Causes of Shortness of Breath in the Acute Patient: A National Study.
Hale ZE, Singhal A, Hsia RY. | Acad Emerg Med. 2018 Novembre;25(11):1227-1234 - First Published: May 2018
DOI: https://doi.org/10.1111/acem.13448
Keywords: Aucun

Original contribution

Introduction : Dyspnea is a common and ambiguous complaint that results in 3.4 million emergency department (ED) visits annually. While learners may encounter lists of differential diagnoses to consider while in training, often these lists are not empirically based. We sought to establish an evidence-based differential diagnosis for dyspnea and to determine whether normal vital signs can rule out a life-threatening diagnosis.

Méthode : We analyzed data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2014 for ED visits with a chief complaint of dyspnea and tallied the principal discharge diagnosis. We included 10,170 sampled ED visits by adults with a chief complaint of dyspnea, representing nearly 42 million visits nationally. We then calculated the most common principal discharge diagnoses by age group and the frequency of abnormal respiratory vital signs in cases with life-threatening diagnoses.

Résultats : The most represented age group was 45 to 64 years (31.6%). Most visits were discharged directly from the ED (57.5%), while 8.1% required admission to an intensive care unit (ICU). The most common diagnosis in patients aged 18 to 44 was acute asthma exacerbation (14.8%). Obstructive chronic bronchitis was the most common specified diagnosis in both patients ages 45 to 64 (11.1%) and patients ages 65 to 79 (12.4%), while congestive heart failure was the most common for patients ages 80 and over (15.9%). Respiratory vital signs were frequently normal in the 44.6% of visits that resulted in a potentially life-threatening diagnosis but corresponded to increased ICU utilization when abnormal.

Conclusion : For patients with dyspnea, the high utilization of ICUs highlights the importance of an accurate differential. The frequencies established here can be used as pretest probabilities in Bayesian analysis to improve the accuracy of differential diagnosis lists.

Conclusion (proposition de traduction) : Pour les patients présentant une dyspnée, le recours élevée aux unités de soins intensifs souligne l'importance d'un diagnostic différentiel précis. Les fréquences établies ici peuvent être utilisées comme probabilités de pré-test dans l'analyse bayésienne pour améliorer la précision des listes de diagnostics différentiels.

Commentaire : Les résultats montrent une prévalence des pathologies selon l'âge :
- de 18 à 44 ans (14,8 %), une exacerbation aigüe d'asthme (14,8 %) ;
- 45 à 64 ans (11,1 %) et de 65 à 79 ans (12,4 %), une décompensation de BPCO ;
- patients de 80 et plus (15,9 %), un OAP.
Les signes vitaux respiratoires étaient normaux chez 44,6 % des patient ayant abouti à un diagnostic potentiellement mortel, ce qui donnait lieu à une utilisation accrue des soins intensifs en cas d'anomalie.

D-dimer in Adolescent Pulmonary Embolism.
Sharaf N, Sharaf VB, Mace SE, Nowacki AS, Stoller JK, Carl JC. | Acad Emerg Med. 2018 Novembre;25(11):1235-1241 - First Published: 16 Jul 16
DOI: https://doi.org/10.1111/acem.13517  | Télécharger l'article au format  
Keywords: Aucun

Original contribution

Introduction : D-dimer is used to aid in diagnosing adult pulmonary embolism (PE). D-dimer has not been validated in adolescents. Clinicians must balance the risk of overtesting with that of a missed PE. D-dimer may be useful in this context. This study evaluates D-dimer in PE-positive and PE-negative adolescents.

Méthode : PE-positive patients < 22 years were diagnosed with PE by computed tomography (CT) or high-probability ventilation/perfusion, seen at emergency departments (EDs)/hospitals within a 16-hospital system across two states, January 1998 through December 2016. Of the 189 PE-positive patients, 88 (46.5%) had a D-dimer and were matched 1:1 by age, sex, and race to patients suspected of PE but confirmed negative by CT angiogram.

Résultats : Ages of PE-positive patients ranged from 13 to 21 years, 64 (73%) were female, and 52 (60%) were Caucasian. Mean D-dimer was significantly higher (3,256 ng/mL, 95% confidence interval [CI] = 2,505-4,006 ng/mL) in PE-positive versus PE-negative patients (1,244 ng/mL, 95% CI = 493-1,995 ng/mL; p < 0.001). Mean D-dimer was higher in patients with massive or submassive PE (8,742 ng/mL, 95% CI = 5,994-11,491 ng/mL), followed by PE in central (4,795 ng/mL [95% CI = 3,465-6,125 ng/mL), lobar (3,758 ng/mL [95% CI = 1,841-5,676), and distal (2,327 ng/mL [95% CI = 1,273-3,381 ng/mL]) arteries. When comparing thresholds of positive D-dimer (≥500, ≥750, and ≥1,000 ng/mL), D-dimer had sensitivities of 90, 82, and 67% and specificities of 16, 53, and 67%, respectively. Negative predictive values were 61, 75, and 71% while positive likelihood ratios were 1.1, 1.8, and 2.2, respectively.

Conclusion : This study represents the largest available cohort of adolescent patients examining the diagnostic value of D-dimer for PE. Our results indicate that depending on the threshold selected, D-dimer can be a sensitive test for PE in adolescents and that discriminative value is higher for a cutoff of 750 ng/mL than that for 500 ng/mL. Prospective studies investigating the diagnostic value of D-dimer and a clinical decision rule for PE in pediatrics are needed.

Conclusion (proposition de traduction) : Cette étude représente la plus grande cohorte disponible de patients adolescents chez qui l'on dose la valeur diagnostique du D-dimère dans l’EP. Nos résultats indiquent que, selon le seuil choisi, les D-dimères peuvent être un test sensible dans l’EP chez les adolescents et que la valeur discriminante est plus élevée pour une valeur limite de 750 ng/mL par rapport à 500 ng/mL (chez l'adulte).
Des études prospectives portant sur la valeur diagnostique des D-dimères et sur une règle de décision clinique en matière d'EP en pédiatrie sont nécessaires.

Complex Febrile Seizures, Lumbar Puncture, and Central Nervous System Infections: A National Perspective.
Lee J, DeLaroche AM, Janke AT, Kannikeswaran N, Levy PD. | Acad Emerg Med. 2018 Novembre;25(11):1242-1250 - First Published: 27 Apr 2018
DOI: https://doi.org/10.1111/acem.13441
Keywords: Aucun

Original contribution

Introduction : The objective was to determine the national lumbar puncture (LP) practice patterns relative to the incidence of central nervous system (CNS) infections among children presenting to the emergency department (ED) with complex febrile seizures (CFS).

Méthode : This was a retrospective study of ED visits for CFS from 2007 to 2014 in patients aged 0 to 5 years using a national sample. Primary outcomes include the frequency of LP, incidence of CNS infections, and ED disposition.

Résultats : Of 28,810 ED visits for CFS (44.4% female; mean age = 1.39 years), LP was performed in 7,445 (25.8%, 95% confidence interval [CI] 23.5%-28.2%). There was no significant difference in the proportion due to hospital teaching status or geographical region. The proportion decreased from 31.4% to 17.8% over the study period (Rao-Scott statistic = 5.85, p < 0.001). CNS infection was diagnosed in 80 (0.3%) encounters (95% CI = 41-112). The most commonly associated infections were otitis media (16.8%), upper respiratory infections (15.8%), and other viral infections (14.6%). A total of 14,696 encounters (51.0%, 95% CI = 47.9%-54.1%) resulted in a hospital admission.

Conclusion : Although rates have been declining, LP was performed in one-fourth of ED encounters for CFS over the 8-year study period. The incidence of CNS infections was very low, however, suggesting that this procedure could be avoided in many patients.

Conclusion (proposition de traduction) : Bien que les taux aient diminué, la PL a été réalisée chez un quart des patients consultant aux urgences pour des crises fébriles complexes au cours de la période de huit ans visée par l'étude. L'incidence des infections du SNC était toutefois très faible, ce qui donne à penser que cette intervention pourrait être évitée chez de nombreux patients.

Emergency Department Adult Fiberoptic Intubations: Incidence, Indications, and Implications for Training.
Hayden EM, Pallin DJ, Wilcox SR, Gordon JA, Carlson JN, Walls RM, Brown CA; National Emergency Airway Registry (NEAR) III Investigators. | Acad Emerg Med. 2018 Novembre;25(11):1263-1267 - First Published: 27 April 2018
DOI: https://doi.org/10.1111/acem.13440
Keywords: Aucun

Original contribution

Introduction : The objective was to describe the frequency, indications, and outcomes of flexible fiberoptic intubations (FFI) performed in the emergency department (ED).

Méthode : From the National Emergency Airway Registry (NEAR), we identified all encounters from July 1, 2002, through December 31, 2012, with the use of FFI. We determined patient, provider, and intubation characteristics; success and failure rates; and modes of intubation rescue.

