A Systematic Review and Meta-analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department.
Karlow N, Schlaepfer CH, Stoll CRT, Doering M, Carpenter CR, Colditz GA, Motov S, Miller J, Schwarz ES. | Acad Emerg Med. 2018 Oct;25(10):1086-1097
DOI: https://doi.org/10.1111/acem.13502  | Télécharger l'article au format  
Keywords: Aucun

Editor's pick

Introduction : Opioids are commonly prescribed in the emergency department (ED) for the treatment of acute pain. Analgesic alternatives are being explored in response to an epidemic of opioid misuse. Low-dose ketamine (LDK) is one opioid alternative for the treatment of acute pain in the ED.

Méthode : This systematic review and meta-analysis sought to quantify whether LDK is an effective and safe opioid alternative for acute pain reduction in adults in the ED setting.

Résultats : This was a systematic review of randomized controlled trials comparing intravenous opioids to LDK for relief of acute pain in the ED. Studies where the control group initially received opioids prior to ketamine were excluded. A research librarian designed the electronic search strategy. Changes in visual analog scale or numeric rating scale pain scales were analyzed to determine the relative effects of LDK and opioids in the treatment of acute pain.

Discussion : Three studies met the criteria for inclusion in this meta-analysis. Compared to pain scale reduction with morphine, ketamine was not inferior (relative reduction = 0.42, 95% confidence interval = -0.70 to 1.54). No severe adverse events were reported in any study, but higher rates of nonsevere adverse events were observed with ketamine.

Conclusion : Ketamine is noninferior to morphine for the control of acute pain, indicating that ketamine can be considered as an alternative to opioids for ED short-term pain control.

Conclusion (proposition de traduction) : La kétamine n'est pas inférieure à la morphine pour le contrôle de la douleur aiguë, ce qui indique que la kétamine peut être considérée comme une alternative aux opioïdes pour le contrôle de la douleur aigüe au service aux urgences.

Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey.
Schoenfeld EM, Kanzaria HK, Quigley DD, Marie PS, Nayyar N, Sabbagh SH, Gress KL, Probst MA. | Acad Emerg Med. 2018 Oct;25(10):1118-1128
DOI: https://doi.org/10.1111/acem.13499
Keywords: Aucun

Original contribution

Introduction : As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED.

Méthode : We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person.

Résultats : Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved.

Conclusion : We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.

Conclusion (proposition de traduction) : Nous avons constaté que la majorité des patients de notre vaste échantillon de patients aux urgences souhaitaient participer aux décisions médicales, en particulier dans le cas d'un problème médical « grave » et estimaient qu'ils étaient en mesure de le faire.
Néanmoins, de nombreux patients étaient peu susceptibles de rechercher activement une implication et ne permettaient pas au médecin de prendre des décisions lors de la consultation aux urgences. Après avoir expliqué en détail les conséquences d'une décision, les cliniciens doivent s'efforcer de déterminer explicitement le niveau d'implication souhaité du patient dans la prise de décision.

Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists.
Pathan SA, Pathan SA, Mitra B, Mirza S, Momin U, Ahmed Z, Andraous LG, Shukla D, Shariff MY, Makki MM, George TT, Khan SS, Thomas SH, Cameron PA. | Acad Emerg Med. 2018 Oct;25(10):1129-1137
DOI: https://doi.org/10.1111/acem.13432
Keywords: Aucun

Original Contribution

Introduction : The ability of emergency physicians (EPs) to identify hydronephrosis using point-of-care ultrasound (POCUS) has been assessed in the past using computed tomography (CT) scans as the reference standard. We aimed to determine the ability of EPs to identify and grade hydronephrosis on POCUS using the consensus interpretation of POCUS by emergency radiologists as the reference standard.

Méthode : The study was conducted at an urban academic emergency department (ED) as a secondary analysis of previously collected ultrasound data from the EP-performed POCUS databank. Patients were eligible for inclusion if they had both POCUS and CT scanning performed during the index ED visit. Two board-certified emergency radiologists and six EPs interpreted each POCUS study independently. The interpretations were compared with the consensus interpretation by emergency radiologists. Additionally, the POCUS interpretations were also compared with the corresponding CT findings. Institutional approval was obtained for conducting this study. All the analyses were performed using Stata MP 14.0 (StataCorp).

Résultats : A total of 651 patient image-data sets were eligible for inclusion in this study. Hydronephrosis was reported in 69.6% of POCUS examinations by radiologists and 72.7% of CT scans (p = 0.22). Using the consensus radiology interpretation of POCUS as the reference standard, EPs had an overall sensitivity of 85.7% (95% confidence interval [CI] = 84.3%-87.0%), specificity of 65.9% (95% CI = 63.1%-68.7%), positive likelihood ratio of 2.5 (95% CI = 2.3-2.7), and negative likelihood ratio of 0.22 (95% CI = 0.19-0.24) for hydronephrosis. When using CT scan as the reference standard, the EPs had an overall sensitivity of 81.1% (95% CI = 79.6% to 82.5%), specificity of 59.4% (95% CI = 56.4%-62.5%), positive likelihood ratio of 2.0 (95% CI = 1.8-2.2), and negative likelihood ratio of 0.32 (95% CI = 0.29-0.35) for hydronephrosis. The specificity of EPs was improved to 94.6% (95% CI = 93.7%-95.4%) for categorizing the degree of hydronephrosis as "moderate or severe" versus "none or mild," with positive likelihood ratio of 6.33 (95% CI = 5.3-7.5) and negative likelihood ratio of 0.69 (95% CI = 0.66-0.73).

Conclusion : Emergency physicians were found to have moderate to high sensitivity for identifying hydronephrosis on POCUS when compared with the consensus interpretation of the same studies by emergency radiologists. These POCUS findings by EPs produced more definitive results when at least moderate degree of hydronephrosis was present.

Conclusion (proposition de traduction) : Les urgentistes ont montré une sensibilité modérée à élevée pour l'identification de l'hydronéphrose au point d'intervention par rapport à l'interprétation consensuelle des mêmes études par les radiologues d'urgence.
Ces constats échographiques au point d'intervention par les urgentistes ont donné de meilleurs résultats quand un degré modéré d'hydronéphrose était présent.

Pain One Week After an Emergency Department Visit for Acute Low Back Pain Is Associated With Poor Three-month Outcomes.
Friedman BW, Conway J, Campbell C, Bijur PE, John Gallagher E. | Acad Emerg Med. 2018 Oct;25(10):1138-1145
DOI: https://doi.org/10.1111/acem.13453
Keywords: Aucun

Original contribution

Introduction : Low back pain (LBP) is responsible for more than 2.5 million visits to U.S. emergency departments (EDs) annually. Nearly 30% of patients who present to an ED with acute LBP report functional impairment or pain 3 months later. These patients are at risk of chronic LBP, a highly debilitating condition. In this study, we assessed whether three variables assessable shortly after symptom onset could independently predict poor 3-month outcomes among LBP patients who present to an ED.

Méthode : This was a planned analysis of data from two randomized comparative effectiveness studies of patients with acute, nontraumatic, nonradicular LBP. Patients were enrolled during an ED visit, contacted by telephone 1 week after the ED visit, and then followed up by telephone 3 months later. The coprimary 3-month outcomes were LBP-related functional impairment and persistent moderate or severe LBP. Two of the three hypothesized predictor variables were assessed during the index visit: 1) the STarT Back Screening Tool score, a nine-item, multidimensional tool validated and widely used in the outpatient setting, and 2) the patient's own anticipated duration of LBP. The third hypothesized predictor was presence of pain assessed by phone 1 week after the ED visit. We then determined whether these three predictor variables were independently associated with poor outcomes at 3 months, after controlling for medication received, age, and sex.

Résultats : A total of 354 patients were enrolled. Of these, 309 (87%) provided 3-month impairment data and 311 (88%) provided 3-month pain data. At 3 months, 122 of 309 (39%) patients reported functional impairment and 51 of 311(16%) patients reported moderate or severe LBP. Among the three hypothesized predictor variables, 58 of 352 (16%) patients with available data reported a moderate or high STarT Back Screening Tool score, 35 of 321 (11%) patients with available data reported anticipated duration of LBP > 1 week, and 235 of 346 (68%) patients reported pain at 1-week telephone follow-up. After age, sex, and medication received were controlled for in a multivariable logistic regression model, only pain at 1 week was independently associated with 3-month impairment (odds ratio [OR] = 2.42, 95% CI = 1.39-4.22) and 3-month moderate or severe pain (OR = 3.83, 95% CI = 1.53-9.58).

Conclusion : More than one-third of patients reported functional impairment 3 months after an ED visit for acute, nontraumatic, nonradicular LBP. Moderate or severe LBP was less common, reported in about half as many patients (16%). Of the three hypothesized predictor variables, only persistent pain at 1 week was independently associated with poor outcomes at 3 months. Despite its important role in the outpatient setting, the STarT Back Tool was not associated with poor outcomes in this ED cohort.

Conclusion (proposition de traduction) : Trois mois après une visite aux urgences, plus d'un tiers des patients ont signalé une altération fonctionnelle en raison de douleurs lombaires aiguës, non traumatiques et non radiculaires. La douleur au bas du dos était moins fréquente. Elle a été rapportée chez environ la moitié moins de patients (16 %). Parmi les trois variables prédictives hypothétiques, seule la douleur persistante à 1 semaine était associée de manière indépendante à de mauvais résultats à 3 mois. Malgré son rôle important en ambulatoire, l'outil STarT Back Tool n'était pas associé à de piètres résultats dans cette cohorte de services d'urgence.

Integrating Point-of-care Testing Into a Community Emergency Department: A Mixed-methods Evaluation.
Pines JM, Zocchi MS, Carter C, Marriott CZ, Bernard M, Warner LH. | Acad Emerg Med. 2018 Oct;25(10):1146-1156
DOI: https://doi.org/10.1111/acem.13450
Keywords: Aucun

Original contribution

Introduction : Point-of-care testing (POCT) is a commonly used technology that hastens the time to laboratory results in emergency departments (ED). We evaluated an ED-based POCT program on ED length of stay (LOS) and time to care, coupled with qualitative interviews of local ED stakeholders.

Méthode : We conducted a mixed-methods study (2012-2016) to examine the impact of POCT in a single, community ED. The quantiative analysis involved an observational before-after study comparing time to laboratory test result (POC troponin or POC chemistry) and ED LOS after implementation of POCT, using a propensity-weighted interrupted time series analysis (ITSA). A complementary qualitative analysis involved five semistructured interviews with staff using grounded theory on the benefits and challenges to ED POCT.

Résultats : A total of 47,399 ED visits were included in the study (24,705 in the preintervention period and 22,694 in the postintervention period). After POCT implementation, overall laboratory testing increased marginally from 61% to 62%. Central laboratory troponin and chemistry declined by > 50% and was replaced by POCT. Prior to POCT implementation, time to troponin and chemistry had declined steadily due to other improvements in laboratory efficiency. After POCT implementation, there was an immediate 20-minute further decline (p < 0.001) in both time to troponin and time to chemistry results using the propensity-weighted comparisons. However, the declining trend observed prior to POCT implementation did not continue at the same rate after implementation. Similarly, prior to POCT implementation, ED LOS declined due to other quality improvements. After POCT implementation, LOS continued declined at a similar rate. Because of this prior trend, the ITSA did not show a significant decline in LOS attributable to POCT. Common benefits of POCT perceived by staff in qualitative interviews included improved quality of care (64%) and reductions in time to test results (44%). Common challenges included concerns over POCT accuracy (32%) and technical barriers (29%).

Conclusion : In the study ED, implementation of POCT was associated with a reduction in time to test result for both troponin and chemistry. Local staff felt that faster time to test result improved quality of care; however, concerns were raised with POCT accuracy.

Conclusion (proposition de traduction) : Dans les services d’urgence de l’étude, la mise en œuvre de la biologie délocalisée était associée à une réduction du temps nécessaire pour obtenir les résultats de troponine et de biochimie.
Le personnel local a estimé qu'un délai plus court pour obtenir les résultats améliorait la qualité des soins ; cependant, des préoccupations ont été soulevées quant à la précision des tests de biologie délocalisés.

Service médical du RAID, Antenne médicale spécialisée de Satory (GIGN), Lapostolle F, Loeb T, Lecarpentier E, Vivien B, Pasquier P, Raux M. | Ann Fr Med Urgence. 2018 october;8(5):316-325
DOI: https://doi.org/10.3166/afmu-2018-0084  | Télécharger l'article au format  
Keywords: Mass causualty incident / Tactical medecine / Prehospital medecine

Mise au point / Update

Editorial : France faces terrorism for many years. Recent terror attacks, as Paris on November 13, 2015, required prehospital medical teams (Smur) as well as medical dispatching (Samu), to work together with police and SWAT teams. Smur teams had to cope with unusual and hostile environment. This unusual environment generated fear in prehospital medical teams. This article aims at providing answers to justified questions that arise in such circumstances. It comes along with recent French guidelines that specify the prehospital organization when treating terrorist attack. It helps performing an adequate assessment of the scene. Moreover, it is committed to provide tricks to enhance personal emotional control for a better efficiency. Indeed, initial emotional sideration may slow down patients’ rescue. Check lists help prehospital physician to perform all the tasks. The prehospital physicians not only provide medical assistance, but also provide tactical and operational competences to enhance casualties’ evacuation toward safety nests. The very first physician must be competent to act as a pre-chief medical officer and collaborate with chief officer and police officer until chief medical officer arrives.

Conclusion (proposition de traduction) : Lors d’une intervention préhospitalière pour tuerie de masse, les équipes Smur sont sous tension dès leur déclenchement. Les soins ne constituent qu’une partie de leur mission, et en général, c’est l’organisation qui occupe le premier plan. Les équipes de secours et de soins primo-intervenantes, en accord avec le COS, agissent comme de véritables accélérateurs de flux d’évacuation des blessés. Pour ce faire, elles identifient les problèmes (menace, nombre de victimes et accès à ces dernières) qu’elles partagent avec la régulation médicale du Samu, dans le but d’adapter en sécurité la montée en puissance tout comme le circuit d’aval des blessés. Elles assurent le tri et les soins aux victimes, tel qu’elles l’ont appris. L’ensemble de ces actions se fait dans un contexte dégradé, forcément anxiogène. Pour surmonter ces difficultés, elles font appel à des techniques de gestion du stress, à des entraînements et à de la simulation.

Mastrodicasa1 A, Cuenoud A, Pasquier M et Carron PN. | Ann Fr Med Urgence. 2018 octobre:8(5):326-331
DOI: https://doi.org/10.3166/afmu-2018-0082  | Télécharger l'article au format  
Keywords: Aucun

Cas clinique commenté / Commented case report

Introduction : Une production de CO₂ est observée dans diverses situations professionnelles ou lors de combustion de dérivés du carbone, lors de fermentations alcooliques ou lactiques, au départ de sources telluriques, ou lors de production endogène en milieu confiné. Le CO₂ est un gaz normalement présent à très faible concentration dans l’air ambiant, mais pouvant se retrouver en quantité supraphysiologique dans certaines conditions environnementales, accidentelles ou professionnelles. À doses modérées, le CO₂ produit des symptômes aspécifiques, mais s’avère rapidement létal à des concentrations élevées. Bien que des situations d’intoxications soient régulièrement rapportées en Europe, le risque de toxicité lié au CO₂ et les principes de sa prise en charge sont peu connus des urgentistes.

Conclusion (proposition de traduction) : L’intoxication aiguë au CO₂ est une cause rare mais souvent fatale d’accident, par toxicité directe et par asphyxie. Cette étiologie doit être suspectée en fonction du contexte et de l’anamnèse, étant donné les propriétés physicochimiques du CO₂ qui le rendent non détectable pour l’être humain en l’absence de détecteurs spécifiques. L’identification précoce est primordiale afin de garantir la sécurité des intervenants et d’éviter le suraccident. Le traitement est principalement symptomatique, avec une oxygénothérapie large, sans évidence démontrée à ce jour d’un éventuel traitement hyperbare. Le cas clinique typique est celui d’une victime unique, victime d’une intoxication ayant lieu dans un espace confiné d’une petite entreprise non industrielle dont elle n’est pas employée. Plus rarement, l’intoxication peut concerner un nombre important de patients.

Czolnowski1 D, Duret E, Baugnon D, Losser MR. | Ann Fr Med Urgence. 2018 octobre;8(5):309-315
DOI: https://doi.org/10.3166/afmu-2018-0072
Keywords: Thermal Burns; Epidemiology; Telemedicine; Care network; Dressing

Article original

Introduction : Décrire l’épidémiologie des brûlures, le parcours de soins dans un service des urgences et l’adéquation du traitement avec celle des recommandations de la Société française de brûlologie.

