive pour prévenir les effets indésirables et les retards dans les soins.