Résultats : Among 17,910 intubations of patients > 15 years old at 13 EDs, FFI was used in 204 cases (1.1%, 95% confidence interval [CI] = 0.26%-2.0%). FFI was the first method chosen (primary FFI) in 180 encounters (1%, 95% CI = 0.2%-1.8%). The most common indication for FFI was airway obstruction (36.1%, 95% CI = 24.6%-47.7%). For primary FFI, first-attempt intubation success was 51.1% (95% CI = 43.6%-58.6%), and overall intubation success with FFI was 74.3% (95% CI = 65.7%-82.9%). FFI was used as a rescue airway strategy in 24 cases (0.1% of all encounters) and was successful in 17 of those (70.8%, 95% CI = 65.4%-85.2%).

Conclusion : Emergency department flexible fiberoptic intubations is uncommon and typically used as a nonsurgical alternative for airway obstruction. First-attempt ED flexible fiberoptic intubations is successful in half of cases and in two-thirds of rescue attempts. These data provide an important baseline to help better characterize the nature of flexible fiberoptic intubations as a rare critical procedure in the ED and offer an empiric basis for ongoing discussions on the optimal role of flexible fiberoptic intubations in ED training and practice.

Conclusion (proposition de traduction) : L'intubation par fibre optique flexible aux urgences est rare et est généralement utilisée comme alternative non chirurgicale à l'obstruction des voies aériennes supérieures. La première tentative d'intubation par fibre optique flexible est réussie dans la moitié des cas et dans les deux tiers des tentatives de sauvetage.
Ces données fournissent une base de référence importante pour aider à mieux caractériser la nature des intubations par fibres optiques flexibles en tant que procédure critique rare aux urgences et offrent une base empirique pour les discussions en cours sur le rôle optimal des intubations par fibres optiques flexibles dans la formation et la pratique aux urgences.

Commentaire : Dans cette étude, l'intubation difficile représentait 1,1 % des intubations et 0,1 % étaient des intubations impossibles.

Hot Off the Press: A Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients with Atrial Fibrillation.
Morgenstern J, Heitz C, Bond C, Milne WK. | Acad Emerg Med. 2018 Novembre;25(11):1263-1267 - First Published: 12 Jul 2018
DOI: https://doi.org/10.1111/acem.13514
Keywords: Aucun

Hot Off the Press

Editorial : This is a retrospective cohort study with a before and after design, comparing the admission rate for patients with AFib during a one‐year period before the initiation of a new management algorithm to a one‐year period after the algorithm was introduced. Physicians were first instructed to determine whether the AFib was secondary to another important diagnosis, such as sepsis or pulmonary embolism. (These patients were admitted to hospital). Among the patients with primary AFib, physicians assessed for four high‐risk criteria: hemodynamic instability, acute heart failure, syncope, and acute coronary syndrome. Patients with no high‐risk criteria were managed with either rate or rhythm control and then discharged home with close outpatient follow‐up. The admission rate for AFib patients fell from 80% in the before period to 67% after, with no change in emergency department return visits.

Conclusion : This before‐and‐after observational trial demonstrated that fewer patients with Atrial fibrillation were admitted to hospital after the introduction of a new management algorithm, without any increase in ED return visits. Managing more patients with primary Atrial fibrillation in the outpatient setting is a reasonable goal.

Conclusion (proposition de traduction) : Cet essai d’observation avant et après a montré que moins de patients présentant une fibrillation atriale ont été admis à l’hôpital après l’introduction d’un nouvel algorithme de prise en charge, sans augmentation du nombre de consultations aux urgences. La gestion d'un plus grand nombre de patients atteints de fibrillation atriale primaire en consultation externe est un objectif raisonnable.

Commentaire : Discussing: DeMeester S, Hess RA, Hubbard B, LeClerc K, Ferraro J, Albright JJ. Implementation of a novel algorithm to decrease unnecessary hospitalizations in patients presenting to a community emergency department with atrial fibrillation. Acad Emerg Med 2018;25:641–9. Associated podcast: http://thesgem.com/2018/06/sgem222-rhythm-is-gonna-get-you-into-an-atrial-fibrillation-pathway/  . The authors have no relevant financial information or potential conflicts to disclose.
Voir l'algorithme : Algorithm to decrease AFibs admissions  

S. Carmès | Ann Fr Med Urgence. 2018 Novembre;8(6):359-362
DOI: https://doi.org/10.3166/afmu-2018-0054
Keywords: Nail traumatism; Door finger trap; Epidemiology; Nail injury

Article original

Introduction : Nous rapportons une étude épidémiologique des lésions unguéales vues dans un centre de traumatologie de la main pendant une période de 18 mois. Les traumatismes unguéaux représentaient 8 % de tous les traumatismes des doigts.

Méthode : Nous avons pris en charge de façon continue 187 patients dont les dossiers ont été revus rétrospectivement.

Résultats : Cent trente-huit hommes (74 %), avec un âge moyen de 38,5 ans, et 49 femmes (26 %), d’âge moyen de 46,1 ans. La main droite était atteinte 80 fois (43 %), la gauche 106 fois (57 %), et les données étaient manquantes dans un cas. Les patients étaient atteints sur leur main dominante dans 37%des cas. Le pouce était le doigt le plus souvent touché, 55 cas (29 %), puis le majeur (23 %), l’index (17 %), l’annulaire (15 %) et l’auriculaire (10 %). Dans 5 % des cas, il y avait plusieurs doigts touchés, et le majeur était alors toujours atteint. Un mécanisme d’écrasement était la cause la plus fréquente (44 %), avec un doigt coincé dans une porte dans 42 cas (23 %) ou écrasé par un objet (22 %). Venaient ensuite les plaies franches, 55 cas (30 %). L’exploration des lésions a retrouvé 47 lésions isolées de la tablette unguéale (25 %), 103 lésions du lit de l’ongle (55 %), 14 lésions de la matrice ± associées à une lésion du lit et 23 hématomes sous-unguéaux (12 %). Dans 134 cas (72 %), il existait une autre lésion associée à celle de l’ongle. Il s’agissait d’une lésion pulpaire dans 50 cas (27%), d’une fracture de la phalange distale dans 29 cas (16 %), d’une lésion associant à une fracture de la phalange distale une lésion de la pulpe dans 49 cas (26 %) et d’une autre lésion du doigt ou de la main dans 22 cas (12%). La lésion siégeait sur le même doigt dans 128 cas.

Conclusion : Nail injuries are frequent. The emergency physician must know these injuries and not underestimate them as more than 75% should be treated “surgically”.

Conclusion (proposition de traduction) : Les lésions unguéales sont fréquentes. Le médecin urgentiste doit connaître ces lésions et ne pas les sous-estimer, car dans plus de trois quarts des cas elles nécessitent un geste technique qui relève le plus souvent de la compétence de l’urgentiste.

Serres M, Gil-Jardiné C, Evrard G, Revel P, Tentillier E, Galinski M. | Ann Fr Med Urgence. 2018 Novembre;8(6):363-367
DOI: https://doi.org/10.3166/afmu-2018-0066
Keywords: Prehospital emergency care; Attitude of health personnel; Analgesics; Hypnotics and sedatives

Article original

Introduction : L’analgésie-sédation procédurale (ASP) consiste à administrer des agents sédatifs permettant aux patients de tolérer des procédures désagréables. L’ASP a fait l’objet de recommandations formalisées d’experts de la Société française de médecine d’urgence (SFMU) depuis 2010. L’objectif était d’évaluer l’impact de ces recommandations sur les pratiques des smuristes en France concernant la réalisation d’une ASP.

Méthode : Enquête téléphonique réalisée de janvier à juillet 2016. Nous avons joint un médecin de permanence le jour de l’appel dans chaque service mobile d’urgence et de réanimation (Smur) métropolitain. Il devait répondre à un questionnaire focalisé sur une situation clinique pour laquelle une ASP était indiquée : fracture fémorale déplacée.

Résultats : Chaque Smur métropolitain a été joint (n = 384), et 309 médecins ont répondu au questionnaire (80 %). Quarante-deux combinaisons thérapeutiques différentes ont été proposées, et 308 médecins (99 %) administraient soit un sédatif, soit un opioïde, soit les deux. La morphine était le principal antalgique utilisé (n = 232 ; 75 %), les posologies et les modalités correspondant aux dernières recommandations. La kétamine était le sédatif le plus utilisé (n = 163 ; 53 %), mais les posologies étaient inférieures à celles recommandées La douleur des patients communicants était évaluée avec une échelle adaptée. La douleur des patients non communicants, adultes ou enfants, n’était pas évaluée avec une échelle adaptée. Un tiers des Smur avait un protocole d’ASP, et 27 % des médecins disaient connaître les recommandations.

Conclusion : There was a great heterogeneity of the modalities concerning the realization of PSA, particularly with difficulties to use sedative drugs, a weak knowledge of recommendations and a weak proportion of protocols in the Smurs.

Conclusion (proposition de traduction) : Au total, il y avait une grande hétérogénéité des modalités de réalisation de l’ASP, avec notamment des difficultés de maniement des sédatifs, des recommandations peu connues et un faible taux de protocoles dans les Smur.