Méthode : Étude observationnelle prospective monocentrique sur un an incluant toute brûlure cutanée de deuxième et troisième degrés prise en charge aux urgences de Verdun (France) avec une analyse rétrospective téléphonique à trois mois.

Résultats : Sur un an, 117 patients ont été inclus, âgés de 27 ± 22 ans, avec une brûlure d’origine thermique (92 %) surtout par liquide chaud (41 %). Les lésions étaient essentiellement inférieures à 5 % de la surface cutanée (87 % des patients) surtout de deuxième degré superficiel (80 % des lésions). Un protocole de pansement et de remplissage vasculaire non recommandé était majoritairement prescrit. Neuf patients furent transférés le jour même vers un centre de référence, cinq l’ont été à 48 heures. L’usage de la télémédecine a échoué par dysfonctionnement du logiciel. Le suivi était essentiellement réalisé par un médecin urgentiste sur un court terme. Sur les 71 dossiers réévalués téléphoniquement à trois mois, seuls quatre cas ont révélé un retentissement personnel ou professionnel.

Conclusion : The establishment of a care network in connection with emergency department, general practice and reference centres seems to benefit the patients both in terms of quality of care initiated at the emergency department and follow-up and prevention of early and late complication of burn.

Conclusion (proposition de traduction) : L’établissement d’un réseau de soins articulé entre le service des urgences, la médecine de ville et les centres de traitement des brûlés semble démontrer un intérêt tant sur le plan de la qualité des soins initiés aux urgences que sur le suivi et la prévention des complications aiguës et tardives de la brûlure.

A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses.
Stiell IG, Clement CM, Lowe M, Sheehan C, Miller J, Armstrong S, Bailey B, Posselwhite K, Langlais J, Ruddy K, Thorne S, Armstrong A, Dain C, Perry JJ, Vaillancourt C. | Ann Emerg Med. 2018 Oct;72(4):333-341
DOI: https://doi.org/10.1016/j.annemergmed.2018.03.033  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization.

Méthode : We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to "clear" the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries).

Résultats : In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule.

Conclusion : We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.

Conclusion (proposition de traduction) : Nous avons clairement démontré que les infirmières et infirmiers responsables du triage aux urgences peuvent appliquer avec succès la règle canadienne C-Spine, permettant ainsi une gestion plus rapide et plus confortable des patients, sans aucune menace pour la sécurité des patients. L'adoption généralisée de cette approche devrait améliorer les soins et le confort des patients traumatisés, et pourrait réduire la durée de séjour dans nos urgences très surpeuplées.

Commentaire : Pour consulter les articles sur la règle canadienne C-Spine :
JStiell IG and al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8   et Stiell IG and al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510-8  .
Retrouvez la « Canadian C-Spine Rule » dans la page Scores, onglet traumatologie   sur mon site Internet…

Resuscitative Endovascular Balloon Occlusion of the Aorta Improves Cardiac Compression Fraction Versus Resuscitative Thoracotomy in Patients in Traumatic Arrest.
Teeter W, Romagnoli A, Wasicek P, Hu P, Yang S, Stein D, Scalea T, Brenner M. | Ann Emerg Med. 2018 Oct;72(4):354-360
DOI: https://doi.org/10.1016/j.annemergmed.2018.02.020
Keywords: Aucun

Trauma

Introduction : Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as an alternative to resuscitative thoracotomy for proximal aortic control in select patients with exsanguinating hemorrhage below the diaphragm. The purpose of this study is to compare interruptions in closed chest compression or open chest cardiac massage during REBOA versus resuscitative thoracotomy.

Méthode : From May 2014 to December 2016, patients in arrest who received aortic occlusion with REBOA or resuscitative thoracotomy were included. Total cardiac compression time was defined as the total time that closed chest compression was performed for REBOA patients and the total time that closed chest compression (before resuscitative thoracotomy) and open chest cardiac massage (after thoracotomy) were performed for resuscitative thoracotomy patients. Cardiac compression fraction was defined as the time compressions occurred during the entire resuscitation phase. All resuscitations were captured by multiview, time-stamped videography.

Résultats : Fifty patients with aortic occlusion after arrest were enrolled: 22 REBOA and 28 resuscitative thoracotomy. Most were men (86%) (median age 30.2 years, interquartile range [IQR] 24.9 to 42.3; median Injury Severity Score 27, IQR 16 to 42; neither differed between groups). The median duration of total cardiac compression time was 945 seconds (IQR 697 to 1,357) for REBOA versus 496 seconds (IQR 375 to 933) for resuscitative thoracotomy. During initial resuscitation, compressions occurred 86.5% of the time (SD 9.7%) during resuscitation with REBOA versus 35.7% of the time (SD 16.4%) in patients receiving resuscitative thoracotomy. Cardiac compression fraction improved after open cross clamp in resuscitative thoracotomy patients to 73.2% of the time (SD 18.0%) but remained significantly less than the same period for REBOA (86.7%; SD 9.4%). Mean cardiac compression fraction for REBOA was significantly improved over that for resuscitative thoracotomy (86.2% [SD 9.1%] versus 55.3 [SD 17.1%]; mean difference 31.0%; 95% confidence interval for difference 22.7% to 39.23%; P<.001). Median pause in resuscitation related to procedural tasks was 0 seconds (IQR 0 to 13) for REBOA and 148 seconds (IQR 118 to 223) in resuscitative thoracotomy.

Conclusion : Total duration of interruptions of cardiac compressions is shorter for patients receiving REBOA versus resuscitative thoracotomy before and during resuscitation with aortic occlusion. Markers for perfusion during resuscitation must be examined to understand the effects of cardiac compressions and aortic occlusion on patients in arrest because of hemorrhagic shock.

Conclusion (proposition de traduction) : La durée totale des interruptions des compressions cardiaques est plus courte chez les patients bénéficiant d'une réanimation par occlusion endovasculaire de l'aorte par ballonnet par rapport à la réanimation par thoracotomie avant et pendant la réanimation avec occlusion aortique. Les marqueurs de perfusion lors de la réanimation doivent être examinés afin de comprendre les effets des compressions cardiaques et de l'occlusion aortique sur les patients en arrêt en raison d'un choc hémorragique.

Agitation Crisis Control.
Mason J, Colwell CB, Grock A. | Ann Emerg Med. 2018 Oct;72(4):371-373
DOI: https://doi.org/10.1016/j.annemergmed.2018.08.004
Keywords: Aucun

EM:RAP Commentary

Editorial : The often frustrating and occasionally dangerous challenge of acute agitation in the emergency department (ED) seems to be increasing in frequency and severity. Acutely agitated patients are not only experiencing distress themselves but also creating a threat to the safety of themselves, staff, and even their fellow patients; hence, the vital need for safe and prompt treatment. In this month’s Annals, Miner et al1 look at the prevalence of agitation at an urban ED. Spoiler alert: it is common! Decisions to restrain or sedate agitated patients can vary by provider and patient. Let’s take a closer look at the options and what you might choose in some scenarios.

Conclusion : Try to treat the underlying cause of agitation. Choose the mildest effective intervention; verbal de-escalation and oral medications are a great place to start. Protect your patients and your staff by controlling the situation, using physical restraints and calming medications when needed. When faced with patients in excited delirium, aggressive management is necessary to ensure appropriate care.

Conclusion (proposition de traduction) : Il faut essayez de traiter la cause sous-jacente de l'agitation. Choisir l'intervention efficace la plus légère ; la désescalade verbale et les médicaments oraux sont un excellent point de départ. Protéger les patients et le personnel en contrôlant la situation, en utilisant des moyens de contention physique et des médicaments apaisants au besoin. Face à des patients en délire agité, une gestion agressive est nécessaire pour assurer les soins appropriés.

Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department.
Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. | Ann Emerg Med. 2018 Oct;72(4):374-385
DOI: https://doi.org/10.1016/j.annemergmed.2018.04.027
Keywords: Aucun

Pain Management and Sedation

Introduction : Agitation in the emergency department (ED) can pose a threat to patient and provider safety; therefore, treatment is indicated. The purpose of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone to treat agitation.

Méthode : This was a prospective observational study of consecutive patients receiving intramuscular medication to treat agitation in the ED. Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3-week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg. The primary outcome was the proportion of patients adequately sedated at 15 minutes, assessed with the Altered Mental Status Scale.

Résultats : Seven hundred thirty-seven patients were enrolled (median age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated (Altered Mental Status Scale <1) compared with ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%), haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg (difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI -1% to 20%). Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI 10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and ziprasidone (difference 8%; 95% CI -3% to 19%). Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group.

Conclusion : Intramuscular midazolam achieved more effective sedation in agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine. Olanzapine provided more effective sedation than haloperidol. No differences in adverse events were identified.

Conclusion (proposition de traduction) : Le midazolam en intramusculaire a permis d'obtenir une sédation plus efficace chez les patients agités aux urgences de 15 minutes plus tôt que l'halopéridol, la ziprasidone et peut-être l'olanzapine. L'olanzapine a entraîné une sédation plus efficace que l'halopéridol. Aucune différence dans les événements indésirables n'a été relevée.

Liberal Versus Restrictive Intravenous Fluid Therapy for Early Septic Shock: Rationale for a Randomized Trial.
Self WH, Semler MW, Bellomo R, Brown SM, deBoisblanc BP, Exline MC, Ginde AA, Grissom CK, Janz DR, Jones AE, Liu KD, Macdonald SPJ, Miller CD, Park PK, Reineck LA, Rice TW, Steingrub JS, Talmor D, Yealy DM, Douglas IS, Shapiro NI; CLOVERS Protocol Committee and NHLBI Prevention and Early Treatment of Acute Lung Injury (PETAL) Network Investigators. | Ann Emerg Med. 2018 Oct;72(4):457-466
DOI: https://doi.org/10.1016/j.annemergmed.2018.03.039
Keywords: Aucun

Infectious Disease

Editorial : Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume of initial fluid (50 to 75 mL/kg [4 to 6 L in an 80-kg adult] during the first 6 hours) and later use of vasopressors, versus a restrictive fluids approach, consisting of a smaller volume of initial fluid (≤30 mL/kg [≤2 to 3 L]), with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies, the Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis trial. The purpose of this article is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial.

Conclusion : despite significant progress during the past 2 decades, morbidity and mortality from septic shock remain unacceptably high and additional improvement is needed. Intravenous fluid resuscitation is considered an important initial step in sepsis management, but the optimal dosing for intravenous fluid and timing for vasopressors are unknown. Although large-volume fluid boluses of 4 to 5 L within the first 6 hours of treatment are common, this practice is based on low-quality evidence. A growing body of literature has highlighted potential adverse effects from rapid, large-volume fluid boluses. Shifting toward earlier vasopressors and less intravenous fluid during initial resuscitation for septic shock is a potential avenue to improve outcomes; however, current evidence for this approach on patient-centered outcomes is lacking. The upcoming CLOVERS trial will directly compare a liberal and restrictive fluids strategy for early septic shock management in EDs and ICUs in the United States, with the goal of providing patient outcome data needed to inform and guide clinical practice.

Conclusion (proposition de traduction) : En dépit des progrès importants réalisés au cours des deux dernières décennies, la morbidité et la mortalité dues au choc septique restent élevées de façon inacceptable et des améliorations supplémentaires sont nécessaires. Le remplissage vasculaire intraveineux est considéré comme une étape initiale importante dans la gestion du sepsis, mais le volume optimal de remplissage et le moment choisi pour les vasopresseurs sont inconnus.
Bien que les apports important de liquides de 4 à 5 L au cours des 6 premières heures de traitement soient courants, cette pratique repose sur des preuves de faible qualité.
Un nombre croissant de publications a mis en évidence les effets néfastes potentiels d'un remplissage rapides et volumineux. L'administration précoce de vasopresseurs et moins de remplissage vasculaire lors de la réanimation initiale en cas de choc septique est un moyen potentiel d’améliorer les résultats ; cependant, les preuves actuelles de cette approche sur les résultats centrés sur le patient font défaut. Le prochain essai CLOVERS comparera directement une stratégie libérale et restrictive en matière de remplissage pour la gestion précoce des chocs septiques dans les services d'urgences et les unités de soins intensifs aux États-Unis, dans le but de fournir les données sur les résultats des patients nécessaires pour informer et guider la pratique clinique.

Are qSOFA Criteria Better Than the Systemic Inflammatory Response Syndrome Criteria for Diagnosing Sepsis and Predicting Inhospital Mortality?.
Long B, April MD. | Ann Emerg Med. 2018 Oct;72(4):470-472
DOI: https://doi.org/10.1016/j.annemergmed.2018.03.008  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : Investigators identified studies from MEDLINE, the Cumulative Index of Nursing and Allied Health, and the Web of Science databases released after the Third International Consensus Definitions for Sepsis and Septic Shock, describing clinical criteria for sepsis.1 Authors also searched bibliographies of retrieved articles and review articles.

Méthode : Investigators included prospective observational cohorts and clinical trials evaluating patients older than 16 years that assessed qSOFA and systemic inflammatory response syndrome criteria for the diagnosis of sepsis or prediction of inhospital mortality among adult patients with suspected infection. Studies were excluded if they described only a specific population or were case reports or case series. Three authors performed study selection and included studies through consensus.

Résultats : Two investigators independently extracted data from included studies. Authors assessed methodological quality with the Newcastle-Ottawa Scale. Authors evaluated performance of systemic inflammatory response syndrome criteria and qSOFA criteria for sepsis diagnosis and outcomes. Investigators described standard mean difference for continuous outcomes, with 95% confidence intervals (CIs). Authors expressed the relationship of sepsis and mortality with the area under the receiver operator curve, performed sensitivity meta-analysis by estimating CIs, and used the I2 test to describe heterogeneity.

Conclusion : Systemic inflammatory response syndrome (SIRS) criteria are more sensitive for diagnosing sepsis, while quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) criteria are marginally more accurate for predicting inhospital mortality among patients identified with sepsis.

Conclusion (proposition de traduction) : Les critères du syndrome de réponse inflammatoire systémique (SRIS) sont plus sensibles pour le diagnostic de la septicémie, tandis que les critères d'évaluation séquentielle rapide de l'insuffisance organique[liée à la septicémie] (qSOFA) sont légèrement plus précis pour prédire la mortalité inhospitalière chez les patients atteints de sepsis.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators.
Atkinson PR, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Henneberry R, Fraser JM, Howlett MK, Mekwan J, Ramrattan B, Middleton J, van Hoving DJ, Peach M, Taylor L, Dahn T, Hurley S, MacSween K, Richardson LR, Stoica G, Hunter S, Olszynski PA, Lewis DA. | Ann Emerg Med. 2018 Oct;72(4):478-489
DOI: https://doi.org/10.1016/j.annemergmed.2018.04.002
Keywords: Aucun

Imaging

Introduction : Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes.

Méthode : This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay.

Résultats : Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay.

Conclusion : To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.

Conclusion (proposition de traduction) : À notre connaissance, il s'agit du premier essai comparatif randomisé à comparer l'échographie au lit du patient à l'échographie standard sans échographie au lit du patient chez des patients atteints d'urgence hypotensive indifférenciée. Nous n'avons trouvé aucun avantage pour la survie, la durée du séjour, les taux de tomodensitométrie, l'utilisation d'inotropes ou l'administration de liquides. L'ajout d'un protocole d'échographie au lit du patient aux soins standard peut ne pas se traduire par un bénéfice de survie dans ce groupe.

A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses.
Stiell IG, Clement CM, Lowe M, Sheehan C, Miller J, Armstrong S, Bailey B, Posselwhite K, Langlais J, Ruddy K, Thorne S, Armstrong A, Dain C, Perry JJ, Vaillancourt C. | Ann Emerg Med. 2018 Oct;72(4):333-341
DOI: https://doi.org/10.1016/j.annemergmed.2018.03.033  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization.

Méthode : We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to "clear" the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries).

Résultats : In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule.

Conclusion : We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.

Conclusion (proposition de traduction) : Nous avons clairement démontré que les infirmières de tri des services des urgences peuvent appliquer avec succès la règle canadienne C-Spine, permettant ainsi une gestion plus rapide et plus confortable des patients, sans aucune menace pour la sécurité des patients. L'adoption généralisée de cette approche devrait améliorer les soins et le confort des patients traumatisés, et pourrait réduire la durée de séjour dans nos urgences très surpeuplées.