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 Novembre;8(6):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

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) : Le risque terroriste présent sur l’ensemble de notre territoire depuis plusieurs années conduit les équipes de Samu–Smur à intervenir sur les lieux d’une tuerie de masse aux côtés de forces de sécurité, voire en tant que primointervenants. De telles circonstances exposent les équipes à un environnement de travail inhabituel et hostile. Cette mise au point, proposée en complément de la recommandation formalisée d’experts sur la prise en charge de tuerie de masse, répond aux interrogations qui naissent sur le terrain en pareilles circonstances. Elle facilite une juste appréciation des événements, aide à réguler ses émotions, dans le but d’augmenter la capacité des soignants à agir, tout en réduisant la phase de sidération initiale, elle-même responsable d’une inertie à même d’impacter le pronostic des blessés en choc hémorragique. Des procédures anticipées, sous forme de check-lists, guident les actions à mener de manière sereine. Les équipes médicales préhospitalières doivent apporter sur le terrain non seulement une compétence médicale, mais également une compétence tactique et décisionnelle pour accélérer les flux d’évacuation. Le premier médecin engagé doit aider à la décision aux côtés du commandant des opérations de secours, du commandant des opérations de police et de gendarmerie et des médecins intégrés aux forces de sécurité intérieure en attendant le directeur des secours médicaux. Il doit donc également faire preuve d’une compétence de chef d’équipe.

The Characteristics and Outcomes of Patients Who Make an Emergency Department Visit for Hypertension After Use of a Home or Pharmacy Blood Pressure Device.
Atzema CL, Wong A, Masood S, Zia A, Al-Bulushi S, Sohail QZ, Cherry A, Chan FS. | Ann Emerg Med. 2018 Nov;72(5):534–543
DOI: https://doi.org/10.1016/j.annemergmed.2018.06.002  | Télécharger l'article au format  
Keywords: Aucun

Cardiology

Introduction : Emergency department (ED) visits for hypertension are rapidly increasing. Hypertension guidelines began recommending use of self-measurement blood pressure (BP) devices in the early 2000s, which could be contributing to the increase. We aim to examine the proportion of ED visits for hypertension that occurred after a BP measurement with a self-measuring device, and the associated outcomes.

Méthode : This retrospective observational study included adults who made an ED visit and received a primary diagnosis of hypertension at 1 of 5 community and tertiary hospitals in Ontario, Canada, between April 2010 and March 2011. We categorized ED visits into 4 groups: those made after a home BP reading, a pharmacy reading, as a result of a physician referral, and all others (termed "not documented"). We examined rates of admission to the hospital, ED treatment (administration of antihypertensive medication and prescription provision), and post-ED clinical events (follow-up care, return ED visits, and long-term all-cause mortality) by group.

Résultats : Among 1,508 qualifying patients, median presenting ED BP was 182/97 mm Hg (interquartile range 164 to 200/85 to 109 mm Hg). The percentage of patients who presented to the ED after a reading at home, at a pharmacy, or by physician referral and the remaining patients not documented was 40.9%, 8.3%, 13.3%, and 37.5%, respectively. Overall, 109 patients (7.2%) were admitted to the hospital. The proportion of patients admitted after a home or pharmacy reading, after a physician referral, or who were not documented was 3.1%, 11.9%, and 11.0%, respectively. Two-year mortality rates were 5.4%, 0.0%, 6.5%, and 5.3% for the home, pharmacy, physician referral, and not documented groups, respectively. Among the 92.8% of patients who were discharged from the ED, 11% made another ED visit for hypertension within a year.

Conclusion : In this study, half of patients with an ED visit that was primarily for hypertension presented after elevated readings on self-measurement devices. Only 3% of these patients were admitted to the hospital.

Conclusion (proposition de traduction) : Dans cette étude, la moitié des patients ayant eu une visite aux urgences principalement pour hypertension s'est présentée après des lectures élevées sur des dispositifs d'auto-mesure. Seulement 3 % de ces patients ont été admis à l'hôpital.

Trends in Hospitalization, Readmission, and Diagnostic Testing of Patients Presenting to the Emergency Department With Syncope.
Anderson TS, Thombley R, Dudley RA, Lin GA. | Ann Emerg Med. 2018 Nov;72(5):523-532
DOI: https://doi.org/10.1016/j.annemergmed.2018.08.430
Keywords: Aucun

Cardiology

Introduction : Emergency department (ED) visits for syncope are common and routine diagnostic testing is frequently low yield. Our objective is to determine whether recent guidelines emphasizing limiting hospitalization and advanced diagnostic testing to high-risk patients have changed patterns of syncope care.

Méthode : This was a retrospective population epidemiology study of syncope-related ED visits and hospitalizations using the National Emergency Department Sample from 2006 to 2014 and the State Inpatient Databases and Emergency Department Databases from 2009 and 2013. Primary outcomes were annual incidence rates of syncope ED visits and subsequent hospitalizations, and rates of hospitalization, observation, 30-day revisits, and diagnostic testing comparing 2009 with 2013. Differences were estimated with multivariable logistic regression modeling adjusted for patient clinical and demographic characteristics.

Résultats : From 2006 to 2014, we identified 15,154,920 survey-weighted ED visits for syncope. Annual rates of ED visits increased from 643 to 771 per 100,000 adults, whereas hospitalizations declined from 36.3% to 24.7% (-11.6% absolute difference; 95% confidence interval [CI] -13.0% to -10.2%). In multistate adjusted analyses, the proportion of ED visits resulting in hospital admission decreased 11.7% (95% CI -11.9% to -11.6%) between 2009 and 2013, whereas the proportion of ED visits resulting in observation care increased by 7.9% (95% CI 7.8% to 8.0%), with no significant change in 30-day ED revisit rates (absolute difference 0.1%; 95% CI -0.1% to 0.3%). The frequency of advanced cardiac testing increased from 13.8% to 17.0%, and neuroimaging increased from 40.6% to 44.3%, driven by increased testing of patients receiving observation and inpatient care.

Conclusion : Although the incidence of ED visits for syncope has increased, hospitalization rates have declined, without an adverse effect on ED revisits, possibly because of increased use of observation care. Use of advanced cardiac testing and neuroimaging has increased, driven by growth in testing of patients receiving observation and inpatient care.

Conclusion (proposition de traduction) : Bien que l'incidence des consultations aux urgences pour syncope ait augmenté, les taux d'hospitalisation ont diminué, sans que cela ait un effet négatif sur les consultations au service des urgences, probablement en raison d'un recours accru aux soins d'observation. Le recours aux tests cardiaques avancés et à la neuro-imagerie a augmenté, en raison de la croissance du nombre de tests de patients sous observation et de soins hospitaliers.

Is the Risk of Bleeding Among Older Adults With Atrial Fibrillation Lower With Antiplatelet Compared With Oral Anticoagulants?.
Gettel C, Goldberg EM. | Ann Emerg Med. 2018 Nov;72(5):547-549
DOI: https://doi.org/10.1016/j.annemergmed.2017.10.011  | Télécharger l'article au format  
Keywords: Aucun

Cardiology

Introduction : Two reviewers independently conducted a robust search of MEDLINE PubMed, EMBASE, and the Cochrane Database of Controlled Clinical Trials from their inception to January 2016; bibliographies of identified articles were screened for additional relevant articles.

Méthode : Randomized controlled trials, quasi-randomized controlled trials, nonrandomized controlled trials, controlled before-and-after studies, and prospective or retrospective parallel cohort studies reporting frequency of bleeding events were reviewed if they compared one or several antiplatelet drugs with any oral anticoagulant, included patients aged 65 years and older (ie, 70% or more of all included patients were !65 years, or the studies reported separate data for this age group), or followed patients for 6 months or more. Studies on post- or perioperative bleeding complications and patients receiving combined treatment with anticoagulant and antiplatelet drugs were excluded. Patients younger than 65 years were excluded.

Résultats : Two authors independently assessed every study for inclusion, assessed its risk of bias, and extracted data with predefined forms. The main outcome analyzed was major bleeding, defined as clinically overt bleeding involving a critical anatomic site or associated with death, permanent disability, a decrease in hemoglobin concentration greater than 2 g/dL, or a patient’s requiring transfusion of greater than or equal to 2 units of whole blood or packed RBCs. Secondary outcomes were intracranial bleeding, any severity of bleeding, and all-cause mortality. Outcomes were analyzed at 12 months. The risk of bias was assessed with the tool developed by the Cochrane Collaboration.1 Subgroup analyses were predefined by age (patients 65 to 79 years, or 80 years or older), by indication for anticoagulation (atrial fibrillation or other indications), and by aspirin dose (less than or greater than 100 mg/day).

Conclusion : In conclusion, antiplatelet agents are associated with the same risk of major bleeding events as anti- coagulants, and clinical evaluation for potential bleeding complica- tions should be commensurate with this equivalent risk.

Conclusion (proposition de traduction) : En conclusion, les agents antiplaquettaires sont associés au même risque d'événements hémorragiques majeurs que les anticoagulants et l'évaluation clinique des complications hémorragiques potentielles doit être proportionnelle à ce risque équivalent.