Commentaire : Retrouvez la « Canadian C-Spine Rule » dans la page Scores, onglet traumatologie   sur mon site Internet…

Prior CT imaging history for patients who undergo whole-body CT for acute traumatic injury and are discharged home from the emergency department.
Matthews M, Richman P, Krall S, Leeson K, Xu KT, Gest AL, Blow O. | BMC Emerg Med. 2018 Oct 16;18(1):34
DOI: https://doi.org/10.1186/s12873-018-0186-1
Keywords: Acute traumatic injury; CT scans; Discharge from ED

Research article

Introduction : Recurrent CT imaging is believed to significantly increase lifetime malignancy risk. We previously reported that high acuity, admitted trauma patients who received a whole-body CT in the emergency department (ED) had a history of prior CT imaging in 14% of cases. The primary objective of this study was to determine the CT imaging history for trauma patients who received a whole-body CT but were ultimately deemed safe for discharge directly home from the ED.

Méthode : This was a retrospective cohort study conducted at an academic ED. All trauma patients who were discharged directly home from the ED after whole-body CT were analyzed. The decision to utilize whole-body CT was at the discretion of the caring physician during the study period. Clinical data for the most recent trauma visit was recorded in a structured fashion on a standardized data collection instrument utilizing the hospital system electronic medical record (EMR). Subsequently, study investigators reviewed a shared, electronic radiological archive for the 6-hospital system to evaluate prior CT exposure for each patient.

Résultats : 165 patients were in the study group. The mean age of the study group was 39+/- 16 years old, 40% were female and 64% were Hispanic. The most common mechanism of injury in our study group was motor vehicle crash (MVC) (66%). In our study group, 25% had at least one prior CT. The most common prior studies performed were: CT abdomen/pelvis (13%), CT head (9.1%), CT face (6.7%), and CT chest (1.8%). Within a multivariate logistic regression model we found that the large majority of patient characteristics and mechanisms of injury were not associated with a positive prior CT imaging history.

Conclusion : We found a positive history for prior CT for 25% of trauma patients who received whole-body CT scan but were discharged from the ED to home.

Conclusion (proposition de traduction) : Nous avons trouvé des antécédents de tomodensitométrie antérieure chez 25 % des patients traumatisés ayant eu une tomodensitométrie corps entier (body scan) aux urgences et qui ont quitté l'hôpital vers leur domicile après l'acte.

High time to omit oxygen therapy in ST elevation myocardial infarction.
Khoshnood A | BMC Emerg Med. 2018 Oct 20;18(1):35
DOI: https://doi.org/10.1186/s12873-018-0187-0  | Télécharger l'article au format  
Keywords: Emergency medicine; Oxygen; Oxygen therapy; Pathology; Physiology; ST elevation myocardial infarction; STEMI

Editorial

Editorial : Supplemental oxygen (O2) therapy in patients with chest pain has been a cornerstone in the treatment of suspected myocardial infarction (MI). Recent randomized controlled trials have, however, shown that supplemental O2 therapy has no positive nor negative effects on cardiovascular functions, mortality, morbidity or pain in normoxic patients with suspected MI and foremost patients with ST Elevation Myocardial Infarction (STEMI). O2 therapy in normoxic STEMI patients should therefore be omitted. More studies are needed in discussing hemodynamically unstable STEMI patients, as well as patients with non-STEMI, unstable angina and other emergency conditions.

Conclusion : More studies are therefore needed in discussing sup- plemental O2 therapy in hemodynamic unstable STEMI patients, patients with non-STEMI as well as unstable angina. This is especiCally of importance since some studies argue that supplemental O2 therapy adminis- trated to acutely ill patients can be toxic and increase mortality and morbidity.

Conclusion (proposition de traduction) : Des études supplémentaires sont donc nécessaires pour discuter le traitement complémentaire par l'oxygène chez les patients hémodynamiques instables présentant un infarctus du myocarde avec élévation du segment ST, les patients présentant un infarctus du myocarde sans élévation du segment ST ainsi que les patients souffrant d'un angor instable.
Cela revêt une importance particulière, car certaines études affirment que la supplémentation en oxygène chez des patients gravement malades peut être toxique et augmenter la mortalité et la morbidité.

Commentaire : Voir les recommandations de l'European Society of Cardiologie (ESC) :
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.  
 
Articles sur les effets de l'oxygène dans l'infarctus aigu :
Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, Cameron P, Barger B, Ellims AH, Taylor AJ: Air versus oxygen in ST-segment elevation myocardial infarction. Circulation 2015:CIRCULATIONAHA. 114.014494  .
 
Articles à lire sur la toxicité de l'oxygène :
Girardis M, Busani S, Damiani E, et al. Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit: the oxygen-icu randomized clinical trial. JAMA. 2016;316(15):1583–9  .
Chu DK, Kim LHY, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018;391(10131):1693–705  .

Evaluation of public awareness, knowledge and attitudes towards basic life support: a cross-sectional study.
Jarrah S, Judeh M, AbuRuz ME. | BMC Emerg Med. 2018 Oct 29;18(1):37
DOI: https://doi.org/10.1186/s12873-018-0190-5  | Télécharger l'article au format  
Keywords: Attitudes; Awareness; Jordan; Knowledge; Life support; Public

Research article

Introduction : Out-of-hospital cardiac arrest is a major cause of mortality worldwide. When basic life support techniques are implemented quickly, the chance of survival is doubled. Therefore, this study evaluated public awareness, knowledge and attitudes towards basic life support in Jordan.

Méthode : A descriptive, cross-sectional design with a convenience sample of 300 Jordanian adults aged over 18 years, recruited from three metropolitan areas in the northern, middle and southern regions.

Résultats : A total of 87 participants (29%) stated that they have received training about cardiopulmonary resuscitation (CPR). Among them, 20 participants (23%) received their training through the media. The highest response rate for cardiac arrest signs was chest pain (n = 129, 43%). Participants who received training had greater knowledge of the three signs of consciousness evaluation. The numbers of participants who received training and performed chest compression, mouth-to-mouth ventilation, and both compression and ventilation were higher than those who did not receive training. Overall, 256 participants (88.3%) reported that they would perform CPR on someone from their family without hesitation. The most important concern about performing CPR was making a mistake.

Conclusion : Improving knowledge about cardiopulmonary resuscitation is an important topic, which can be achieved by training the general population. Media can play an important role in this issue.

Conclusion (proposition de traduction) : L’amélioration des connaissances sur la réanimation cardiopulmonaire est un sujet important qui peut être atteint en formant la population en général. Les médias peuvent jouer un rôle important dans ce dossier.

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma.
Inagaki T, Kimura A, Makishi G, Tanaka S, Tanaka N. | Emerg Med J. 2018 Oct;35(10):614-618
DOI: http://dx.doi.org/10.1136/emermed-2017-206930  | Télécharger l'article au format  
Keywords: ct/mri; emergency departments; trauma, spine and pelvis

Original article

Introduction : Previous cervical spine imaging decision rules have been based on positive findings on plain X-ray and are limited by lack of specificity, age restrictions and complicated algorithms. We previously derived and validated a clinical decision rule (Rule 1) for detecting cervical spine injury (CSI) on CT in a single-centre study. This recommended CT for patients with (1) GCS score <14, (2) GCS 14-15 and posterior cervical tenderness or neurological deficit, (3) age ≥60 years and fall down stairs, or (4) age <60 and injured in a motorcycle collision or fallen from height. This study assessed the accuracy and reliability of this rule and refined the rule.

Méthode : We conducted a prospective, dual-centre study at two Japanese EDs between August 2012 and March 2014. Patients with head or neck injury ≥16 years of age were included. Clinical data were collected from medical records. Imaging was at the discretion of the treating physician. CSI was diagnosed as a fracture or dislocation seen on CT; patients who were not imaged were followed for 14 days. We analysed the sensitivity and specificity of Rule 1 and refined it post hoc using recursive partitioning.

Résultats : 1192 patients were enrolled. 927 completed follow-up. Of these, 584 (63.0%) underwent CT imaging and 38 had CSI. Sensitivity and specificity of Rule 1 were 92.1% (95% CI 79.2% to 97.3%) and 58.6% (95% CI 55.4% to 61.9%). A second rule (Rule 2) was derived recommending CT for those with any of the following: GCS <14, cervical tenderness, neurological deficit or mechanism of injury (fall down stairs, motorcycle collision or fall from height) without age limits. Sensitivity and specificity were 100% (95% CI 90.8% to 100%) and 51.9% (95% CI 48.6% to 55.2%), respectively.

Conclusion : Our initial CT decision rule had lower sensitivity than in our initial validation study. A refined decision rule based on GCS, neck tenderness, neurological deficit and mechanism of injury showed excellent sensitivity with a small loss of specificity. Rule 2 will now need validation in an independent cohort.

Conclusion (proposition de traduction) : Notre première règle de décision sur l'indication d'une tomodensitométrie était moins sensible que dans notre étude de validation initiale. Une règle de décision améliorée basée sur le score de Glasgow, la sensibilité de la nuque, le déficit neurologique et le mécanisme de la blessure a montré une excellente sensibilité avec une légère perte de spécificité. La deuxième règle devra maintenant être validée par une cohorte indépendante.

The association between systolic blood pressure and in-hospital mortality in older emergency department patients who are hospitalised with a suspected infection.
Warmerdam M, Baris L, van Liebergen M, Ansems A, Esteve Cuevas L, Willeboer M, Rijpsma D, Shetty AL, de Groot B. | Emerg Med J. 2018 Oct;35(10):619-622
DOI: https://doi.org/10.1136/emermed-2018-207502
Keywords: aged; emergency department; geriatrics; infectious diseases; risk management

CLINICAL PRACTICE

Introduction : In existing risk stratification and resuscitation guidelines for sepsis, a hypotension threshold of systolic blood pressure (SBP) below 90-100 mmHg is typically used. However, for older patients, the clinical relevance of a SBP in a seemingly 'normal' range (>100 mmHg) is still poorly understood, as they may need higher SBP for adequate tissue perfusion due to arterial stiffening. We therefore investigated the association between SBP and mortality in older emergency department (ED) patients hospitalised with a suspected infection.

Méthode : In this observational multicentre study in the Netherlands, we interrogated an existing prospective database of consecutive ED patients hospitalised with a suspected infection between 2011 and 2016. We investigated the association between SBP categories (≤100, 101-120, 121-139, ≥140 mmHg) and in-hospital mortality in patients of 70 years and older. We adjusted for demographics, comorbidity, disease severity and admission to ward/intensive care using multivariable logistic regression.

Résultats : In the 833 included older patients, unadjusted in-hospital mortality increased from 4.7% (n=359) in SBP ≥140 mmHg to 20.8% (n=96) in SBP ≤100 mmHg. SBP categories were linearly associated with case-mix-adjusted in-hospital mortality. The adjusted ORs (95% CI) for ≤100, 101-120 and 121-139 mmHgcompared with the reference of ≥140 mmHg were 3.8 (1.8 to 7.8), 2.8 (1.4 to 5.5) and 1.9 (0.9 to 3.7), respectively.

Conclusion : In older ED patients hospitalised with a suspected infection, we found an inverse linear association between SBP and case-mix-adjusted in-hospital mortality. Our data suggest that the commonly used threshold for hypotension is not clinically meaningful for risk stratification of older ED patients with a suspected infection.

Conclusion (proposition de traduction) : Chez les patients plus âgés hospitalisés pour une suspicion d'infection, nous avons trouvé une association linéaire inverse entre la PA systolique et la mortalité à l'hôpital ajustée en fonction de l'ajustement de la composition des groupes de cas. Nos données suggèrent que le seuil d'hypotension couramment utilisé n'est pas cliniquement significatif pour la stratification du risque chez les patients âgés présentant une suspicion d'infection.

Lung ultrasound in diagnosing pneumonia in the emergency department: a systematic review and meta-analysis.
Orso D, Guglielmo N, Copetti R. | Eur J Emerg Med. 2018 Oct;25(5):312-321
DOI: https://doi.org/10.1097/MEJ.0000000000000517
Keywords: emergency department, meta-analysis, pneumonia, ultrasound

Review Articles

Editorial : Community-acquired pneumonia (CAP) is one of the most widespread and severe infectious diseases worldwide. In the emergency department (ED), there is still a need for a rapid and accurate tool that can diagnose CAP. Lung ultrasound (LUS) is a recent tool that is increasingly being for this purpose. So far, the LUS has been evaluated on a wide range of patients, but not yet on the specific population in the ED through a meta-analysis. Our aim was to assess the accuracy of the LUS in diagnosing CAP in this setting through a systematic review and a meta-analysis. A systematic research of literature was carried out for all published studies comparing the diagnostic accuracy of the LUS against chest radiography or computerized tomography scan in patients older than 18 years of age with clinical criteria for CAP assessed in the ED. We extracted the descriptive and quantitative data from eligible studies, and calculated the pooled sensitivity, specificity, and diagnostic odds ratio. We defined the summary receiver operating characteristic curve. Our initial search strategy yielded 10 377 studies, of which 17 (0.2%) were eligible. These studies provided a combined sample size of 5108 participants. The general risk of bias of the considered studies was quite low, but some concerns were highlighted. The diagnostic odds ratio was around 181 (I: 27%). The pooled area under the curve, sensitivity, and specificity were, respectively, 97, 92, and 93%. The LUS was found to be an accurate tool in diagnosing CAP in adult patients in the ED. More methodologically rigorous trials are needed.

Conclusion : The lung ultrasound proved to be a sufficiently useful and accurate tool to diagnose community-acquired pneumonia in an adult population in the emergency department. Some concerns have been raised on the robustness of the obtained results, because of the lack of a well-standardized methodology in the studies included (in particular on the choice of reference standards, the experience of the sonographer, and the ultrasound patterns considered significant for community-acquired pneumonia). More methodologically rigorous studies are needed.

Conclusion (proposition de traduction) : L'échographie pulmonaire s'est révélée être un outil suffisamment utile et précis pour diagnostiquer la pneumopathie communautaire dans une population adulte au service des urgences.
Certaines inquiétudes ont été exprimées quant à la robustesse des résultats obtenus, en raison de l’absence de méthodologie bien standardisée dans les études incluses (en particulier sur le choix des étalons de référence, l’expérience du médecin échographe et les échographies considérées significatives pour pneumopathie communautaire). Des études méthodologiques plus rigoureuses sont nécessaires.

Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?.
Quinten VM, van Meurs M, Wolffensperger AE, Ter Maaten JC, Ligtenberg JJM. | Eur J Emerg Med. 2018 Oct;25(5):328-334
DOI: https://doi.org/10.1097/MEJ.0000000000000460
Keywords: Aucun

Original Articles

Introduction : The aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff.

Méthode : This was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records.

Résultats : We included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620).

Conclusion : Clinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of 'treat first what kills first' can be supplemented with 'judge first and calculate later'.

Conclusion (proposition de traduction) : Le jugement clinique est une méthode rapide et fiable de stratification entre l'admission aux soins intensifs et l'admission générale dans le service des urgences chez les patients en sepsis. Les scores PIRO et qSOFA n’ajoutent pas de valeur à cette stratification, mais donnent de meilleurs résultats sur la prédiction de la mortalité. Par conséquent, chez les patients présentant un sepsis, le principe de « traiter d'abord ce qui tue en premier » peut être complété par « juger d'abord et calculer plus tard ».

Prevalence and in-hospital outcome of aspiration in out-of-hospital intubated trauma patients.
Radu RR, Kaserer A, Seifert B, Simmen HP, Ruetzler K, Spahn DR, Neuhaus V. | Eur J Emerg Med. 2018 Oct;25(5):362-367
DOI: https://doi.org/10.1097/MEJ.0000000000000465
Keywords: aspiration, intubation, outcome, out-of-hospital, prevalence, trauma

Original articles

Introduction : The aim of this study was to evaluate the prevalence for aspiration in out-of-hospital intubated trauma patients and its impact on the in-hospital outcome.

Méthode : Medical records of out-of-hospital intubated trauma patients, admitted from 2009 to 2014 to a level 1 trauma center, were retrospectively reviewed. Patients younger than 18 years, treated with a supraglottic airway device, without a thorax computed tomography at admission, and with lung contusions were excluded. Two hundred and eighty-one patients were further analyzed. The definition of aspiration was based on computer tomographic findings at admission. Variables were analyzed in multivariate logistic and Cox regression analyses.

Résultats : Aspiration occurred in 90 (32%) patients. The mean Injury Severity Score was significantly higher in the aspiration group (40 ± 26 vs. 33 ± 22, P = 0.032), whereas the mean initial Glasgow Coma Scale (GCS) on scene was significantly lower (5 ± 3 vs. 7 ± 4, P < 0.001). In multivariate analysis, a lower initial GCS was a significant predictor for aspiration. Pneumonia, systemic inflammatory response syndrome, and sepsis occurred at similar frequencies. The 1-day (41 vs. 23%, P = 0.003) and the 30-day mortality (53 vs. 34%, P = 0.003) were significantly higher in the aspiration group. In survival analysis, a lower initial GCS, a higher Injury Severity Score, and older age were independent predictors of 30-day mortality, but not aspiration.