Is Adenosine or an Intravenous Calcium Channel Blocker More Effective for Treating Supraventricular Tachycardia?.
Gottlieb M, Gore K, Gore SR. | Ann Emerg Med. 2018 Nov;72(5):553-555
DOI: https://doi.org/10.1016/j.annemergmed.2017.11.024  | Télécharger l'article au format  
Keywords: Aucun

Cardiology

Introduction : The authors conducted electronic searches of the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from 2006 to July 2017 to identify new articles published after the previous 2006 review. Further searches were performed in databases of ongoing trials from ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform, as well as reference lists of relevant publications.

Méthode : Randomized controlled trials comparing intravenous calcium channel antagonists with adenosine in the setting of patients with supraventricular tachycardia were included. The authors included studies regardless of age, in which the participant received a diagnosis of supraventricular tachycardia on 12-lead ECG within 24 hours of symptom onset. The authors excluded any studies in which supraventricular tachycardia was induced in an electrophysiology laboratory. Primary outcomes included conversion to sinus rhythm and major adverse events (defined as cardiac arrest, prolonged hypotension, symptomatic bradycardia requiring treatment, and acute cardiac failure). Secondary outcomes included time to conversion to sinus rhythm, incidence of relapse into supraventricular tachycardia within 2 hours of conversion, length of hospital stay, minor adverse events, and patient satisfaction. Two authors screened and identified appropriate studies for inclusion, and any disagreements were mediated by a third review author.

Résultats : For each qualified study, 2 of 4 authors extracted data independently. Data were gathered in a standardized form and included trial characteristics, participants, intervention, reversal to sinus rhythm, and adverse events (eg, hypotension). Two authors independently evaluated the quality of the included studies, using the Grading of Recommendations Assessment, Development and Evaluation approach. Risk of bias was assessed with the Cochrane risk-of-bias tool. For dichotomous outcomes, odds ratios and 95% confidence intervals were calculated, whereas for continuous outcomes mean differences and 95% confidence intervals were used. Heterogeneity was assessed with forest plots and both c2 and I2 testing. Publication bias could not be assessed because of the limited number of studies.

Conclusion : Among patients presenting with supraventricular tachycardia, rates of reversion to sinus rhythm and hypotension were similar between patients who were given adenosine or calcium channel blockers.

Conclusion (proposition de traduction) : Parmi les patients présentant une tachycardie supraventriculaire, les taux de réversion du rythme sinusal et d'hypotension étaient similaires chez les patients ayant reçu de l'adénosine ou des inhibiteurs des canaux calciques.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Suspected Non–ST-Elevation Acute Coronary Syndromes:, Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown M. | Ann Emerg Med. 2018 Nov;72(5):e65-e106
DOI: https://doi.org/10.1016/j.annemergmed.2018.07.045  | Télécharger l'article au format  
Keywords: Aucun

Cardiology

Editorial : This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non-ST-elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events? (2) In adult patients with suspected acute non-ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? (3) In adult patients with suspected non-ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events? (4) Should adult patients with acute non-ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.

Conclusion (proposition de traduction) : Cette politique clinique de l'American College of Emergency Physicians (ACEP) aborde des questions clés dans l'évaluation et la prise en charge des patients présentant des syndromes coronariens aigus soupçonnés de ne pas présenter d'élévation du segment ST. Un sous-comité de rédaction a effectué un examen systématique de la documentation afin de formuler des recommandations fondées sur des données probantes pour répondre aux questions cliniques suivantes :
(1) Chez les patients adultes qui ne présentent aucun signe de syndrome coronarien aigu avec élévation du segment ST, la stratification initiale du risque peut-elle être utilisée pour prédire un faible taux d'événements cardiaques indésirables majeurs de 30 jours ?
(2) Chez les patients adultes soupçonnés d'être atteints d'un syndrome coronarien aigu sans élévation du segment ST, un test à la troponine peut-il être utilisé dans les 3 heures suivant la présentation à l'urgence pour prédire un faible taux d'événements cardiaques indésirables majeurs de 30 jours ?
(3) Chez les patients adultes soupçonnés d'avoir un syndrome coronarien aigu sans élévation de l'élévation du segment ST et chez qui un infarctus aigu du myocarde a été exclu, est-ce que d'autres tests diagnostiques (provocateurs, stress test, angiographie par tomodensitométrie) pour le syndrome coronaire aigu avant la sortie permettent de réduire les événements indésirables cardiaques majeurs de 30 jours ?
(4) Les patients adultes souffrant d'infarctus aigu du myocarde sans élévation du segment ST devraient-ils recevoir immédiatement un traitement antiplaquettaire en plus de l'aspirine pour réduire les événements cardiaques indésirables majeurs de 30 jours ?
Les données probantes ont été notées et des recommandations ont été formulées en fonction de la solidité des données disponibles.

Is Hyperpronation More Effective Than Supination for Reduction of a Radial Head Subluxation?.
Bertucci N, Cowling K. | Ann Emerg Med. 2018 Nov;72(5):586-587
DOI: https://doi.org/10.1016/j.annemergmed.2018.01.002  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : The authors searched the Cochrane Bone, Joint and Muscle Trauma Group specialized register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, LILACS, and PEDro. For this update of a previously published Cochrane review, the searches were limited to 2011 onward.

Méthode : Randomized and quasi-randomized controlled clinical trials that evaluated manipulative interventions for radial head subluxation were included.

Résultats : Trials were screened for inclusion independently by 2 review authors. For the included trials, the 2 authors independently extracted data and assessed the risk of bias. The results were statistically pooled with a fixed-effect model and presented as relative risk with 95% confidence intervals (CIs). Statistical heterogeneity was assessed by forest plots, I2 statistic, and Χ2 test for heterogeneity.

Conclusion : Hyperpronation has higher success rates than supination for reduction of radial head subluxation, according to low-quality evidence.

Conclusion (proposition de traduction) : La pronation forcée a des taux de réussite plus élevés que la supination pour la réduction de la pronation douloureuse, selon des preuves de faible qualité.

Does Lidocaine Gel Decrease Procedural Pain for Pediatric Urethral Catheterization?.
Long B, April MD. | Ann Emerg Med. 2018 Nov;72(5):588-590
DOI: https://doi.org/10.1016/j.annemergmed.2018.01.019  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : Two investigators independently searched Ovid MEDLINE, EMBASE, SCOPUS, and the Cochrane Library, with no language restrictions, for literature evaluating lidocaine gel as local anesthetic for transurethral bladder catheterization. Authors also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for unpublished trials. Investigators independently reviewed relevant articles and reference lists for other potential studies.

Méthode : Authors included randomized controlled trials evaluating lidocaine gel versus nonanesthetic gel to reduce pain in patients younger than 18 years undergoing transurethral bladder catheterization. The primary outcome measure was pain associated with transurethral bladder catheterization, as measured by various validated scales.

Résultats : One meta-analysis author extracted study characteristics and primary outcome data. A second author double-checked all data entries. If data were incomplete, meta-analysis investigators contacted primary study authors. The authors registered the meta- analysis study protocol in PROSPERO.1 Authors reported results according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement and used the randomized controlled trial risk-of-bias assessment tool from the Cochrane handbook for review of intervention to assess several study domains for bias.2 The authors resolved discrepancies through consensus. Investigators pooled data with a random-effects model and assessed treatment effect heterogeneity with Pearson’s c2 test, study variation with the I2 statistic, and publication bias with a funnel plot. Authors calculated the standardized mean difference with 95% confidence intervals for between-group treatment effect estimation. They compared mean differences between baseline and procedural pain when possible; when these data were not available, authors compared procedural pain scores.

Conclusion : Lidocaine gel does not reduce the pain of transurethral bladder catheterization in children younger than 4 years compared with nonanesthetic gel. Further study evaluating lidocaine gel in patients older than 4 years is required.

Conclusion (proposition de traduction) : Le gel de lidocaïne ne réduit pas la douleur causée par le cathétérisme de la vessie transurétrale chez les enfants de moins de 4 ans par rapport au gel non anesthésique. Des études complémentaires sont nécessaires pour évaluer le gel de lidocaïne chez les patients âgés de plus de 4 ans.

Among Patients With Intracerebral Hemorrhage, Is Intensive Blood Pressure Decreasing Associated With Improved Outcome?.
Brodrick ZT, Freeze-Ramsey R, Seupaul RA. | Ann Emerg Med. 2018 Nov;72(5):611-612
DOI: https://doi.org/10.1016/j.annemergmed.2018.01.018  | Télécharger l'article au format  
Keywords: Aucun

Neurology

Introduction : The authors performed a search of PubMed, EMBASE, and the Cochrane databases, with the last search conducted June 10, 2016. They also reviewed bibliographies for additional records and checked the references of the publications until no further publications were found.

Méthode : Randomized controlled trials reporting functional outcomes of acute blood pressure decreasing in patients with intracerebral hemorrhage were included for analysis. Primary outcomes were 3- month mortality and significant disability (using a modified Rankin Scale score >3). Secondary outcomes were rates of substantial hemorrhage expansion and serious adverse events.