Conclusion : Aspiration was frequent in out-of-hospital intubated trauma patients and was associated with higher mortality and less favorable outcome, but was not an independent predictor of mortality and morbidity. However, a low initial GCS on scene was shown to be an independent predictor for aspiration and mortality.

Conclusion (proposition de traduction) : L'inhalation était fréquente chez les patients traumatisés intubés en extrahospitalier et était associée à une mortalité plus élevée et à des résultats moins favorables, mais n'était pas un facteur prédictif indépendant de mortalité et de morbidité. Cependant, une GCS initial faible sur les lieux s'est révélée être un prédicteur indépendant de l'inhalation et de la mortalité.

The superiority of the two-thumb over the two-finger technique for single-rescuer infant cardiopulmonary resuscitation.
Lee SY, Hong JY, Oh JH, Son SH. | Eur J Emerg Med. 2018 Oct;25(5):372-376
DOI: https://doi.org/10.1097/MEJ.0000000000000461
Keywords: Aucun

Original articles

Introduction : The two-finger technique (TFT) using the index-middle fingers of the right hand (TFT-R23) was recently confirmed to produce deeper chest compression depth (CCD) compared with the TFT using any other fingers. This study was carried out to confirm whether the TFT-R23 would be as effective as the two-thumb technique (TTT). In addition, individual finger strengths were measured to identify the reasons why the TTT and TFT-R23 produced deeper CCD than any other methods.

Méthode : This prospective randomized cross-over trial compared TTT with TFT-R23. A total of 37 doctors conducted 2 min single-rescuer cardiopulmonary resuscitation using TTT and TFT-R23 in a random order using a 3-month-old sized infant manikin laid on the floor. The chest compression to ventilation ratio was set to 15 : 2. In addition, finger strengths were measured using a pinch meter.

Résultats : The actual CCD of the TTT was significantly deeper than that of the TFT-R23 (41.3±1.3 vs. 39.8±1.5 mm, P<0.001). Although the hands-off time of the TTT was significantly longer than that of the TFT-R23 (55.6±5.7 vs. 53.6±5.8 s, P=0.002), the mean difference was only 2.0±3.7 s (95% confidence interval: 0.755-3.245). The finger strength of the TTT was significantly higher than that of TFT-R23 (23.8±10.1 vs. 13.7±5.1 kg, P<0.001).

Conclusion : The TTT produced deeper CCD compared with that of the TFT-R23 because the finger strength of the TTT was significantly higher than that of the TFT-R23.

Conclusion (proposition de traduction) : La technique à deux pouces produisait une profondeur de compression thoracique plus profonde que celle de la technique à deux doigts utilisant les doigts index-médians de la main droite car la force des doigts de la technique des deux pouces était significativement supérieure à celle de la technique à deux doigts utilisant les doigts index-médians de la main droit.

End tidal carbon dioxide monitoring in acute asthma: a prospective pilot study in emergency department patients.
Truchot J, Gayet AR, Philippon AL, Chauvin A, Malka J, Vicaut E, Plaisance P. | Eur J Emerg Med. 2018 Oct 22
DOI: https://doi.org/10.1097/MEJ.0000000000000581
Keywords: Aucun

Original Articles

Introduction : The peak expiratory flow rate (PEFR) is the gold standard for monitoring asthmatic patients. However, its measurement requires understanding and active participation. End tidal carbon dioxide (EtCO2) may be considered an accurate surrogate for PaCO2, a severity marker in acute asthma. We studied the use of EtCO2 as a monitoring tool in acute asthma.

Méthode : This was a prospective study that included consecutive patients admitted to our emergency department for acute asthma exacerbation. Data were collected at first medical contact (T0) and after 1 h of treatment (T60). The primary endpoint was the change in EtCO2; the secondary endpoints included changes in the EtCO2Q angle value, plateau T time, and change in EtCO2 values for the patients with a PEFR ratio less than 50% after treatment.

Résultats : Fifty-five patients were included and 36 waveforms were analysed. The mean age was 37 years and 26 (47%) were women. The median initial PEFR was 200 [interquartile range (IQR): 150-240]; the median EtCO2 at T0 and T60 was 35 (IQR: 30-38) and 34 (IQR: 29-37). There was no significant change in EtCO2 after treatment. There was no significant change in the Q angle and the T time after treatment. At T60, 20 (36%) patients had a PEFR ratio less than 50%. Change in EtCO2 from T60 to T0 was associated with a PEFR ratio less than 50%.

Conclusion : After 1 h of treatment, there was no significant change in EtCO2. A decrease in EtCO2 seems to be associated with a higher risk of PEFR ratio less than 50% after treatment.

Conclusion (proposition de traduction) : Après 1 heure de traitement, il n'y avait pas de changement significatif de EtCO2. Une diminution de l'EtCO2 semble être associée à un risque plus élevé de survenue d'un débit expiratoire de pointe inférieur à 50 % après le traitement.

Management of major bleeding and outcomes in patients treated with direct oral anticoagulants: results from the START-Event registry.
Testa S, Ageno W, Antonucci E, Morandini R, Beyer-Westendorf J, Paciaroni M, Righini M, Sivera P, Verhamme P, Pengo V, Poli D, Palareti G. | Intern Emerg Med. 2018 Oct;13(7):1051-1058
DOI: https://doi.org/10.1007/s11739-018-1877-z
Keywords: Aucun

IM - ORIGINAL

Editorial : The management of major bleeding in patients treated with direct oral anticoagulants (DOACs) is still not well established. START-Events, a branch of the START registry (Survey on anTicoagulated pAtients RegisTer) (NCT02219984), aims to describe the actual management of bleeding or recurrent thrombotic events in routine clinical practice. We here present the results of the management of bleeding patients. The START-Event registry is a prospective, observational, multicenter, international study. Baseline characteristics (demographic, clinical, risk factors) of patients, laboratory data at admission and during follow-up, site of bleeding, therapeutic strategies, and outcomes at the time of hospital discharge and after 6 months were recorded on a web-based case report form. Between January 2015 and December 2016, 117 patients with major bleeding events were enrolled. Non-valvular atrial fibrillation (NVAF) was the indication for treatment in 84% (62% males); 53 patients had intracranial bleeding (13 fatal), 42 had gastrointestinal bleeding (1 fatal), and 22 had bleeding in other sites. Therapeutic interventions for the management of bleeding were performed in 71% of patients. Therapeutic strategies with/without surgery or invasive procedures included: fluid replacement or red blood cells transfusion, prothrombin complex concentrates (3 or 4 factors), antifibrinolytic drugs, and the administration of idarucizumab. Creatinine, blood cell count, and PT/aPTT were the most frequent tests requested, while specific DOAC measurements were performed in 23% of patients. Mortality during hospitalization was 11.9%, at 6-month follow-up 15.5%. Our data confirm a high heterogeneity in the management of bleeding complications in patients treated with DOACs.

Conclusion : We believe this experience highlights the following needs: (1) homogeneous and more structured guidelines; (2) available reversal agents; (3) DOAC-specific measure- ments, rapidly available in emergency; (4) specific training on anticoagulation reversal for emergency department physi- cians; and (5) available consultants expert on thrombosis and haemostasis, who may ensure upgraded, homogeneous, and probably more effective management of acute major bleeding complications in anticoagulated patients.

Conclusion (proposition de traduction) : Nous pensons que cette expérience met en évidence les besoins suivants :
(1) des directives homogènes et plus structurées ;
(2) des agents de réversion ;
(3) des mesures spécifiques pour les patients traités avec des anticoagulants oraux directs, disponibles rapidement en cas d'urgence ;
4) une formation spécifique sur la réversion de l'anticoagulation pour les médecins des services d'urgence ;
et (5) des consultants experts disponibles en thrombose et hémostase, qui pourraient assurer une gestion améliorée, homogène et probablement plus efficace des complications hémorragiques aiguës chez les patients traités par anticoagulants.

Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists.
Cipriano A, Pecori A, Bionda AE, Bardini M, Frassi F, Leoli F, Lami V, Ghiadoni L, Santini M. | Intern Emerg Med. 2018 Oct;13(7):1077-1087
DOI: https://doi.org/10.1007/s11739-018-1806-1
Keywords: Anticoagulation; Direct oral anticoagulants; Intracranial hemorrhage; Mild traumatic brain injury

EM - ORIGINAL

Editorial : Prognosis after mild traumatic brain injury (MTBI) on oral anticoagulant therapy (OAT) is uncertain. We evaluated the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) and the safety of a clinical management protocol. In this single-center prospective observational study, we enrolled 220 patients on OAT with MTBI. After a first negative CT scan, asymptomatic patients underwent a close neurological observation; if neurologically stable, they were discharged without a second CT scan and followed up for 1 month. Out of the 220 patients, 206 met the inclusion criteria. 23 of them (11.2%) had a positive first CT scan for ICH. Only 1 (0.5%, 95% CI 0.0-1.4%) died because of ICH; no one required neurosurgical intervention. The observed prevalence rate of immediate ICH resulted statistically higher in VKAs-treated patients compared to those treated with DOACs (15.7 vs. 4.7%, RR 3.34, 95% CI 1.18-9.46, P < 0.05). In the 1-month follow-up, 5 out of the 183 patients with a negative CT scan were lost. Out of the remaining 178 patients, only 3 showed a delayed ICH (1.7%, 95% CI 0.0-3.6%), 1 of them died (0.6%, 95% CI 0.5-1.7%) and the others did not require neurosurgical intervention. DOACs resulted safer than VKAs also in the setting of MTBI. In our observation, the rate of delayed hemorrhage was relatively low. Patients presenting with a negative first CT scan and without neurological deterioration could be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan.

Conclusion : The observed prevalence rate of immediate intracranial hemorrhagic complications in patients on vitamin K antagonists suffering an mild traumatic brain injury is relatively high, as shown in previous stud- ies. The prevalence rate of intracranial hemorrhage in patients taking direct oral anticoagulants and suffering an mild traumatic brain injury is statistically lower compared to the one of patients taking vitamin K antagonists, despite the fact that the analysis cannot be controlled for clinical characteris- tics because of the very low rate observed in patients on direct oral anticoagulants. High-energy impact, evidence of trauma above the clavicles, simultaneous presence of fractures and the presence of post-traumatic amnesia are predictors of hemorrhagic complications. These factors could be more closely addressed in patients on oral anticoagulant therapy referring to ED for mild traumatic brain injury. This study identifies a very low incidence rate of delayed traumatic intracranial hemorrhage over 1 month from an mild traumatic brain injury in patients on oral anticoagulant therapy. These delayed intracranial hemorrhages are clinically rel- evant in only a very small percentage of patients. In the present study, patients on oral anticoagulant therapy suffering an mild traumatic brain injury and presenting a negative cranial CT scan at presentation underwent a 24-h clinical follow-up, and, if asymptomatic, were discharged home without being subjected to a second CT scan. This protocol has proven to be safe, with a very low rate of delayed complications.

Conclusion (proposition de traduction) : Le taux de prévalence observé de complications hémorragiques intracrâniennes immédiates chez les patients sous AVK présentant une lésion cérébrale traumatique légère est relativement élevé, comme le démontraient les études précédentes. Le taux de prévalence des hémorragies intracrâniennes chez les patients prenant des anticoagulants oraux directs et souffrant d'une lésion cérébrale traumatique légère est statistiquement inférieur à celui des patients prenant des antagonistes de la vitamine K, bien que l'analyse ne puisse pas être contrôlée pour les caractéristiques cliniques en raison de la très faible taux observé chez les patients sous anticoagulants oraux directs. Les impacts à haute énergie, la présence de traumatismes au-dessus des clavicules, la présence simultanée de fractures et la présence d'une amnésie post-critique sont des signes cliniques prédictifs de complications hémorragiques. Ces facteurs devaient conduire à pratiquer des examens plus poussés chez les patients sous anticoagulants oraux admis aux urgences pour lésion cérébrale traumatique légère.
Cette étude identifie un très faible taux d'incidence d'hémorragie intracrânienne traumatique retardée plus d'un mois après une lésion cérébrale traumatique légère chez des patients sous traitement anticoagulant oral. Ces hémorragies intracrâniennes retardées ne sont cliniquement pertinentes que dans un très faible pourcentage de patients.
Dans cette étude, les patients sous traitement anticoagulant oral, souffrant d'une lésion cérébrale traumatique légère et présentant une tomodensitométrie crânienne négative au moment de l'admission, ont fait l'objet d'un suivi clinique de 24 heures et, s'ils étaient asymptomatiques, ont été renvoyés à la maison sans bénéficier d'une seconde tomodensitométrie de contrôle. Ce protocole s'est avéré sûr, avec un très faible taux de complications retardées.

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial.
Birenbaum A, Birenbaum A, Hajage D, Roche S, Ntouba A, Eurin M, Cuvillon P, Rohn A, Compere V, Benhamou D, Biais M, Menut R, Benachi S, Lenfant F, Riou B. | JAMA Surg. 2018 Oct 17
DOI: https://doi.org/10.1001/jamasurg.2018.3577
Keywords: Aucun

Original Investigation

Introduction : The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial.
OBJECTIVE: To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed.
DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017).
INTERVENTIONS: Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group.

Méthode : Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure.

Résultats : Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group.

Conclusion : This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room.

Conclusion (proposition de traduction) : Cet essai clinique randomisé de grande envergure mené chez des patients soumis à une anesthésie par ISR n'a pas permis de démontrer la non-infériorité de la procédure factice dans la prévention de l'inhalation pulmonaire. Des études complémentaires sont nécessaires chez les femmes enceintes et en dehors de la salle d'opération.

Auvina S, Antonios M, Benoist G, Dommergues MA, Corrarde F, Gajdosg V, Gras Leguenhi C, Launay E, Salaünj A, Titomanlio J, L.Vallée L, Milh M. | JEUR. 2018 Oct;30(3):60-69
DOI: https://doi.org/10.1016/j.jeurea.2018.07.003
Keywords: Aucun

Republication

Introduction : Febrile seizures (FS) are the most common seizures seen in the paediatric populationin the out-of-hospital and emergency department settings, and they account for the majorityof seizures seen in children younger than 5 years old. An FS is a seizure accompanied by fever,without central nervous system infection, occurring in children between 6 months and 5 years old.Five criteria have been used and taught to classify any FS as simple or complex FS. These factors do not bear the same significance for clinical practice, in particular, the decision to perform alumbar puncture for cerebrospinal fluid analysis to rule out an intracranial infection. Moreover,epidemiological studies have illustrated that some factors are predictive of febrile seizure recur-rence while others are predictive of epilepsy occurrence.

Méthode : On this basis, a workshop was organizedto provide an answer to three clinical practice questions: when should a lumbar puncture beperformed in a child who has experienced a seizure during a fever episode, is the prescriptionof a rescue drug required with a risk of a prolonged febrile seizure recurrence, when should aneurological consultation be requested (risk of later epilepsy)? Based on a review of the literatureand on a 1-day workshop, we report here the conclusion of the working group.

Résultats : A lumbar punctureis required in any child with meningitis symptoms or septic signs or behaviour disturbance. A lum-bar puncture should be discussed based on the clinical symptoms and their progression over timewhen a child has experienced a focal FS or repetitive FSs without signs of meningitis or sepsis orbehaviour disturbance. The lumbar puncture is not necessary in case of simple FS without signsof meningitis, including in infants between 6 and 12 months old. An early clinical evaluation (atleast 4 h after the first clinical assessment) could be helpful, in particular in infants younger than12 months of age. A rescue drug might be prescribed when there is a high risk of prolonged FS(i.e., risk higher than 20 %): age at FS < 12 months OR a history of a previous febrile status epilep-ticus OR if the first FS was a focal seizure OR abnormal development/neurological exam/MRI OR afamily history of nonfebrile seizure. A neurological consultation should be requested for any childwho has experienced a prolonged FS before the age of 1 year, for children who have experiencedprolonged and focal FS or repetitive (within 24 h) focal FS, for children who have experiencedmultiple complex (focal or prolonged or repetitive) FS, for children with an abnormal neurolo-gical exam or abnormal development experiencing a FS.

Conclusion : Although childhood febrile seizures inmost cases are benign, witnessing such seizures is always a terrifying experience for the child’sparents. Most parents feel that their child is dying or could have severe brain injury related tothe episode.