Résultats : Three authors independently extracted data with a standardized form and assessed study quality. A random-effects model was used in all analyses. Results were reported as odds ratios with 95% confidence intervals. Trial quality was assessed with the Cochrane Collaboration tool. Heterogeneity was assessed with the I2 statistic and qualitatively with forest plot inspection. Publication bias was assessed with a funnel plot.

Conclusion : Intensive blood pressure decreasing in patients with acute intracerebral hemorrhage does not improve functional outcome or mortality.

Conclusion (proposition de traduction) : Une diminution de la pression artérielle intensive chez les patients présentant une hémorragie intracérébrale aiguë n’améliore pas le résultat fonctionnel ni la mortalité.

Comparison of the use of comprehensive point-of-care test panel to conventional laboratory process in emergency department.
Kankaanpää M, Holma-Eriksson M, Kapanen S, Heitto M, Bergström S, Muukkonen L, Harjola VP. | BMC Emerg Med. 2018 Nov 19;18(1):43
DOI: https://doi.org/10.1186/s12873-018-0198-x  | Télécharger l'article au format  
Keywords: Discharge; Emergency department; Laboratory testing; Length of stay; Point-of-care testing

Research article

Introduction : In this study, we hypothesized that point of care testing (POCT) would reduce length of stay (LOS) in emergency department (ED) when compared to central laboratory testing and be a factor in patient discharge destination.

Méthode : A single centre observational study was performed in ED non-ambulatory patients. Blood testing was performed either with POC instruments for blood gases and chemistry panel, full blood count, and CRP, or at central laboratory, or as a combination of both. Blood draw and POCTs were performed by experienced nurses.

Résultats : During the 4-week study period, 1759 patients underwent sample testing (POCT: n = 160, central lab: n = 951; both n = 648). Median waiting time for blood sampling was 19 min less in POCT than central laboratory (0:52 (95% confidence interval (CI) 0:46-1:02) vs. 1:11 (95% CI 1:05-1:14), p < 0.001). POCT results were available faster in both discharge groups, as expected. When imaging was not required, patients in POCT group were discharged home 55 min faster (4:57 (95% CI 3:59-6:17) vs. 5:52 (95% CI 5:21-6:35), p = 0.012) and 1 h 22 min faster when imaging was performed (5:48 (95% CI 5:26-6:18) vs. 7:10 (95% CI 6:47-8:26), p = 0.010). Similar reduction in sampling time and LOS was not seen among those admitted to hospital.

Conclusion : POCT shortened the laboratory process and made results available faster than the central lab. This allowed patients to be discharged home quicker. Thus, with proper training and education of the ED care team, POCT can be used as an effective tool for improving patient flow.

Conclusion (proposition de traduction) : La biologie délocalisée a raccourci le processus de laboratoire et rendu les résultats disponibles plus rapidement que le laboratoire central. Cela a permis aux patients d'être renvoyés chez eux plus rapidement. Ainsi, avec une formation et une éducation appropriées de l'équipe soignante des services des urgences, la biologie délocalisée peut être utilisée comme un outil efficace pour améliorer le flux de patients.

Pain score, desire for pain treatment and effect on pain satisfaction in the emergency department: a prospective, observational study.
van Zanden JE, Wagenaar S, Ter Maaten JM, Ter Maaten JC, Ligtenberg JJM. | BMC Emerg Med. 2018 Nov 8;18(1):40
DOI: https://doi.org/10.1186/s12873-018-0189-y  | Télécharger l'article au format  
Keywords: Emergency department; Numeric rating scale; Oligoanalgesia; Pain management; Pain satisfaction

Research article

Introduction : Pain management in the Emergency Department has often been described as inadequate, despite proven benefits of pain treatment protocols. The aim of this study was to investigate the effectiveness of our current pain protocol on pain score and patient satisfaction whilst taking the patients' wishes for analgesia into account.

Méthode : We conducted a 10-day prospective observational study in the Emergency Department. Demographics, pain characteristics, Numeric Rating Scale pain scores and the desire for analgesics were noted upon arrival at the Emergency Department. A second Numeric Rating Scale pain score and the level of patient satisfaction were noted 75-90 min after receiving analgesics. Student T-tests, Mann-Whitney U tests and Kruskall-Wallis tests were used to compare outcomes between patients desiring vs. not desiring analgesics or patients receiving vs. not receiving analgesics. Univariate and multivariate logistic regression models were used to investigate associations between potential predictors and outcomes.

Résultats : In this study 334 patients in pain were enrolled, of which 43.7% desired analgesics. Initial pain score was the only significant predictive factor for desiring analgesia, and differed between patients desiring (7.01) and not desiring analgesics (5.14). Patients receiving analgesics (52.1%) had a greater decrease in pain score than patients who did not receive analgesics (2.41 vs. 0.94). Within the group that did not receive analgesics there was no difference in satisfaction score between patients desiring and not desiring analgesics (7.48 vs. 7.54). Patients receiving analgesics expressed a higher satisfaction score than patients not receiving analgesics (8.10 vs. 7.53).

Conclusion : This study pointed out that more than half of the patients in pain entering the Emergency Department did not desire analgesics. In patients receiving analgesics, our pain protocol has shown to adequately treat pain, leading to a higher satisfaction for emergency health-care at discharge. This study emphasizes the importance of questioning pain score and desire for analgesics to prevent incorrect conclusions of inadequate pain management, as described in previous studies.

Conclusion (proposition de traduction) : Cette étude a montré que plus de la moitié des patients douloureux entrant dans le service des urgences ne désiraient pas d'antalgiques. Chez les patients recevant des antalgiques, il a été démontré que notre protocole de traitement de la douleur traitait correctement la douleur, ce qui entraînait une plus grande satisfaction des soins de santé d'urgence à la sortie. Cette étude souligne l’importance de remettre en question le score de douleur et le désir d'antalgiques afin d’éviter des conclusions erronées d’une gestion de la douleur inadéquate, comme décrit dans des études précédentes.

Select Rhythm and rate control of atrial fibrillation in the emergency department – A large community-based observational study Rhythm and rate control of atrial fibrillation in the emergency department – A large community-based observational study.
Gilbert CJ, Angaran P, Mariano Z, Aves T, Dorian P. | CJEM. 2018 Nov;20(6):834-840
DOI: https://doi.org/10.1017/cem.2017.421  | Télécharger l'article au format  
Keywords: atrial fibrillation; emergency department; rate control; rhythm control

Original Research

Introduction : Atrial fibrillation (AF) is the most common arrhythmia presentation to the emergency department (ED) and frequently results in admission to the hospital. Although rarely life-threatening and not usually an emergent condition, AF places a large burden on our health-care system. The objective of this study was to describe the practices of ED physicians in the management of AF in a large urban Canadian city.

Méthode : From January 1, 2010 to December 31, 2010, patients with a primary diagnosis of AF were identified across 10 EDs in Toronto, Canada (N=2,609). Fifty patients were selected at random from each hospital for a detailed chart review (n=500).

Résultats : Two hundred thirty-two patients (46%) received rate control, and 129 (26%) received rhythm control with the remainder (28%) receiving neither therapy. Sixty-seven percent of patients were discharged home. Most patients (79%) were symptomatic on arrival; however, only a minority of these (31%) received rhythm control. Factors that were associated with rhythm control included younger age, duration of palpitations ≤ 48 hours, a lower CHADS2 score, and the absence of left ventricular dysfunction.

Conclusion : Our data suggest a wide range of practice amongst ED physicians treating patients presenting to the ED with a primary diagnosis of AF. A randomized trial is needed to better understand the optimal management strategy in this patient population and setting.

Conclusion (proposition de traduction) : Nos données suggèrent un large éventail de pratiques parmi les médecins des urgences traitant des patients présentant un diagnostic primaire de FA. Un essai randomisé est nécessaire pour mieux comprendre la stratégie de gestion optimale dans cette population de patients et dans ce cadre.

Commentaire : Pour mémoire : Prise en charge de la fibrillation atriale en médecine d’urgence  . Recommandations de la Société française de médecine d’urgence en partenariat avec la Société française de cardiologie - 2015

Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department.
Gagné AJ, Voyer P, Boucher V, Nadeau A, Carmichael PH, Pelletier M, Gouin E, Berthelot S, Daoust R, Wilchesky M, Richard H, Pelletier I, Ballard S, Laguë A, Émond M. | CJEM. 2018 Nov;20(6):903-910
DOI: https://doi.org/10.1017/cem.2018.367  | Télécharger l'article au format  
Keywords: Aucun

Original Research

Introduction : Delirium is very frequent in older patients presenting to the emergency department (ED), but is often undetected. The purpose of this study was to evaluate the performance of the French version of the 4 A’s Test (4AT-F) for the detection of delirium and cognitive impairment in older patients.

Méthode : The study was conducted in four Canadian ED. Participants (n = 320) were independent or semi-independent patients (able to perform ≥5 activities of daily living) aged 65 and older and had an 8-hour exposure to the ED environment. The Telephone Interview for Cognitive Status (TICS-m), the Confusion Assessment Method (CAM) as well as the 4AT-F were administered to patients at the initial interview. The CAM and 4AT-F were then administered twice a day during the patients’ ED or hospital stay. The 4AT-F’s sensitivity and specificity were compared to those of the CAM (for delirium), and to that of the TICS (for cognitive impairment).

Résultats : Our results suggest that the 4AT-F has a sensitivity of 84% (95% CI: [76, 93]) and a specificity of 74% (95% CI: [70, 78]) for delirium, as well as a sensitivity of 49% (95% CI: [34, 64]) and a specificity of 87% (95% CI: [82, 92]) for cognitive impairment.

Conclusion : The 4AT-F is a fast and reliable screening tool for delirium and cognitive impairment in ED. Due to its quick administration time, it allows a systematic screening of patients at risk of delirium, without significantly increasing the workload of the ED staff.

Conclusion (proposition de traduction) : Le test 4AT-F se révèle donc un instrument rapide et efficace pour la détection du délirium et des troubles cognitifs au service des urgences. Compte tenu de sa rapidité d’administration, il permet un dépistage systématique du délirium chez les patients susceptibles d’en souffrir, sans pour autant augmenter, de manière importante, la charge de travail du personnel du service des urgences.

Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department.
Thompson C, Brienza VJM, Sandre A, Caine S, Borgundvaag B, McLeod S. | CJEM. 2018 Nov;20(6):911-919
DOI: https://doi.org/10.1017/cem.2018.427  | Télécharger l'article au format  
Keywords: analgesia, delirium, emergency department, hip fracture

Original Research

Introduction : he primary objective was to identify risk factors independently associated with acute in-hospital delirium within 72 hours of emergency department (ED) arrival for patients diagnosed with a hip fracture.

Méthode : This was a retrospective chart review of patients ages 65 years and older presenting to one of two academic EDs with a discharge diagnosis of a hip fracture from January 1, 2014, to December 31, 2015. A multivariable logistic regression analysis was used to determine variables inde- pendently associated with the development of acute in- hospital delirium within 72 hours of ED arrival.

Résultats : Of the 668 included patients, 181 (27.1%) developed delirium within 72 hours of ED arrival. History of neurode- generative disease or dementia (odds ratio [OR]: 5.7, 95% confidence interval [CI]: 3.9, 8.4), age > 75 (OR: 2.8, 95% CI: 1.4, 5.6), and absence of analgesia (no opioid or nerve block) in the ED (OR: 2.1, 95% CI: 1.3, 3.2) were independently associated with the development of acute in-hospital delir- ium; 525 (78.6%) patients received opioid analgesia in the ED. The most common analgesics used in the ED were intrave- nous (IV) morphine (35.8%), IV hydromorphone (35.2%), or dual therapy with both IV hydromorphone and IV morphine (2.2%). Femoral nerve blocks were initiated for 36 (5.4%) patients and successfully completed in 35 (5.2%) patients in the ED.

Conclusion : Advanced age and signs of dementia or neurodegenerative disease are predictors of 72-hour delirium that can be screened for during triage. Improved pain control in the ED may reduce the risk of acute in-hospital delirium.

Conclusion (proposition de traduction) : Un âge avancé et des signes de démence ou de maladie neurodégénérative sont des facteurs prévisionnels d’apparition, dans les 72 heures suivant l’arrivée à l’hôpital, d’un état confusionnel aigu, pouvant être dépistés au moment du triage. Par ailleurs, une amélioration du soulage- ment de la douleur au SU peut diminuer le risque d’apparition d’un état confusionnel aigu à l’hôpital.

Are third-generation cephalosporins associated with a better prognosis than amoxicillin-clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?.
Batard E, Javaudin F, Montassier E. | Clin Microbiol Infect. 2018 Nov;24(11):1171-1176
DOI: https://doi.org/10.1016/j.cmi.2018.07.016
Keywords: Amoxicillin–clavulanate; Cefotaxime; Ceftriaxone; Community-onset pneumonia; Mortality

Original article

Introduction : We aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin-clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia.

Méthode : We conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin-clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other β-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin-clavulanate.

Résultats : 1698 patients (median age, 80 y) were included, of which 716 and 198 were treated with amoxicillin-clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9-12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4-5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3-15.7)), do-not-resuscitate order (aOR 8.7 (5.2-14.6)) and fluid therapy (aOR 6.3 (2.5-15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin-clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7-3.0)).

Conclusion : In the largest study aiming to compare amoxicillin-clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin-clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin-clavulanate for patients hospitalized in medical wards with community-onset pneumonia.

Conclusion (proposition de traduction) : Dans la plus grande étude visant à comparer l'amoxicilline-clavulanique et la ceftriaxone/céfotaxime au cours d'une pneumopathie communautaire, la ceftriaxone/céfotaxime n'a pas été associée à une mortalité intrahospitalière inférieure à celle de l'amoxicilline-clavulanique. Nos résultats suggèrent que la ceftriaxone/céfotaxime ne devrait pas être préférée à l'amoxicilline-clavulanique chez les patients hospitalisés dans des services de médecine pour pneumopathie communautaire.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Amoxicilline + Ac. clavulanique ou Céfotaxime/Ceftriaxone pour traiter les Pneumonie Aiguë Communautaire hospitalisées ?  . Rédigé par le Dr Jean-Pierre Bru.

Managing accidental hypothermia: progress but still some way to go.
Gordon L, Paal P. | Emerg Med J. 2018 Nov;35(11):657-658
DOI: https://doi.org/10.1136/emermed-2018-207898
Keywords: environmental medicine, hypothermia

Commentary

Editorial : Accidental hypothermia has become much better understood over the last 25 years. Not only is it recognised that it significantly worsens the prognosis if it occurs alongside many medical conditions including major trauma and elective surgery, but it is also well established that severe accidental hypothermia (core temperature <28°C) is eminently survivable if treated correctly, even in the presence of cardiac arrest.

Conclusion : In the absence of a formal guideline, individual organisations have to decide locally how to manage hypothermia, perhaps at short notice, with all the potential for inaccuracy that this approach engenders. An authoritative evidence-based guideline supported by education and the availability of essential equipment is the ideal, as seen with ALS. Without this approach, a repeat of this survey done in 5 years’ time will probably find no improvements.

Conclusion (proposition de traduction) : En l'absence de recommandations formelles, les organisations individuelles doivent décider localement comment gérer l'hypothermie, peut-être à bref délai, avec tout le potentiel d'inexactitude que cette approche engendre.
Une recommandation fondée sur des données probantes, étayée par l'éducation et par la disponibilité d'équipements essentiels, est l'idéal, comme le montre le traitement de l'arrêt cardio-respiratoire. Sans cette approche, la répétition de cette enquête réalisée dans cinq ans ne permettra probablement pas d’améliorer la situation.

Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation.
Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, Smith JE; PERUKI (Paediatric Emergency Research in the UK and Ireland). | Emerg Med J. 2018 Nov;35(11):669-674
DOI: https://doi.org/10.1136/emermed-2018-207739  | Télécharger l'article au format  
Keywords: cardiac arrest; major trauma management; paediatric emergency med; paediatric injury; paediatric resuscitation

PAEDIATRICS

Introduction : Paediatric traumatic cardiac arrest (TCA) is a high acuity, low frequency event. Traditionally, survival from TCA has been reported as low, with some believing resuscitation is futile. Within the adult population, there is growing evidence to suggest that with early and aggressive correction of reversible causes, survival from TCA may be comparable with that seen from medical out-of-hospital cardiac arrests. Key to this survival has been the adoption of a standardised approach to resuscitation. The aim of this study was, by a process of consensus, to develop an algorithm for the management of paediatric TCA for adoption in the UK.

Méthode : A modified consensus development meeting of UK experts involved in the management of paediatric TCA was held. Statements discussed at the meeting were drawn from those that did not reach consensus (positive/negative) from a linked three-round online Delphi study. 19 statements relating to the diagnosis, management and futility of paediatric TCA were initially discussed in small groups before each participant anonymously recorded their agreement with the statement using 'yes', 'no' or 'don't know'. In keeping with our Delphi study, consensus was set a priori at 70%. Statements reaching consensus were included in the proposed algorithm.

Résultats : 41 participants attended the meeting. Of the 19 statements discussed, 13 reached positive consensus and were included in the algorithm. A single statement regarding initial rescue breaths reached negative consensus and was excluded. Consensus was not reached for five statements, including the use of vasopressors and thoracotomy for haemorrhage control in blunt trauma.

Conclusion : In attempt to standardise our approach to the management of paediatric TCA and to improve outcomes, we present the first consensus-based algorithm specific to the paediatric population. While this algorithm was developed for adoption in the UK, it may be applicable to similar healthcare systems internationally.