Conclusion (proposition de traduction) : Bien que les crises fébriles de l’enfance dans la plupart des cas soient bénignes, le fait d’être témoin de telles crises est toujours une expérience terrifiante pour les parents de l’enfant. La plupart des parents pensent que leur enfant est en train de mourir ou pourrait avoir une lésion cérébrale grave liée à l'épisode.

Ravassea P, Jouffroy R. | JEUR. 2018 October;30(3):89-94
DOI: https://doi.org/10.1016/j.jeurea.2018.07.001
Keywords: Basic life supportEducationStudentGeneral practitionerFull-scale simulation

Article original

Introduction : Cardiac arrest (CA) is a public health priority and doctors are expected to be efficient in cardio-pulmonary resuscitation (CPR). In France, medical students must complete a mandatory basic life support (BLS) course during medical training. We aim to assess the main knowledge regarding last international CPR recommendations of the residents from Paris.

Méthode : A cross-sectional survey was conducted among 1699 French general practitioners (GP) residents.

Résultats : Six hundred and fifteen GP residents were included. Three hundred eight GP residents (50%) declared an exposition lower than 5 CA during their internship. Of them, 602 (98%) received education on BLS during medical training. Thirty-eight percent of residents never renew the training. Two hundred fifty-one GP residents (48%) declared that international recommendations are published every 5 years. Two hundred and ninety-seven (48%) declared that the ABC sequence must be preferred during BLS.

Conclusion : Last international recommendations concerning CPR are poorly known by French GP residents contrasting with a strong teaching and exposition to CA during the internship. Recycling on international recommendations concerning CPR seems to be necessary (knowledge) and completed by practical training using full-scale simulation (expertise) from the beginning of the internship. Improvement of knowledge and expertise of French GP residents from Paris by should improve care of cardiac arrest.

Conclusion (proposition de traduction) : La connaissance, par les internes de médecine générale de Paris Île-de-France, des points principaux des dernières recommandations internationales concernant la prise en charge de l’AC est insuffisante, contrastant avec une formation théorique dispensée à l’université et une confrontation non négligeable à l’AC au cours des stages hospitaliers. En adéquation avec les besoins ressentis des médecins généralistes de demain, une mise à jour des connaissances théoriques au cours du troisième cycle des études médicales (« savoir ») paraît nécessaire, complétée par une mise en pratique via la simulation sur mannequin (« savoir-faire »), et ce, dès le début de l’internat. La prise en charge de l’AC par les internes de médecine générale de Paris Île-de-France devrait être possible par une amélioration du savoir et du savoir-faire.

Lapostolle F, Laghmari N, Reuter PG, Akodad H, Adnet F. | JEUR. 2018 October;30(3):103-105
DOI: https://doi.org/10.1016/j.jeurea.2017.06.002
Keywords: PacemakerAlarmeUrgencesSamu

Republication

Introduction : More than 60,000 pacemakers are inserted every year in France. This number has been steadily increasing for a decade. Miscellaneous incidents can lead patients with pacemakers or their relatives to contact emergency services. Following the call to the SAMU-Center 15 of a asymptomatic 90-year-old woman reported that her pacemaker was making “beep-beep”, we assessed the knowledge of physicians of the SAMU-Center 15 (call center) dispatching center on the existence of pacemaker sound alarms.

Méthode : Forty-two physicians, emergency physicians and general practitioners, regularly participating in the medical dispatching of the SAMU-Center 15 in Seine-Seine-Denis were interviewed. We asked them how a patient with a pacemaker could be informed of a malfunction of it without being symptomatic.

Résultats : No physician interviewed mentioned an audible alarm. All of them confirmed their ignorance of its existence. One physician had already been asked for a similar reason and had referred the patient to the emergency department without knowing it was an alarm.

Conclusion : Patients and physicians seem insufficiently aware of the existence of the existence of pacemakers’ sound alarm. An effort must be made regarding the information on the existence of such an alarm and the way to managed it.

Conclusion (proposition de traduction) : Patients et médecins semblent insuffisamment informés de l’existence d’une alarme sonore dans les pacemakers. Un effort doit être fait pour que l’existence d’une telle alarme et la conduite à tenir lors de son déclenchement soit connues des patients et des médecins amenés à les prendre en charge.

Maurice-Szamburski A | Prat Anesth Reanim. 2018 October;22(5):257-263
DOI: https://doi.org/10.1016/j.pratan.2018.08.006
Keywords: Multimodal analgesia; Postoperative analgesia; Non steroidal anti-inflammatory drugs; Gabapentinoids; Opioids

Mise au point

Editorial : L’analgésie multimodale est un concept établi qui postule que l’association d’antalgiques augmente leur efficacité et permet de limier leurs effets secondaires. L’évolution actuelle consiste à limiter l’usage des opiacés sous la pression du risque d’addiction documenté dans la population nord-américaine du fait d’une prescription extra hospitalière trop libérale. L’administration conjointe de gabapentinoides n’a pas fait la preuve de son efficacité et provoque également des effets secondaires. Les anti-inflammatoires non stéroïdiens ont un effet d’épargne morphinique significatif. Les effets secondaires qui ont été discutés tels que l’insuffisance rénale aiguë ou les désunions d’anastomose digestive ainsi que la majoration du saignement périopératoire ne sont pas établis solidement et ne contre-indiquent pas leur prescription.

Conclusion (proposition de traduction) : L’analgésie multimodale est devenue la modalité dominante de la prise en charge postopératoire de la douleur. Son inté- gration dans une prise en charge globale de réhabilitation aux côtés de techniques d’anesthésie locorégionales per- met de réduire la consommation d’opioïde, de diminuer les complications respiratoires et digestives ainsi que les durées d’hospitalisations

Langlais E, Ecoffey C. | Prat Anesth Réanim. 2018 October;22(5):269-274
DOI: https://doi.org/10.1016/j.pratan.2018.08.002
Keywords: Sedation; Paediatric anaesthesia; Invasive procedures

Mise au point

Editorial : Une sédation est de plus en plus fréquemment requise pour effectuer des gestes interventionnels chez l’enfant. Cette pratique implique la réalisation d’une consultation anesthésique au préalable. Les moyens non pharmacologiques de la sédation (hypnose) ont un fort impact sur la qualité de la sédation et du confort de l’enfant. Les avantages et les effets secondaires des agents sédatifs (kétamine, propofol, protoxyde d’azote) sont discutés.

Conclusion (proposition de traduction) : La prise en charge de l’enfant pour un acte intervention- nel est donc un challenge pour lequel nous devons nous aider des moyens pharmacologiques dont dispose le méde- cin anesthésiste-réanimateur, mais également des moyens non pharmacologiques, et ce en particulier pour les enfants très anxieux : langage adapté, techniques de communica- tion thérapeutique, hypnose, sont des alternatives à ne pas négliger car elles nous permettront de réduire, voire de supprimer la médication. Même si ces actes interventionnels ne sont en géné- ral pas réalisés dans le bloc opératoire, il faut souligner l’importance d’une véritable évaluation pré-anesthésique préalable, de la présence de professionnels formés à la prise en charge des urgences vitales en pédiatrie et d’un équipe- ment minimal pour réaliser ces actes en toute sécurité.

Do All Clavicle Fractures in Children Need To Be Managed by Orthopedic Surgeons?.
Adamich J, Howard A, Camp M. | Pediatr Emerg Care. 2018 Oct;34(10):706-710
DOI: https://doi.org/10.1097/PEC.0000000000001269
Keywords: Aucun

Original Articles

Introduction : Although many uncomplicated pediatric fractures do not require routine long-term follow-up with an orthopedic surgeon, practitioners with limited experience dealing with pediatric fractures will often defer to a strategy of frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the health care system.

Méthode : A retrospective analysis including patients who presented to the Hospital for Sick Children (SickKids) for management of clavicle fractures was performed.

Résultats : Three hundred forty patients (227 males, 113 females) with an average age of 8.1 years (range, 0.1-17.8) were included in the study. The mean number of clinic visits including initial consultation in the emergency department was 2.1 (1.3). The mean number of radiology department appointments was 1.8 (1.3), where patients received a mean number of 4.2 (3.0) radiographs. Complications were minimal: 2 refractures in our series and no known cases of nonunion. All patients achieved clinical and radiographic union and returned to sport after fracture healing.

Conclusion : Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary care physician, then routine clinical or radiographic follow-up is unnecessary. Our pediatric clavicle fracture pathway will reduce patient radiation exposure and reduce costs incurred by the health care system and patients' families without jeopardizing patient outcomes.

Conclusion (proposition de traduction) : Notre série suggère que la décision de traiter de manière opératoire est prise lors de l'évaluation initiale. Si aucune indication chirurgicale n'était posée lors de l'évaluation initiale par le médecin de premier recours, un suivi clinique ou radiographique de routine est alors inutile.
Notre trajectoire de fracture de la clavicule chez les enfants réduira l'exposition des patients au rayonnement et les coûts supportés par le système de santé et les familles des patients sans compromettre les résultats pour les patients.

Prehospital Invasive Arterial Pressure: Use of a Minimized Flush System.
Karlsson J, Linde J, Svensen C, Gellerfors M. | Prehosp Disaster Med. 2018 Oct;33(5):490-494
DOI: https://doi.org/10.1017/S1049023X18000729
Keywords: DBP diastolic blood pressure; IBP invasive blood pressure; MAP mean arterial pressure; NS normal saline; SBP systolic blood pressure; mIBP minimized flush system IBP; sIBP standard IBP; arterial line; flush; invasive blood pressure; prehospital

Original Research

Introduction : Invasive blood pressure (IBP) monitoring could be of benefit for certain prehospital patient groups such as trauma and cardiac arrest patients. However, there are disadvantages with using conventional IBP devices. These include time to prepare the transducer kit and flush system as well as the addition of long tubing connected to the patient. It has been suggested to simplify the IBP equipment by replacing the continuous flush system with a syringe and a short stopcock.HypothesisIn this study, blood pressures measured by a standard IBP (sIBP) transducer kit with continuous flush was compared to a transducer kit connected to a simplified and minimized flush system IBP (mIBP) using only a syringe.

Méthode : A mechanical, experimental model was used to create arterial pressure pulsations. Measurements were made simultaneously using a sIBP and mIBP device, respectively. This was repeated four times using different mean arterial pressure (MAP): 40, 70, 110, and 140mm Hg. For each series, 16 measurements were taken during 20 minutes. Data were analyzed using Bland-Altman plots. Measurement error greater than five percent was regarded as clinically significant.

Résultats : Mean bias and standard deviation (SD) for systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP was -3.05 (SD = 2.07), 0.2 (SD = 0.48), and -0.3 (SD = 0.55) mmHg, respectively. Bland-Altman plots revealed that the bias and SD for systolic pressures was mainly due to an increased under-estimation of pressures in lower ranges. All MAP and 98.4% of diastolic pressure measurements had an error of less than five percent. Systolic pressures in the MAP 40 series all had an error of greater than five percent. All other systolic pressures had an error of less than five percent.

Conclusion : Thus, IBP with the mIBP flush system provides accurate measurement of MAP and DBP in a wide range of physiological pressures. For SBP, there was a tendency to under-estimate pressures, with larger error in lower pressures. Implementation of a simplified flush system could allow further development and potentially simplify the use of IBP for prehospital critical care teams.

Conclusion (proposition de traduction) : Ainsi, la pression artérielle invasive avec le système de rinçage à pression artérielle invasive minimisée permet une mesure précise de la pression artérielle moyenne et de la pression artérielle diastolique dans une large gamme de pressions physiologiques. Pour la pression artérielle systolique, il y avait une tendance à sous-estimer les pressions, avec une erreur plus grande dans les pressions plus basses. La mise en place d'un système de rinçage simplifié pourrait permettre un développement plus poussé et potentiellement simplifier l'utilisation de la pression artérielle invasive pour les équipes de soins intensifs préhospitaliers.

Extracorporeal cardiopulmonary resuscitation for cardiac arrest: A systematic review.
Holmberg MJ, Geri G, Wiberg S, Guerguerian AM, Donnino MW, Nolan JP, Deakin CD, Andersen LW; International Liaison Committee on Resuscitation’s (ILCOR) Advanced Life Support and Pediatric . | Resuscitation. 2018 Oct;131:91-100
DOI: https://doi.org/10.1016/j.resuscitation.2018.07.029  | Télécharger l'article au format  
Keywords: Cardiac arrest; ECPR; Extracorporeal cardiopulmonary resuscitation

Reviews

Introduction : To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in adults and children.

Méthode : The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.

Résultats : We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.

Conclusion : There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.

Conclusion (proposition de traduction) : Il n’existe pas de preuves concluantes permettant d’appuyer ou de réfuter l’utilisation de l'ECPR dans l’arrêt cardiaque extra et intra-hospitalier chez les adultes et les enfants. La qualité des preuves dans les études est très faible.

Traumatic cardiac arrest is associated with lower survival rate vs. medical cardiac arrest - Results from the French national registry.
Escutnaire J, Genin M, Babykina E, Dumont C, Javaudin F, Baert V, Mols P, Gräsner JT, Wiel E, Gueugniaud PY, Tazarourte K, Hubert H; on behalf GR-RéAC. | Resuscitation. 2018 Oct;131:48-54
DOI: https://doi.org/10.1016/j.resuscitation.2018.07.032
Keywords: Guidelines; Outcome; Propensity model; Resuscitation; Traumatic cardiac arrest

Clinical Papers

Introduction : The survival from traumatic vs. medical out-of-hospital cardiac arrest (OHCA) are not yet well described. The objective of this study was to compare survival to hospital discharge and 30-day survival of non-matched and matched traumatic and medical OHCA cohorts.

Méthode : National case-control, multicentre study based on the French national cardiac arrest registry. Following descriptive analysis, we compared survival rates of traumatic and medical cardiac arrest patients after propensity score matching.

Résultats : Compared with medical OHCA (n = 40,878) trauma victims (n = 3209) were younger, more likely to be male and away from home at the time and less likely to be resuscitated. At hospital admission and at 30 days their survival odds were lower (OR: respectively 0.456 [0.353;0.558] and 0.240 [0.186;0.329]). After adjustment the survival odds for traumatic OHCA were 2.4 times lower at admission (OR: 0.416 [0.359;0.482]) and 6 times lower at day 30 (OR: 0.168 [0.117;0.241]).

Conclusion : The survival rates for traumatic OHCA were lower than for medical OHCA, with wider difference in matched vs. non-matched cohorts. Although the probability of survival is lower for trauma victims, the efforts are not futile and pre-hospital resuscitation efforts seem worthwhile.

Conclusion (proposition de traduction) : Les taux de survie des arrêt cardiaque extra-hospitaliers traumatiques étaient inférieurs à ceux des arrêt cardiaque extra-hospitaliers médicaux, avec une différence plus grande entre les cohortes appariées et non appariées. Bien que la probabilité de survie soit moindre pour les victimes de traumatismes, les efforts ne sont pas vains et les efforts de réanimation pré-hospitalière semblent valoir la peine.

Acute kidney injury after out of hospital pediatric cardiac arrest.
Cornell TT, elewski DT, Alten JA, Askenazi D, Fitzgerald JC, Topjian A, Holubkov R, Page K, Slomine BS, Christensen JR, Dean JM, Moler FW. | Resuscitation. 2018 Oct;131:63-68
DOI: https://doi.org/10.1016/j.resuscitation.2018.07.362  | Télécharger l'article au format  
Keywords: Acute kidney injury; Neurologic outcomes; Post-cardiac arrest; Therapeutic hypothermia

Clinical papers

Introduction :  IMPORTANCE : Many children with return of spontaneous circulation (ROSC) following cardiac arrest (CA) experience acute kidney injury (AKI). The impact of therapeutic hypothermia on the epidemiology of post-CA AKI in children has not been fully investigated.
OBJECTIVE : The study aims were to: 1) describe the prevalence of severe AKI in comatose children following out-of-hospital CA (OHCA), 2) identify risk factors for severe AKI, 3) evaluate the impact of therapeutic hypothermia on the prevalence of severe AKI, and 4) evaluate the association of severe AKI with survival and functional outcomes.

Méthode :  DESIGN: A post hoc secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial.
titreSETTING_en_plus: Thirty-six pediatric intensive care units in the United States and Canada.
PARTICIPANTS: Of 282 eligible subjects with an initial creatinine obtained within 24 h of randomization, 148 were randomized to therapeutic hypothermia and 134 were randomized to therapeutic normothermia. MAIN OUTCOMES AND MEASURES: Primary outcome was prevalence of severe AKI, as defined by stage 2 and 3 Kidney Disease Improving Global Outcomes (KDIGO) consensus definition; secondary outcome was survival with a favorable neurobehavioral outcome. For this study, risk factors and outcomes were compared between those with/without severe AKI.

Résultats : Of the 282 subjects enrolled, 180 (64%) developed AKI of which 117 (41% of all enrolled) developed severe AKI. Multivariable modeling found younger age, longer duration of chest compressions, higher lactate level at time of temperature intervention and higher number of vasoactive agents through day 1 of intervention associated with severe AKI. There was no difference in severe AKI between therapeutic hypothermia (39.9%) and therapeutic normothermia (43.3%) groups (p = 0.629). Survival was lower in those with severe AKI at 28 days (21% vs no severe AKI 49%, p < 0.001) and 12 months (21% vs no severe AKI 42%, p < 0.001). One year survival with favorable functional outcome was lower in those with severe AKI.

Conclusion : Severe AKI occurs frequently in children with ROSC after OHCA, especially in younger children and those with higher initial lactates and hemodynamic support. Severe AKI was associated with worse survival and functional outcome. Therapeutic hypothermia did not reduce the incidence of severe AKI.

Conclusion (proposition de traduction) : Les lésions rénales aiguës sévères surviennent fréquemment chez les enfants avec retour de la circulation spontanée après un arrêt cardiaque hors de l'hôpital, en particulier chez les enfants plus jeunes et chez ceux ayant un taux initial élevé de lactates et un soutien hémodynamique. Une lésion rénale aiguë sévère était associée à une survie et à un résultat fonctionnel inférieurs. L’hypothermie thérapeutique n’a pas réduit l’incidence des lésions rénales aiguës graves.

mplementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks.
Clattenburg EJ, Wroe PC, Gardner K, Schultz C, Gelber J, Singh A, Nagdev A. | Resuscitation. 2018 Oct;131:69-73
DOI: https://doi.org/10.1016/j.resuscitation.2018.07.030
Keywords: Cardiopulmonary resuscitation; Point-of-care ultrasound

Clinical papers

Introduction : We aim to evaluate whether implementation of the "Cardiac Arrest Sonographic Assessment" (CASA) protocol reduces the duration of interruptions in CPR during resuscitation of cardiac arrest (CA) compared to the pre-intervention period.

Méthode : his was a quasi-experimental pre and post intervention study completed over 19 months in an urban Emergency Department. CA resuscitations were filmed and analyzed with respect to pulse check duration and use of point-of-care ultrasound (POCUS). After one year, an intervention was implemented: ED residents and faculty were taught the CASA protocol and instructed on how to implement it within CA resuscitation. The primary outcome was the difference in CPR pulse check duration between the pre and post intervention period. Videos from pre and post intervention CA resuscitations were coded by two reviewers.

Résultats : Data was collected prospectively for 267 sequential cardiac arrests. 38 pre-intervention and 45 post-intervention resuscitations were videoed and included in analysis. Both groups had a median of 3 pulse checks and 2 POCUS exams performed per code. CPR pulse checks involving POCUS exams were 4.0 s (95%CI 1.7-6.3) shorter in the post-intervention group than in the pre-intervention group. CPR pause durations were 3.1 s (95%CI 0.7-5.6) shorter when the ultrasound probe was placed on the chest before stopping CPR compared to placement after stopping CPR, and 3.1 s (95%CI 0.6-5.6) shorter when an ED ultrasound fellowship trained faculty was present compared to non-ultrasound fellowship faculty. The proportion of pulse checks with ultrasound use increased from 64% before the intervention to 80% after the intervention.

Conclusion : In this pre and post-intervention study, the implementation of a structured algorithm for ultrasound use during cardiac arrest significantly reduced the duration of CPR interruptions when ultrasound was performed.

Conclusion (proposition de traduction) : Dans cette étude avant et après intervention, la mise en œuvre d'un algorithme structuré pour l'utilisation de l'échographie dans l'arrêt cardiaque réduisait de manière significative la durée des interruptions de la RCP avec l'échographie.

Electro-clinical characteristics and prognostic significance of post anoxic myoclonus.
Dhakar MB, Sivaraju A, Maciel CB, Youn TS, Gaspard N, Greer DM, Hirsch LJ, Gilmore EJ. | Resuscitation. 2018 Oct;131:114-120
DOI: https://doi.org/10.1016/j.resuscitation.2018.06.030
Keywords: Cardiac arrest; EEG; Heart arrest; Myoclonic status; Myoclonus; Post anoxic; Status epilepticus

Clinical papers

Introduction : To systematically examine the electro-clinical characteristics of post anoxic myoclonus (PAM) and their prognostic implications in comatose cardiac arrest (CA) survivors.

Méthode : Fifty-nine CA survivors who developed myoclonus within 72 h of arrest and underwent continuous EEG monitoring were included in the study. Retrospective chart review was performed for all relevant clinical variables including time of PAM onset ("early onset" when within 24 h) and semiology (multi-focal, facial/ocular, whole body and limbs only). EEG findings including background, reactivity, epileptiform patterns and EEG correlate to myoclonus were reviewed at 6, 12, 24, 48 and 72 h after the return of spontaneous circulation (ROSC). Outcome was categorized as either with recovery of consciousness (Cerebral Performance Category (CPC) 1-3) or without recovery of consciousness (CPC 4-5) at the time of discharge.

Résultats : Seven of the 59 patients (11.9%) regained consciousness, including 6/51 (11.8%) with early onset PAM. Patients with recovery of consciousness had shorter time to ROSC, and were more likely to have preserved brainstem reflexes and normal voltage background at all times. No patient with suppression burst or low voltage background (N = 52) at any point regained consciousness. In the subset where precise electro-clinical correlation was possible, all (5/5) those with recovery of consciousness had multi-focal myoclonus and most (4/5) had midline-maximal spikes over a continuous background. No patient with any other semiology (N = 21) regained consciousness.

Conclusion : Early onset PAM is not always associated with lack of recovery of consciousness. EEG can help discriminate between patients who may or may not regain consciousness by the time of hospital discharge.

Conclusion (proposition de traduction) : Les myoclonies post-anoxiques précoces ne sont pas toujours associées au manque de récupération de la conscience. L'EEG peut aider à faire la distinction entre les patients qui peuvent ou non reprendre conscience au moment de leur sortie de l'hôpital.

Standardized model of porcine resuscitation using a custom-made resuscitation board results in optimal hemodynamic management.
Wollborn J, Ruetten E, Schlueter B, Haberstroh J, Goebel U, Schick MA. | Am J Emerg Med. 2018 Oct;36(10):1738-1744
DOI: https://doi.org/10.1016/j.ajem.2018.01.059
Keywords: Advanced cardiac life support; Cardiac arrest; Cardiopulmonary resuscitation; Hemodynamics; Swine

Original Contribution

Introduction : Standardized modeling of cardiac arrest and cardiopulmonary resuscitation (CPR) is crucial to evaluate new treatment options. Experimental porcine models are ideal, closely mimicking human-like physiology. However, anteroposterior chest diameter differs significantly, being larger in pigs and thus poses a challenge to achieve adequate perfusion pressures and consequently hemodynamics during CPR, which are commonly achieved during human resuscitation. The aim was to prove that standardized resuscitation is feasible and renders adequate hemodynamics and perfusion in pigs, using a specifically designed resuscitation board for a pneumatic chest compression device.

Méthode : A "porcine-fit" resuscitation board was designed for our experiments to optimally use a pneumatic compression device (LUCAS® II, Physio-Control Inc.), which is widely employed in emergency medicine and ideal in an experimental setting due to its high standardization. Asphyxial cardiac arrest was induced in 10 German hybrid landrace pigs and cardiopulmonary resuscitation was performed according to ERC/AHA 2015 guidelines with mechanical chest compressions. Hemodynamics were measured in the carotid and pulmonary artery. Furthermore, arterial blood gas was drawn to assess oxygenation and tissue perfusion.

Résultats : The custom-designed resuscitation board in combination with the LUCAS® device demonstrated highly sufficient performance regarding hemodynamics during CPR (mean arterial blood pressure, MAP 46 ± 1 mmHg and mean pulmonary artery pressure, mPAP of 36 ± 1 mmHg over the course of CPR). MAP returned to baseline values at 2 h after ROSC (80 ± 4 mmHg), requiring moderate doses of vasopressors. Furthermore, stroke volume and contractility were analyzed using pulse contour analysis (106 ± 3 ml and 1097 ± 22 mmHg/s during CPR). Blood gas analysis revealed CPR-typical changes, normalizing in the due course. Thermodilution parameters did not show persistent intravascular volume shift.

Conclusion : Standardized cardiopulmonary resuscitation is feasible in a porcine model, achieving adequate hemodynamics and consecutive tissue perfusion of consistent quality.

Conclusion (proposition de traduction) : La réanimation cardiopulmonaire standardisée est réalisable dans un modèle porcin, permettant d'obtenir une hémodynamique adéquate et une perfusion tissulaire consécutive de qualité constante.

Emergency department sepsis screening tool decreases time to antibiotics in patients with sepsis.
Shah T, Sterk E, Rech MA. | Am J Emerg Med. 2018 Oct;36(10):1745-1748
DOI: https://doi.org/10.1016/j.ajem.2018.01.060
Keywords: Antibiotics; Bundle compliance; Emergency medicine management; Fluid resuscitation; Sepsis

Original contribution

Introduction : Recent literature has highlighted the importance of early identification and treatment of sepsis; however, limited data exists to help recognize sepsis in the emergency department (ED) through use of a screening tool. The purpose of this study was to evaluate the impact of a sepsis screening tool implemented in an academic medical center ED on compliance with the 3-hour sepsis bundle.

Méthode : This was a retrospective cohort study that included a total of 115 patients, of which 58 were in the pre-tool group and 57 were in the post-toolgroup.

Résultats : There was no difference in 3-hour bundle compliance between groups (36.2% vs. 47.4%, P = 0.26). There was no difference in the following bundle components: lactate (79.3% vs. 80.7%, P = 0.85), blood cultures (86.2% vs. 96.5%, P = 0.09), blood cultures before administering antibiotics (91.4% vs. 100%, P = 0.57) and adequate fluids administration (44.7% vs. 41.9%, P = 0.820). A significantly higher number of patients received antibiotics within 3 h in the post-tool group (58.6% vs. 89.5%, P < 0.001). Statistically significant secondary outcomes included average time to antibiotics (P = 0.04), administering antibiotics within an hour (P > 0.001), and ICU length of stay (P = 0.03). There was no difference in 30-day mortality, however mortality was numerically lower in the post-tool group (36.2% vs. 26.3%, P = 0.25).

Conclusion : Although implementation of an ED sepsis screening tool did not increase 3-hour bundle compliance, it did increase the proportion of patients receiving timely antimicrobial therapy and demonstrated a trend towards decreased mortality.

Conclusion (proposition de traduction) : Bien que la mise en œuvre d'un outil de dépistage de la septicémie aux urgences n'ait pas permis d'augmenter le taux de conformité au processus de soins des traitements de 3 heures, elle a augmenté la proportion de patients recevant un traitement antibiotique en temps opportun et a montré une tendance à la baisse sur la mortalité.

Fluid resuscitation in pre-hospital management of septic shock.
Jouffroy R, Saade A, Muret A, Philippe P, Michaloux M, Carli P, Vivien B. | Am J Emerg Med. 2018 Oct;36(10):1754-1758
DOI: https://doi.org/10.1016/j.ajem.2018.01.078
Keywords: Aucun

Original contribution

Editorial : The estimated incidence of sepsis is approximately 300 per 100,000 inhabitants [1,2], making sepsis a major public health problem, with a mortality rate reaching 30% at day 28 (D28) [1,3-5]. The outcome of sep- tic patients relies on the early identification and rapid implementation of appropriate treatments, including hemodynamic optimization and antibiotics administration [3,6]. Hemodynamic failure is frequently en- countered in most severe forms of sepsis and often has to be initially managed in a pre-hospital setting. Hypotension and its consequences, i.e. neurological failure and/or weakness, are the most common symp- toms for people to call emergency services. In France, out-of-hospital emergencies are managed by the Service d'Aide Médicale d'Urgence (SAMU) [7]. For medical assistance, the SAMU can be reached dialling the number 15. The SAMU hospital-based team is composed of switch- board operators and physicians. Over the phone, the SAMU determine the appropriate level of care to dispatch to the scene, based on patient's symptoms communicated by the patient itself, by a relative or any wit- ness. For life-threatening emergencies, the “Service Mobile d'Urgence et de Réanimation” (SMUR), a mobile intensive care unit (MICU), is dispatched to the scene. The MICU is composed of a driver, a nurse and an emergency physician [7]. MICU is equipped with medical devices and drugs allowing initial management of main organs deficiency (neu- rological, respiratory and cardiovascular). The first step in hemodynamic resuscitation relies on early fluid ex- pansion that has to be administered within the first hour [8]. In a lot of sit- uations, fluid resuscitation is initiated in a pre-hospital setting. The benefit of early fluid expansion is described in the management of trauma [9,10] as in septic shock and associated with a hospital mortality decrease [11]. The aim of this study was to describe qualitative and quantitative fluid resuscitation in patients with septic shock managed by MICU in a pre-hospital setting and its adequacy with recommendations [8] to evaluate its impact on mortality at D28.

Résultats : No significant difference was observed in the duration of pre-hospital medical care between alive and deceased patients (101 ± 34 min vs 93 ± 34 min respectively, p = 0.29). Pre-hospital fluid expansion was performed using crystalloids, e.g. serum saline in 98% of the cases. Mean pre-hospital fluid expansion was 1158 ± 559 ml in the overall population and reached 1287 ± 553 ml vs 906 ± 487 ml in alive and deceased patients respectively (p = 0.001) Mean pre-hospital fluid expansion indexed on body weight was 18 ± 11 ml/ kg in the overall population and 20 ± 10 ml/kg vs 16 ± 12 ml/kg in alive and deceased patients respectively (p = 0.09). Mean pre-hospital fluid expansion indexed on ideal body weight was 18 ± 9 ml/ kg in the overall population, 20 ± 9 ml/kg in alive and 15 ± 8 ml/kg in deceased patients (p = 0.005). The area under the average ROC curve [95% CI] for pre-hospital fluid expansion and pre-hospital fluid expansion indexed on ideal body weight were respectively of 0.70 [0.58–0.81] and 0.67 [0.55–0.78]. Visual subjective analysis of pre-specified categories (< 10, 10–20 and 20 ml/kg fluid expansion indexed on ideal body weight) showed an inversed linear association between fluid expansion indexed on ideal body weight and mortality. Absolute values (A) and proportion (B) of patients in the predefined categories of pre-hospital fluid volume expansion indexed on ideal body weight. Black plot represents deceased patients and white plot alive patients. In univariate analysis, mortality was significantly association with fluid expansion: p = 0.002, OR [95% CI] = 0.998 [0.997–0.999], fluid expansion indexed on ideal body weight: p = 0.007, OR [95% CI] = 0.93 [0.88–0.97], fluid expansion indexed on ideal body weight < 10 p = 0.003, OR [95% CI] = 4.17 [1.89–9.43] and fluid expansion indexed on IBW > 20: p = 0.006, OR [95% CI] = 0.27 [0.12–0.57] (Table 3). No significant association was observed between mortality and fluid expansion indexed on IBM between 10 and 20 ml/kg: p = 0,91, OR [95% CI] = 1.06 [0.47–2.33]. Using logistic regression model, including age, immunosuppression, pre-hospital duration as covariables, association with mortality only remained significant for fluid expansion indexed on IBW: p = 0.02, ORa [95% CI] = 0.93 [0.89–0.98], fluid expansion indexed on ideal body weight < 10 p = 0.005, OR [95% CI] = 4.03 [1.78–9.41] and fluid expansion indexed on ideal body weight > 20: p = 0.01, OR [95% CI] = 0.30 [0.13–0.66

Discussion : Our study is retrospective, monocentric and small sample sized. A sorting bias might exist as data were retrospectively collected from pre-hospital and ICU medical reports. The study was not designed to determine the optimal threshold for fluid volume expansion indexed on IBW. In our work, we report a relationship between mortality and fluid volume expansion indexed on IBW. However, our study does not provide adequate evidence that a causal link between mortality and fluid volume expansion exists in a pre-hospital setting. As previously described by others, we also report the ‘grey zone’ which reinforces the need for further studies designed to precisely define accurate guideline for pre-hospital management of fluid resuscitation in sepsis. Actually, pre-hospital fluid expansion is mostly studied for trauma patients. Yet, studies concerning the management of septic shock in pre-hospital setting remain scarce.

Conclusion : In this study, we observed that fluid resuscitation in septic shock managed by pre-hospital medical care teams, is mainly performed using crystalloids with lower fluid volume expansion than recommended. There is an association between low fluid expansion and mortality underling the importance of optimal initial management in prehospital settings.