Conclusion (proposition de traduction) : Dans le but de normaliser notre approche de la gestion des arrêts cardiaques traumatiques chez les enfants et d’améliorer les résultats, nous présentons le premier algorithme consensuel spécifique à la population pédiatrique. Bien que cet algorithme ait été développé pour adoption au Royaume-Uni, il peut être applicable à des systèmes de soins de santé similaires au niveau international.

The presence of companions during emergency department evaluation and its impact on perceptions of clinician-patient communication.
Cornelius T, Moise N, Birk JL, Edmondson D, Chang BP. | Emerg Med J. 2018 Nov;35(11):701-703
DOI: https://doi.org/10.1136/emermed-2018-207735
Keywords: cardiac care, acute coronary syndrome; clinical care; emergency department; interpersonal

Short report

Introduction : Research in outpatient setting suggests that the presence of companions during a medical encounter can improve clinician-patient communication. It is not known if the presence of companions has a similar effect in the acutely stressful context of the ED. This study tested whether the presence of companions in the ED relate to stronger clinician-patient communication. We further explored effect modification by demographic factors (race/ethnicity, education and language) thought to compromise communication.

Méthode : Participants were drawn from an observational cohort study of patients with suspected acute coronary syndrome (n=876) recruited from an urban academic medical centre between 2013 and 2016. Patient interviews occurred both in the ED and post-ED discharge; communication was assessed using the Interpersonal Processes of Care Survey with possible range of scores of 14-70. Companions were categorised as close others (ie, partner/spouse or child), non-close others (eg, neighbour) or no one.

Résultats : Perceptions of clinician-patient communication were high (mean=57.1, SD=10.6;). There was no association between companions (close/non-close/no one) and clinician-patient communication, p=0.262. Demographic factors were unrelated to communication. There was a significant interaction between education and companions. Having a close other in the ED was associated with stronger clinician-patient communication only for patients with high school education or less, p=0.027.

Conclusion : Neither the presence of companions nor demographic factors were related to clinician-patient communication. The interaction effect suggesting that patients completing high school or less have the most to gain from the presence of close others warrants further exploration.

Conclusion (proposition de traduction) : Ni la présence d'accompagnants ni les facteurs démographiques n'étaient liés à la communication médecin-patient. L'effet d'interaction suggérant que les patients qui ont terminé leurs études secondaires ou moins ont le plus à gagner à la présence de proches mérite une exploration plus approfondie.

Evaluation of ceftriaxone prescriptions in the emergency department of a university hospital: an urgent need for improvement and alternative therapy.
Gennai S, Ortiz S, Boussat B, François P, Pavese P. | Eur J Clin Microbiol Infect Dis. 2018 Nov;37(11):2063-2068
DOI: https://doi.org/10.1007/s10096-018-3339-y
Keywords: Antibiotic consumption; Ceftriaxone; Relevance of antibiotic prescriptions

Original article

Introduction : To evaluate the relevance of ceftriaxone prescriptions in an emergency department of a university hospital and suggest whenever possible an antibiotic alternative with a lower ecological impact.

Méthode : All ceftriaxone prescriptions in the first complete week of each month during the year 2016, in the emergency department of the Grenoble university hospital, have been analyzed by an IDS referent in antibiotic prescriptions. Ceftriaxone prescription was considered appropriate if justified (an antibiotic must be used), relevant (ceftriaxone is a good choice), and adapted (in terms of dose, route, and period of administration), regardless of a potential antibiotic association, consistent with international recommendations. We considered patient outcome regarding the quality of initial prescription. Additionally, alternatives were suggested for relevant prescriptions.

Résultats : We included 327 patients, of which ceftriaxone prescriptions were not appropriate in 37.6% of cases: 13.5% were not justified, 12.8% not relevant, and 11.3% not adapted. The main factors associated with unjustified prescriptions were urinary, dermatological, and less frequent infection sites (p < 0.001). The main factors associated with irrelevant prescriptions were patients carrying multi-resistant bacteria (p = 0.002) or already following an antibiotic prescription at emergency department admission (p = 0.024). Antibiotic prescriptions were poorly adapted in patients with a creatinine rate over 150 μmol/L (p < 0.001) and septic shocks (p = 0.032).

Conclusion : No difference was found concerning the hospital length of stay comparing appropriate initial prescriptions to inappropriate ones. However, alternatives with lower ecological impact were suggested in 55.2% of relevant prescriptions. In emergency departments, it is crucial to preserve ceftriaxone, selecting better indications and considering alternatives.

Conclusion (proposition de traduction) : Aucune différence n'a été constatée concernant la durée de séjour à l'hôpital comparant les ordonnances initiales appropriées aux ordonnances inappropriées. Cependant, des alternatives ayant un impact écologique moindre ont été suggérées dans 55,2 % des prescriptions pertinentes. Dans les services d’urgence, il est crucial de préserver la ceftriaxone en sélectionnant de meilleures indications et en envisageant des alternatives.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Prescriptions de ceftriaxone aux urgences : une grande marge d’amélioration en France d’après cette étude  . Rédigé par le Dr Philippe Lesprit.

Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial.
Writing Group for the PReVENT Investigators, Simonis FD, Serpa Neto A, Binnekade JM, Braber A, Bruin KCM, Determann RM, Goekoop G, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR9, de Wilde RBP, Vriends M, Gama de Abreu M, Pelosi P, Schultz MJ. | JAMA. 2018 Nov 13;320(18):1872-1880
DOI: https://doi.org/10.1001/jama.2018.14280  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS).
OBJECTIVE: To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy.

Méthode : DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands.
INTERVENTIONS: Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484).
MAIN OUTCOMES AND MEASURES: The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax.

Résultats : In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55).

Conclusion : In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy.

Conclusion (proposition de traduction) : Chez les patients des soins intensifs sans SDRA qui ne devaient pas être extubés dans les 24 heures suivant la randomisation, une stratégie de faible volume courant n'a pas entraîné un plus grand nombre de jours sans ventilateur qu'une stratégie intermédiaire de volume courant.

Revisiting the Appendiceal Diameter via Ultrasound for the Diagnosis of Acute Appendicitis.
Chicaiza HP, Malia L, Mulvey CH, Smith SR. | Pediatr Emerg Care. 2018 Nov;34(11):757-760
DOI: https://doi.org/10.1097/PEC.0000000000001278
Keywords: Aucun

Original Articles

Introduction : This study aims to investigate the optimal outer appendiceal diameter via ultrasound for the diagnosis of acute appendicitis.

Méthode : A retrospective chart review was conducted on patients (ages, 2-18 years) presenting to an urban pediatric emergency department between January 1, 2009 and December 31, 2010 with suspected acute appendicitis. Children were considered as having "suspected acute appendicitis" if they (1) presented with acute abdominal pain and had either a surgical consult or an abdominal ultrasound, or (2) presented or transferred with the stated suspicion of acute appendicitis. Pathology reports were used to confirm the diagnosis of appendicitis. The appendiceal diameters were determined by board-certified pediatric radiologists.

Résultats : A total of 320 patient charts were reviewed (females, 57%; mean age, 10.9; SD, 3.9). Seventy-two percent (N = 230) of the patients screened positive for acute appendicitis via ultrasound, 69% (N = 222) had confirmed acute appendicitis, 75% (N = 239) of the ultrasound reports included an outer appendiceal diameter. Overall, ultrasound was found to be highly sensitive (91%) and moderately specific (74%). With an outer appendiceal diameter of 6 mm as a cutoff, ultrasound had an excellent sensitivity (100%) but poor specificity (43%). With an outer diameter of 7 mm as a cutoff, sensitivity decreased to 94% but specificity increased to 71%. With increasing cutoff size, the sensitivity decreased and specificity increased.

Conclusion : Our data suggest that the optimal outer appendiceal diameter for the diagnosis of acute appendicitis should be 7 mm instead of the currently used 6 mm.

Conclusion (proposition de traduction) : Nos données suggèrent que le diamètre appendiculaire externe optimal pour le diagnostic d'appendicite aiguë devrait être de 7 mm au lieu des 6 mm actuellement utilisés.

Dental Abscess in Pediatric Patients: A Marker of Neglect.
Jenkins GW, Bresnen D, Jenkins E, Mullen N. | Pediatr Emerg Care. 2018 Nov;34(11):774-777
DOI: https://doi.org/10.1097/PEC.0000000000001611
Keywords: Aucun

Original articles

Introduction : Neglect is defined as the persistent failure to meet a child or young person's basic physical or psychological needs. Dental caries is explicitly mentioned in guidance on child maltreatment. We discuss the link between dental caries and child abuse in patients presenting to the emergency department.

Méthode : A review of patient medical records was undertaken within the Paediatric Emergency Department at Sunderland Royal Hospital, with the aim to determine whether neglect was considered as a possible contributory factor when a child or young person presented at triage with an "oral cavity" problem.

Résultats : Of the applicable cases with inferences of possible safeguarding concerns, 13% had these concerns documented.

Conclusion : Child abuse recognition has become a prominent issue in recent years due to high profile cases. It is clear from this work, which resonates with the reported literature, that there is a lack of recognition of dental neglect being a possible indicator of more systemic abuse.There is likely underreporting of these cases to the relevant authorities.