Conclusion (proposition de traduction) : Dans cette étude, nous avons observé que la réanimation liquidienne dans le choc septique, gérée par des équipes de soins médicaux pré-hospitaliers, est principalement réalisée à l'aide de cristalloïdes avec une expansion de volume liquidienne inférieure à celle recommandée.
Il existe un lien entre une faible expansion liquidienne et la mortalité, ce qui souligne l’importance d’une gestion initiale optimale en milieu préhospitalier.

Propofol-fentanyl versus propofol-ketamine for procedural sedation and analgesia in patients with trauma.
Aminiahidashti H, Shafiee S, Hosseininejad SM, Firouzian A, Barzegarnejad A, Kiasari AZ, Kerigh BF, Bozorgi F, Shafizad M, Geraeeli A. | Am J Emerg Med. 2018 Oct;36(10):1766-1770
DOI: https://doi.org/10.1016/j.ajem.2018.01.080
Keywords: Emergency department; Fentanyl; Ketamine; Procedural sedation and analgesia; Propofol

Original contribution

Introduction : Many procedures performed in emergency department are stressful and painful, and creating proper and timely analgesia and early and effective assessment are the challenges in this department. This study has been conducted in order to compare the efficacy of propofol and fentanyl combination with propofol and ketamine combination for procedural sedation and analgesia (PSA) in trauma patients in the emergency department.

Méthode : This is a randomized prospective double-blind clinical trial conducted in the emergency department of Imam Khomeini Hospital, a tertiary academic trauma center in northern Iran. Patients with trauma presenting to the emergency department who needed PSA were included in study. Patients were divided into two groups of propofol fentanyl (PF) and propofol ketamine (PK). Pain score and sedation depth were set as primary outcome measures and were recorded.

Résultats : Out of about 379 patients with trauma, who needed PSA, 253 met the criteria to be included in the study, 117 of which were excluded. The remaining 136 patients were randomly allocated to either PF group (n = 70) or PK group (n = 66). Pain management after drug administration was significantly different between the groups and the analgesia caused by fentanyl was significantly higher than ketamine. The sedation score after 15 min of PSA in the group PF was significantly higher than the group PK.

Conclusion : It seems that regarding PSA in the emergency department, PF caused better analgesia and deeper sedation and it is recommended to use PF for PSA in the emergency departments.

Conclusion (proposition de traduction) : En ce qui concerne la sédation et l'analgésie procédurales au service des urgences, le fentanyl/propofol a procuré une meilleure analgésie et une sédation plus profonde. Il est recommandé d'utiliser le fentanyl/propofol pour la sédation et l'analgésie procédurales aux services d'urgence.

The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction.
Noll S, Alvey H, Jayaprakash N, Paranjpe A, Miller J, Moyer ML, Nowak R. | Am J Emerg Med. 2018 Oct;36(10):1771-1774
DOI: https://doi.org/10.1016/j.ajem.2018.01.083
Keywords: Cost-effectiveness; Electrocardiography; STEMI; Triage

Original contribution

Introduction : Current AHA/ACC guidelines on the management of ST-elevation myocardial infarction (STEMI) suggest that an ECG is indicated within 10minutes of arrival for patients arriving to the Emergency Department (ED) with symptoms concerning for STEMI. In response, there has been a creep towards performing ECGs more frequently in triage. The objectives of this study were to quantify the number of triage ECGs performed at our institution, assess the proportion of ECGs performed within current hospital guidelines, and evaluate the rate of STEMI detection in triage ECGs.

Méthode : A retrospective chart review of all emergency department patients presenting over a period of 8days who had a triage ECG performed. Cases of bradycardia or tachycardia were excluded. Data collection included patient demographics, presenting complaint, cardiac risk factors, troponin values, and final diagnosis. Summary statistics are reported in a descriptive manner.

Résultats : During the study period, 538 patients had a triage ECG for possible STEMI with no STEMI identified and 16 NSTEMI diagnoses (confirmed as positive troponins following ED assessment). Sixty-three (11.7%) patients did not meet internal criteria for a triage ECG. A NSTEMI ED diagnosis was identified in 3% of patients who met internal triage ECG criteria and 1.6% who did not meet criteria (p=0.29). A cost analysis was performed using an average of 50 STEMI cases diagnosed in our ED per given year. Current institutional ECG billing rates for ECGs performed and interpreted is $125 per ECG, providing an estimated triage ECG charge to detect one STEMI at $54,295.

Conclusion : This retrospective study of 538 triage ECG's performed over an 8day period identified no STEMIs and 16 NSTEMIs. A very large number of ECGs were done at triage overall and included patients who do not meet our own hospital criteria. Given the extremely low yield and high associated charges, current guidelines for triage ECG for identifying a possible STEMI should be reviewed.

Conclusion (proposition de traduction) : Cette étude rétrospective sur 538 ECG de triage réalisée sur une période de 8 jours n'a identifié aucun STEMI et 16 NSTEMI. Un très grand nombre d'ECG ont été réalisés lors du triage dans son ensemble et incluaient des patients ne répondant pas à nos propres critères hospitaliers.
Compte tenu du rendement extrêmement faible et du coût financier associé élevé, il conviendrait de revoir les recommandations actuelles (AHA/ACC guidelines on the management of ST-elevation myocardial infarction) en matière d'ECG de tri pour identifier un possible STEMI.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department..
Mullinax S, Chalmers CE, Brennan J, Vilke GM, Nordstrom K, Wilson MP. | Am J Emerg Med. 2018 Oct;36(10):1779-1783
DOI: https://doi.org/10.1016/j.ajem.2018.01.087
Keywords: Mass screening; Suicidal ideation; Suicide

Original contribution

Introduction : Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients.

Méthode : This prospective observational study enrolled a convenience sample of patients who answered "yes" to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated.

Résultats : 276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66-0.73).

Conclusion : Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

Conclusion (proposition de traduction) : Trois outils de dépistage du suicide ont montré une capacité modeste à prédire la disposition des patients qui se sont présentés dans un service d'urgence avec des idées suicidaires. Cette étude soutient la politique de soins actuelle de l’ACEP (American College of Emergency Physicians) sur les patients psychiatriques, qui stipule que les outils de dépistage ne doivent pas être utilisés isolément pour guider les décisions en matière de risque de passage à l'acte des patients suicidaires aux urgences.

Prognostic performance of Emergency Severity Index (ESI) combined with qSOFA score.
Kwak H, Suh GJ, Kim T, Kwon WY, Kim KS, Jung YS, Ko JI, Shin SM. | Am J Emerg Med. 2018 Oct;36(10):1784-1788
DOI: https://doi.org/10.1016/j.ajem.2018.01.088
Keywords: Emergency Severity Index; Sepsis; Triage; qSOFA

Original contribution

Introduction : We conducted this study to investigate whether ESI combined with qSOFA score (ESI+qSOFA) predicts hospital outcome better than ESI alone in the emergency department (ED).

Méthode : This was a retrospective study for patients aged over 15years who visited an ED of a tertiary referral hospital from January 1st, 2015 to December 31st, 2015. We calculated and compared predictive performances of ESI alone and ESI+qSOFA for prespecified outcomes. The primary outcome was hospital mortality, and the secondary outcome was composite outcome of in-hospital mortality and ICU admission. We calculated in-hospital mortality rates by positive qSOFA in each subgroup divided according to ESI levels (1, 2, 3, 4+5).

Résultats : 43,748 patients were enrolled. The area under receiver-operating characteristics curves were higher in ESI+qSOFA than in ESI alone for both mortality and composite outcome (0.786 vs. 0.777, P<.001 for mortality; 0.778 vs. 0.774, P<.001 for composite outcome). In each subgroup divided by ESI levels, patients with positive qSOFA had significantly higher in-hospital mortality rate compared to those with negative qSOFA (20.4% vs. 14.7%, P=.117 in ESI level 1 subgroup; 11.3% vs. 2.7%, P=.001 in ESI level 2 subgroup; 2.3% vs. 0.4%, P<.001 in ESI level 3 subgroup; 0.0% vs. 0.0% in ESI level 4 or 5 subgroup).

Conclusion : The prognostic performance of ESI+qSOFA for in-hospital mortality was significantly higher than that of ESI alone. Within each subgroup, patients with positive qSOFA had higher in-hospital mortality compared to those with negative qSOFA.

Conclusion (proposition de traduction) : La performance pronostique de l'ESI associée au qSOFA pour l'évaluation de la mortalité hospitalière était significativement supérieure à celle d'ESI seul. Dans chaque sous-groupe, les patients avec un qSOFA positif avaient une mortalité hospitalière plus élevée par rapport à ceux avec qSOFA négatif.

Diagnosing acute otitis media using a smartphone otoscope; a randomized controlled trial.
Mousseau S, Lapointe A, Gravel J. | Am J Emerg Med. 2018 Oct;36(10):1796-1801
DOI: https://doi.org/10.1016/j.ajem.2018.01.093
Keywords: Children; Emergency; Otitis

Original contribution

Introduction : he CellScope Oto® is a smartphone otoscope attachment allowing physicians to share diagnostic-quality images of the ears. Our primary objective was to evaluate the residents' accuracy in diagnosing acute otitis media in children using the CellScope Oto® attachment compared to traditional otoscope.

Méthode : A randomized crossover controlled trial was performed at a single, tertiary care, pediatric emergency department. Participants were a convenience sample of preschool children, consulting for fever and respiratory symptoms. All children were evaluated by two residents randomized to use the CellScope Oto® smartphone device or a traditional otoscope. The primary outcome was the diagnostic accuracy of residents in ear evaluation compared to pediatric otolaryngologist's using binocular microscopy. Secondary outcomes included the need for a second ear exam by the treating physician and parental preference.

Résultats : Between August 2015 and June 2016, 90 residents examined 100 patients. Six patients were excluded, leaving 94 children evaluated twice. Diagnostic accuracies were 0.69 (95% CI: 0.52 to 0.75) for the residents using a traditional otoscope and 0.74 (95% CI: 0.68 to 0.80) for those using the CellScope Oto® for an absolute difference of 0.06 (95% CI: -0.03 to 0.15). The emergency physicians reported no need for a control exam in 49/91 (54%) situations. Finally, 44 (47%) families preferred the CellScope Oto®, 26 (28%) the traditional otoscope and 23 (25%) had no preference.

Conclusion : Residents using the CellScope Oto® had accuracies as good as those using the traditional otoscope to evaluate the ears of young children at risk of acute otitis media.

Conclusion (proposition de traduction) : Les résidents utilisant le CellScope Oto® avaient une exactitude diagnostique aussi bonne que ceux utilisant l'otoscope traditionnel pour évaluer les oreilles des jeunes enfants à risque d'otite moyenne aiguë.

Safety of bolus-dose phenylephrine for hypotensive emergency department patients.
Swenson K, Rankin S, Daconti L, Villarreal T, Langsjoen J, Braude D. | Am J Emerg Med. 2018 Oct;36(10):1802-1806
DOI: https://doi.org/10.1016/j.ajem.2018.01.095
Keywords: Bolus-dose vasopressor; Hypotension; Phenylephrine; Resuscitation; Safety

Original contribution

Introduction : Bolus-dose phenylephrine (BDPE) is routinely used to treat hypotension in the operating room. BDPE's fast onset of action and ability to be administered peripherally have prompted calls for its use in the Emergency Department (ED). There are few published data on the safety of BDPE use in the ED. Primary concerns include BDPE's potential to cause dangerous hypertension or reflex bradycardia. We hypothesize that BDPE is a safe short-term vasopressor choice for hypotensive ED patients.

Méthode : We conducted a structured chart review for all patients who received BDPE from preloaded syringes over 42months. We defined an adverse event (AE) as sBP>180, dBP>110, or HR<50 within 30min of receiving BDPE. We defined a serious adverse event (SAE) as an AE with pharmacologic intervention to correct vital sign abnormality. We also compared mean arterial pressure (MAP), sBP, and dBP pre/post BDPE administration to assess effectiveness. We used a two-sample t-test to assess for differences between the mean delta MAP after low versus high-dose BDPE.

Résultats : We identified 181 cases of ED use. 147 cases had complete pre/post vital signs. We identified 5 AEs and no SAEs. Three patients developed sBP>180mmHg. The patients suffered no apparent harm. No patients had dBP>110. Two patients developed bradycardia post-drug. In both cases, MAP improved despite bradycardia.

Conclusion : BDPE does not appear to cause reflex bradycardia or hypertension requiring intervention among hypotensive ED patients. The apparent safety of BDPE should be confirmed in prospective trials.

Conclusion (proposition de traduction) : La phényléphrine en bolus ne semble pas entraîner de bradycardie réflexe ni d’hypertension nécessitant une intervention chez les patients hypotendus. L'innocuité apparente de la phényléphrine en bolus doit être confirmée par des essais prospectifs.

Commentaire : La phényléphrine (Néo-Synéphrine®) est un vasoconstricteur α1 synthétique puissant à prédominance artérielle (↑ RAS), sans aucun effet β ; la fréquence cardiaque baisse par réflexe.
Administration en bolus répétés de 50-100 mcg iv (voie périphérique ou centrale) ; dose maximale : 1-2 mg.

Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade.
Alter SM, Haim ED, Sullivan AH, Clayton LM. | Am J Emerg Med. 2018 Oct;36(10):1807-1809
DOI: https://doi.org/10.1016/j.ajem.2018.01.100
Keywords: Blade; Intubation; Laryngoscope; Macintosh; Miller

Original contribution

Introduction : Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades.
METHODS: Design: retrospective chart review.
SETTING: hospital-based suburban ALS service with 20,000 annual calls.

Méthode : prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated.

Résultats : 2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7).

Conclusion : Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success.

Conclusion (proposition de traduction) : Notre étude a mis en évidence une différence significative dans les taux de réussite de l'intubation entre les différents types de lames de laryngoscope. Les lames courbes ont eu des taux de réussite plus élevés au premier essai et dans l'ensemble par rapport aux lames droites.
Les ambulanciers paramédicaux devraient envisager de choisir une lame courbe comme outil de choix afin d'améliorer potentiellement le succès de l'intubation.

Commentaire : Voir l'article dans l'EMC-Oto-rhino-laryngologie 1 (2004) 22–34 : Intubation : technique, indication, surveillance, complications  . Rédigé par L. Vazel, G. Potard, C. Martins-Carvalho, M. LeGuyader, N. Marchadour, R. Marianowski :
(…) Plusieurs types de lames existent. La lame courbe introduite par Macintosh est la plus utilisée. Elle a une courbe uniforme avec une ailette sur la gauche. Il existe une version pour gaucher symétrique de la normale. La lame de Miller est la lame droite la plus répandue. L’extrémité est effilée et relevée vers le haut. L’ampoule peut être dans la spatule ou au niveau de rebord. La lame peut être à droite ou à gauche. La lame droite est particulièrement utile lorsque l’ouverture de bouche est limitée (incisives saillantes), lorsque le larynx est antérieur ou lorsque la distance thyromentonnière est courte. La lame courbe peut être en revanche intéressante lorsque l’on nécessite une place plus importante pour se servir de certains instruments (pince de Magill, changement de sonde endotrachéale…). Enfin, après une première tentative à lame courbe, la lame droite est indiquée pour la seconde laryngoscopie quand l’épiglotte est longue et flottante à direction postérieure cachant la vue du larynx. (…)

Pain management of renal colic in the emergency department with intravenous lidocaine.
Motov S, Drapkin J, Butt M, Monfort R, Likourezos A, Marshall J. | Am J Emerg Med. 2018 Oct;36(10):1862-1864
DOI: https://doi.org/10.1016/j.ajem.2018.07.021
Keywords: Emergency department; Lidocaine; Renal colic

Brief Reports

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

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

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

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

Conclusion (proposition de traduction) : La lidocaïne par voie intraveineuse est potentiellement utilisable chez les patients se présentant au service des urgences pour une douleur de colique néphrétique en tant qu’analgésique primaire ou de secours.
Bien que prometteuse, cette thérapeutique devra être étudiée de manière prospective, randomisée et sur une population de patients plus importante présentant une maladie cardiaque sous-jacente avant de pouvoir être recommandée pour une utilisation large au service des urgences.

Commentaire : Voir les articles :
Makhoul T, Kelly G, Schult RF, Acquisto NM. Intravenous lidocaine for renal colic in the emergency department (ED). Am J Emerg Med. 2018 Aug 23. pii: S0735-6757(18)30694-6  .
Sin B1, Cao J2, Yang D1, Ambert K3, Punnapuzha S. Intravenous lidocaine for renal colic in the emergency department (ED). Am J Ther. 2018 Jan 23  .

A systematic review of safety and adverse effects in the practice of therapeutic hypothermia.
Karcioglu O, Topacoglu H, Dikme O, Dikme O. | Am J Emerg Med. 2018 Oct;36(10):1886-1894
DOI: https://doi.org/10.1016/j.ajem.2018.07.024
Keywords: Adverse effects; Cardiac arrest; Hypothermia; Out-of-hospital cardiac arrest; Side effects; Systematic review; Targeted temperature management; Therapeutic hypothermia

Reviews

Introduction : To carry out a systematic review to estimate the rate and magnitude of adverse effects following therapeutic hypothermia (TH) procedure in patients resuscitated from out-of-hospital cardiac arrest (OHCA) and highlight the specific complications seen after the procedure.

Méthode : A systematic review of currently published studies was performed following standard guidelines. Online database searches were performed for controlled trials for the last twenty years. Papers were examined for methodological soundness before being included. Data were independently extracted by two blinded reviewers. Studies were also assessed for bias using the Cochrane criteria. The adverse effects attributed to TH in the literature were appraised critically.

Résultats : The initial data search yielded 78 potentially relevant studies; of these, 59 were excluded for some reason. The main reason for exclusion (n = 43, 55.8%) was that irrelevance to adverse effects of TH. Finally, 19 underwent full-text review. Studies were of high-to-moderate (n = 12, 63%) to low-to-very low (n = 7, 37%) quality. Five studies (27.7%) were found to have high risk of bias, while 8 (42.1%) had low risk of bias.

Conclusion : Although adverse effects related to the practice of TH have been studied extensively, there is substantial heterogeneity between study populations and methodologies. There is a considerable incidence of side effects attributed to the procedure, e.g., from life-threatening ventricular arrhythmias to self-limited consequences. Most studies analyzed in this systematic review indicated that the procedure of TH has not caused severe adverse effects leading to significant alterations in the outcomes following resuscitation from OHCA.

Conclusion (proposition de traduction) : Bien que les effets indésirables liés à la pratique de l'hypothermie thérapeutique aient fait l'objet de nombreuses études, il existe une grande hétérogénéité entre les populations étudiées et les méthodologies. Il y a une incidence considérable d'effets secondaires attribués à la procédure, par exemple, des arythmies ventriculaires mettant la vie en danger avec comme conséquences une autolimitation thérapeutique. La plupart des études analysées dans le cadre de cette revue systématique indiquent que la procédure d'hypothermie thérapeutique n'a pas causé d'effets indésirables graves entraînant des modifications importantes des résultats après la réanimation à la suite d'un arrêt cardiaque extra-hospitalier.

Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial.
Bellew SD, Johnson KL, Nichols MD, Kummer T. | J Emerg Med. 2018 Oct;55(4):455-464
DOI: https://doi.org/10.1016/j.jemermed.2018.07.004  | Télécharger l'article au format  
Keywords: epinephrine; epistaxis; hemodynamics; oxymetazoline; phenylephrine

Original Contributions

Introduction : Treatment for epistaxis includes application of intranasal vasoconstrictors. These medications have a precaution against use in patients with hypertension. Given that many patients who present with epistaxis are hypertensive, these warnings are commonly overridden by clinical necessity.
OBJECTIVE: Our aim was to determine the effects of intranasal vasoconstrictors on blood pressure.

Méthode : We conducted a single-center, randomized, double-blind, placebo-controlled trial from November 2014 through July 2016. Adult patients being discharged from the emergency department (ED) at Mayo Clinic (Rochester, Minnesota) were recruited. Patients were ineligible if they had a contraindication to study medications, had a history of hypertension, were currently taking antihypertensive or antidysrhythmic medications, or had nasal abnormalities, such as epistaxis. Subjects were randomized to one of four study arms (phenylephrine 0.25%; oxymetazoline 0.05%; lidocaine 1% with epinephrine 1:100,000; or bacteriostatic 0.9% sodium chloride [saline]). Blood pressure and heart rate were measured every 5 min for 30 min.

Résultats : Sixty-eight patients were enrolled in the study; of these, 63 patients completed the study (oxymetazoline, n = 15; phenylephrine, n = 20; lidocaine with epinephrine, n = 11; saline, n = 17). We did not observe any significant differences in mean arterial pressure over time between phenylephrine and saline, oxymetazoline and saline, or lidocaine with epinephrine and saline. The mean greatest increases from baseline in mean arterial pressure, systolic and diastolic blood pressure, and heart rate for each treatment group were also not significantly different from the saline group.

Conclusion : Intranasal vasoconstrictors did not significantly increase blood pressure in patients without a history of hypertension. Our findings reinforce the practice of administering these medications to patients who present to the ED with epistaxis, regardless of high blood pressure.

Conclusion (proposition de traduction) : Les vasoconstricteurs intranasaux n’ont pas augmenté significativement la pression artérielle chez les patients sans antécédents d’hypertension. Nos résultats renforcent la pratique consistant à administrer ces médicaments aux patients présentant une épistaxis au service des urgences, indépendamment de l'hypertension artérielle.

Platelet to Lymphocyte Ratio on Admission and Prognosis in Patients with Acute Cardiogenic Pulmonary Edema.
Demir M, Duyuler PT, Guray U, Celik MC. | J Emerg Med. 2018 Oct;55(4):465-471
DOI: https://doi.org/10.1016/j.jemermed.2018.06.021
Keywords: cardiogenic pulmonary edema; inflammation; platelet to lymphocyte ratio; prognosis

Original Contributions

Introduction : Acute heart failure is a heterogenous syndrome defined by a number of factors, such as its physiopathology, clinical picture, time of onset, and relation to acute coronary syndrome. Acute cardiogenic pulmonary edema (ACPE) constitutes approximately 10-20% of acute heart failure syndromes, and it is the most dramatic symptom of left heart failure. Platelet to lymphocyte ratio (PLR) is a relatively novel inflammatory marker that can be utilized for prognosis in various disease processes.
/ OBJECTIVE: In this study, we investigated the value of the PLR for the prediction of mortality in patients with ACPE.

Méthode : A total of 115 patients hospitalized with a diagnosis of ACPE were included in this study. The patients were divided into tertile groups according to their PLR values: high (PLR > 194.97), medium (98.3-194.97), and low tertile (PLR < 98.3).

Résultats : We compared the PLR groups for in-hospital mortality and total mortality after discharge. Multivariate Cox regression analysis showed that PLR was independently associated with total mortality (hazard ratio 5.657; 95% confidence interval 2.467-12.969; p < 0.001). Survival analysis using the Kaplan-Meier curve showed that the high-PLR group had a significantly higher mortality rate than the other groups.

Conclusion : We showed an association between high PLR and mortality in patients with ACPE. PLR, together with other inflammatory markers and clinical findings, may be used as an adjunctive parameter for the stratification of mortality risk, hospitalization, or discharge criteria scoring.

Conclusion (proposition de traduction) : Nous avons montré une association entre le ratio plaquettes/lymphocytes élevé et la mortalité chez les patients présentant un œdème pulmonaire cardiogénique aigu. Le rapport plaquettes/lymphocytes, associé à d'autres marqueurs inflammatoires et résultats cliniques, peut être utilisé comme paramètre d'appoint pour la stratification du risque de mortalité, de l'hospitalisation ou de la notation des critères de décharge.

Autonomic Nervous System Activity for Risk Stratification of Emergency Patients With Pneumonia.
Mizera L, Boehm K, Duckheim M, Groga-Bada P, Gawaz M, Zuern CS, Eick C. | J Emerg Med. 2018 Oct;55(4):472-480
DOI: https://doi.org/10.1016/j.jemermed.2018.06.016
Keywords: cardiac autonomic function; deceleration capacity; emergency medicine; pneumonia; risk factors

Original Contributions

Introduction : Community-acquired pneumonia (CAP) causes appreciable morbidity and mortality in adults, especially in those ≥65 years of age. At hospital admission, an immediate and reliable risk assessment is necessary to detect patients with possible fatal outcome.
OBJECTIVE: We aimed to evaluate markers of the autonomic nervous system based on an electrocardiogram to predict mortality in patients with CAP.

Méthode : For this purpose, the deceleration capacity (DC) of heart rate was calculated in 253 patients who presented to the emergency department with CAP. The 30-day mortality rate was defined as the primary endpoint (PEP). The secondary endpoint was the total mortality within 180 days.

Résultats : PEP was reached in 33 patients (13%). The DC, measured in milliseconds, was significantly lower in patients who reached the PEP than in those who did not (2.3 ± 1.5 ms vs. 3.6 ± 2.3 ms, p = 0.004). The DC was also significantly lower in nonsurvivors than in survivors at the time of the secondary endpoint (2.3 ± 1.5 ms vs. 3.7 ± 2.4 ms, p < 0.001). Our results indicate that DC is an independent predictor of 30- and 180-day mortality.

Conclusion : DC was independently associated with death from CAP in our study. As a practical consequence, DC could be useful in triage decisions. Patients with certain high risks could benefit from adjuvant treatment and special medical attention.

Conclusion (proposition de traduction) : La capacité de décélération cardiaque était indépendamment associée au décès par pneumopathie acquise communautaire dans notre étude (NDLR : une composante vagale diminuée [fonctionnement altéré du système nerveux autonome] avec une diminution de la capacité de décélération a une discrimination pronostique importante).
En pratique, la capacité de décélération cardiaque pourrait être utile pour les décisions de triage. Les patients présentant un risque élevé pourraient bénéficier d'un traitement adjuvant et d'une attention médicale particulière.

Commentaire : A propos de la décélération cardiaque, deux articles à consulter :
- Arsenos R, Manis G. Deceleration Capacity of heart rate: Two new methods of computation. Biomed Signal Process Control. 2014 November;14:158-163  
- Feng YY, Yang ZJ. Clinical Application of the Heart Rate Deceleration Capacity Test to Predict Epirubicin-induced Cardiotoxicity. J Cardiovasc Pharmacol. 2015 Oct;66(4):371-5  

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge.
Shuen JA, Wilson MP, Kreshak A, Mullinax S, Brennan J, Castillo EM, Hinkle C, Vilke GM. | J Emerg Med. 2018 Oct;55(4):573-581
DOI: https://doi.org/10.1016/j.jemermed.2018.07.023
Keywords: communication; discharged patients; emergency department follow-up; patient satisfaction; randomized controlled trial; telephone contact; text message contact

Administration of Emergency Medicine

Introduction : Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction.
OBJECTIVE: The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction.

Méthode : Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ2 test.

Résultats : Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ2 = 4.57, degrees of freedom [df] = 2, p = 0.10; χ2 = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ2 = 2.88, df = 2, p = 0.24).

Conclusion : Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.

Conclusion (proposition de traduction) : Les patients qui sont contactés par téléphone ou par SMS pour un suivi aux urgences, bien que peut-être moins satisfaits, ont tendance à revoir le service des urgences et à communiquer avec leur médecin traitant ou leur médecin spécialiste moins souvent que les patients recevant les instructions de sortie standard par écrit. Cependant, cette étude pilote est sous-alimentée, de sorte que des études randomisées plus importantes sont nécessaires pour confirmer les résultats.

Rapid Systematic Review: Age-Adjusted D-Dimer for Ruling Out Pulmonary Embolism.
Barth BE, Waligora G, Gaddis GM. | J Emerg Med. 2018 Oct;55(4):586-592
DOI: https://doi.org/10.1016/j.jemermed.2018.07.003
Keywords: D-dimer; age factors; pulmonary embolism

AAEM Clinical Practice

Introduction : Pulmonary embolism (PE) is a disease diagnosed relatively frequently in emergency departments (EDs). Evidence suggests that improved decision making may decrease inappropriate testing, unnecessary radiation exposure, and non-beneficial treatment. Several studies have looked at the utility and safety of age-adjusting the D-dimer levels used to safely rule out PE.
OBJECTIVE: This rapid systematic review sought to answer the question: Can an age-adjusted D-dimer be used to safely rule out PE in patients over 50 years old?

Méthode : We performed a structured review of PubMed from January 2012 to January 2018 limited to reports involving human subjects and written in the English language and containing relevant keywords. The highest-quality studies were then reviewed in a structured format.

Résultats : One hundred and eleven papers were identified for further review. Eight articles were determined to be appropriate for inclusion in this summary. These studies all used patient age (in years over 50) × 10 μg/L (fibrinogen equivalent units) as their definition of an age-adjusted D-dimer.

Conclusion : Age-adjusted D-dimer cutoff values, in combination with a non-high clinical probability, is safe and effective to essentially rule out PE in ED patients.

Conclusion (proposition de traduction) : Les valeurs de seuil des D-dimères ajustées en fonction de l'âge, associées à une probabilité clinique faible, sont sûres et efficaces pour éliminer essentiellement l'embolie pulmonaire chez les patients des urgences.

Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis.
Bolland MJ, Grey A, Avenell A. | Lancet Diabetes Endocrinol. 2018 Oct 4. pii: S2213-8587(18)30265-1
DOI: https://doi.org/10.1016/S2213-8587(18)30265-1
Keywords: Aucun

Articles

Introduction : The effects of vitamin D on fractures, falls, and bone mineral density are uncertain, particularly for high vitamin D doses. We aimed to determine the effect of vitamin D supplementation on fractures, falls, and bone density.

Méthode : In this systematic review, random-effects meta-analysis, and trial sequential analysis, we used findings from literature searches in previously published meta-analyses. We updated these findings by searching PubMed, Embase, and Cochrane Central on Sept 14, 2017, and Feb 26, 2018, using the search term "vitamin D" and additional keywords, without any language restrictions. We assessed randomised controlled trials of adults (>18 years) that compared vitamin D with untreated controls, placebo, or lower-dose vitamin D supplements. Trials with multiple interventions (eg, co-administered calcium and vitamin D) were eligible if the study groups differed only by use of vitamin D. We excluded trials of hydroxylated vitamin D analogues. Eligible studies included outcome data for total or hip fractures, falls, or bone mineral density measured at the lumbar spine, total hip, femoral neck, total body, or forearm. We extracted data about participant characteristics, study design, interventions, outcomes, funding sources, and conflicts of interest. The co-primary endpoints were participants with at least one fracture, at least one hip fracture, or at least one fall; we compared data for fractures and falls using relative risks with an intention-to-treat analysis using all available data. The secondary endpoints were the percentage change in bone mineral density from baseline at lumbar spine, total hip, femoral neck, total body, and forearm.

Résultats : We identified 81 randomised controlled trials (n=53 537 participants) that reported fracture (n=42), falls (n=37), or bone mineral density (n=41). In pooled analyses, vitamin D had no effect on total fracture (36 trials; n=44 790, relative risk 1·00, 95% CI 0·93-1·07), hip fracture (20 trials; n=36 655, 1·11, 0·97-1·26), or falls (37 trials; n=34 144, 0·97, 0·93-1·02). Results were similar in randomised controlled trials of high-dose versus low-dose vitamin D and in subgroup analyses of randomised controlled trials using doses greater than 800 IU per day. In pooled analyses, there were no clinically relevant between-group differences in bone mineral density at any site (range -0·16% to 0·76% over 1-5 years). For total fracture and falls, the effect estimate lay within the futility boundary for relative risks of 15%, 10%, 7·5%, and 5% (total fracture only), suggesting that vitamin D supplementation does not reduce fractures or falls by these amounts. For hip fracture, at a 15% relative risk, the effect estimate lay between the futility boundary and the inferior boundary, meaning there is reliable evidence that vitamin D supplementation does not reduce hip fractures by this amount, but uncertainty remains as to whether it might increase hip fractures. The effect estimate lay within the futility boundary at thresholds of 0·5% for total hip, forearm, and total body bone mineral density, and 1·0% for lumbar spine and femoral neck, providing reliable evidence that vitamin D does not alter these outcomes by these amounts.

Conclusion : Our findings suggest that vitamin D supplementation does not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. There were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. This conclusion should be reflected in clinical guidelines.

Conclusion (proposition de traduction) : Nos résultats suggèrent que la supplémentation en vitamine D ne prévient pas les fractures et les chutes, ni n'a d'effets cliniquement significatifs sur la densité minérale osseuse. Il n'y a pas eu de différence entre les effets de doses plus élevées et plus faibles de vitamine D. Il est peu justifié d'utiliser des suppléments de vitamine D pour maintenir ou améliorer la santé de l'appareil locomoteur. Cette conclusion devrait être reflétée dans les directives cliniques.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Vitamine D : pas d'effet sur les fractures, les chutes et la minéralisation osseuse - Medscape - 8 oct 2018  . Rédigé par Marine Cygler.