Conclusion (proposition de traduction) : La reconnaissance de la maltraitance des enfants est devenue un problème majeur ces dernières années en raison de cas très médiatisés. Il ressort clairement de ces travaux, en résonance avec la littérature rapportée, que le fait que la négligence dentaire soit reconnue comme un indicateur possible d’abus plus systémique est mal reconnu. Il est probable que ces cas ne soient pas signalés aux autorités compétentes.

CPR feedback/prompt device improves the quality of hands-only CPR performed in manikin by laypersons following the 2015 AHA guidelines.
Liu Y, Huang Z, Li H, Zheng G, Ling Q, Tang W, Yang Z. | Am J Emerg Med. 2018 Nov;36(11):1980-1985
DOI: https://doi.org/10.1016/j.ajem.2018.02.034
Keywords: CPR feedback/prompt device; CPR quality; Hands-only CPR; Manikin

Original Contribution

Introduction : We investigated the effects of a cardiopulmonary resuscitation (CPR) feedback/prompt device on the quality of chest compression (CC) during hands-only CPR following the 2015 AHA guidelines.

Méthode : A total of 124 laypersons were randomly assigned into three groups. The first (n=42) followed the 2010 guidelines, the second (n=42) followed the 2015 guidelines with no feedback/prompt device, the third (n=40) followed the 2015 guidelines with a feedback/prompt device (2015F). Participants underwent manual CPR training and took a written basic life support examination, then required to perform 2min of hands-only CPR monitored by a CPR feedback/prompt device. The quality of CPR was quantified as the percentage of correct CCs (mean CC depth and rate, complete recoil and chest compression fraction (CCF)) per 20s, as recorded by the CPR feedback/prompt device.

Résultats : Significantly higher correct ratios of CC, CC depth, and rate were achieved in the 2010 group in each minute vs the 2015 group. The greater mean CC depth and rate were observed in the 2015F group vs the 2015 group. The correct ratio of CC was significantly higher in the 2015F group vs the 2015 group. CCF was also significantly higher in the 2015F group vs the 2015 group in the last 20s of CPR.

Conclusion : It is difficult for a large percentage of laypersons to achieve the targets of CC depth and rate following the 2015 AHA guidelines. CPR feedback/prompt devices significantly improve the quality of hands-only CPR performance by laypersons following the standards of the 2015 AHA guidelines.

Conclusion (proposition de traduction) : Il est difficile pour un pourcentage élevé de secouristes non professionnels d'atteindre les objectifs de profondeur et de taux de compression thoracique des recommandations de 2015 de l'AHA.
Les assistants d'aide à la compression thoracique (non automatisé [NDLR !]) améliorent de manière significative la qualité des performances des compressions thoraciques manuelles lors de la réanimation cardiopulmonaire par des secouristes non professionnels, conformément aux normes des recommandations de l'AHA de 2015.

Commentaire : Il s'agit, notamment, des assistants de compressions thoraciques suivants (par ordre alphabétique, non exhaustif) : , CardiAid CPREzy, Cardio First Angel (Colson), CPRmeter 2 (Laerdal Medical), LinkCPR (SunLife Science), XFT-0008 (Shenzhen XFT Electronics)…

The association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes.
Chen YC, Hung MS, Liu CY, Hsiao CT, Yang YH. | Am J Emerg Med. 2018 Nov;36(11):1998-2004
DOI: https://doi.org/10.1016/j.ajem.2018.03.010
Keywords: Cardiac arrest; OHCA; Out-of-hospital cardiac arrest; Sodium bicarbonate

Original contribution

Introduction : Sodium bicarbonate administration is mostly restricted to in-hospital use in Taiwan. This study was conducted to investigate the effect of sodium bicarbonate on outcomes among patients with out-of-hospital cardiac arrest (OHCA).

Méthode : This population-based study used a 16-year database to analyze the association between sodium bicarbonate administration for resuscitation in the emergency department (ED) and outcomes. All adult patients with OHCA were identified through diagnostic and procedure codes. The primary outcome was survival to hospital admission and secondary outcome was the rate of death within the first 30days of incidence of cardiac arrest. Cox proportional-hazards regression, logistic regression, and propensity analyses were conducted.

Résultats : Among 5589 total OHCA patients, 15.1% (844) had survival to hospital admission. For all patients, a positive association was noted between sodium bicarbonate administration during resuscitation in the ED and survival to hospital admission (adjusted odds ratio [OR]: 4.47; 95% confidence interval [CI]: 3.82-5.22, p<0.001). In propensity-matched patients, a positive association was also noted (adjusted OR, 4.61; 95% CI: 3.90-5.46, p<0.001).

Conclusion : Among patients with OHCA in Taiwan, administration of sodium bicarbonate during ED resuscitation was significantly associated with an increased rate of survival to hospital admission.

Conclusion (proposition de traduction) : Chez les patients ayant subi un arrêt cardiaque extra-hospitalier à Taïwan, l'administration de bicarbonate de sodium pendant la réanimation aux urgences a été associée de façon significative à une augmentation du taux de survie à l'admission à l'hôpital.

Repeat lactate level predicts mortality better than rate of clearance.
Dezman ZDW, Comer AC, Smith GS, Hu PF, Mackenzie CF, Scalea TM, Hirshon JM. | Am J Emerg Med. 2018 Nov;36(11):2005-2009
DOI: https://doi.org/10.1016/j.ajem.2018.03.012
Keywords: Calculation; Clearance; Lactate; Resuscitation; Survival; Trauma

Original contribution

Introduction : Lactate clearance has been developed into a marker of resuscitation in trauma, but no study has compared the predictive power of the various clearance calculations. Our objective was to determine which method of calculating lactate clearance best predicted 24-hour and in-hospital mortality after injury.

Méthode : Retrospective chart review of patients admitted to a Level-1 trauma center directly from the scene of injury from 2010 to 2013 who survived >15min, had an elevated lactate at admission (≥3mmol/L), followed by another measurement within 24h of admission. Lactate clearance was calculated using five models: actual value of the repeat level, absolute clearance, relative clearance, absolute rate, and relative rate. Models were compared using the areas under the respective receiver operating curves (AUCs), with an endpoint of death at 24h and in-hospital mortality.

Résultats : 3910 patients had an elevated admission lactate concentration on admission (mean=5.6±3.0mmol/L) followed by a second measurement (2.7±1.8mmol/L). Repeat absolute measurement best predicted 24-hour (AUC=0.85, 95% CI: 0.84-0.86) and in-hospital death (AUC=0.77; 95% CI, 0.76-0.78). Relative clearance was the best model of lactate clearance (AUC=0.77, 95% CI: 0.75-0.78 and AUC=0.705, 95% CI: 0.69-72, respectively) (p<0.0001 for each). A sensitivity analysis using a range of initial lactate measures yielded similar results.

Conclusion : The absolute value of the repeat lactate measurement had the greatest ability to predict mortality in injured patients undergoing resuscitation.

Conclusion (proposition de traduction) : La valeur absolue de la mesure répétée du lactate est celle qui permet le mieux de prédire la mortalité chez les patients blessés en réanimation.

Relocation of blood gas laboratory to the emergency department helps decrease lactic acid values.
Brazg J, Huang P, Weiner C, Singh G, Likourezos A, Salem L, Dickman E, Marshall J. | Am J Emerg Med. 2018 Nov;36(11):2035-2037
DOI: https://doi.org/10.1016/j.ajem.2018.03.017
Keywords: Blood gas; Critical care; Emergency department laboratory; Lactate

original contribution

Introduction : Emergency Physicians often rely on Lactic Acid (LA) values to make important clinical decisions. Accuracy of LA values improve when blood gas analysis is performed in the emergency department (ED) as opposed to a satellite laboratory (SL).
OBJECTIVE: To investigate an association between blood gas laboratory location and accuracy of ED lactic acid samples.

Méthode : The study team evaluated lactic acid values from venous and arterial blood gas samples drawn between June 1, 2015 and September 30, 2016. The study was exempt from institutional review board approval. Samples were separated into two groups: those which were drawn prior to and after relocation of the blood gas laboratory to the ED. The data, including patient demographic characteristics, acute illness severity indices, and blood gas results were compared within and between each group using t-test for continuous variables and chi-square test for categorical variables. The primary outcome was the mean lactate value measured in the SL group in 2015 compared to the ED group in 2016. Potassium and creatinine values were measured between the two groups as secondary outcomes.

Résultats : Of the 21,595 consecutive samples drawn, 10,363 samples were from the SL group and 11,232 from the ED group. The SL group included 5458 (52.7%) women; mean (SD) age was 61.8 (21.0). The ED group contained 5860 (52.2%) women; mean (SD) age was 61.7 (20.5). Mean Emergency Severity Index (ESI) were the same in each group at 2.31 and rates of Systemic Inflammatory Response Syndrome (SIRS) were also equivalent in each group at 22.2%. Significant differences were found between LA values in the SL group (mean 2.21mmol/L) and in the ED group (mean 1.99mmol/L) with a p value of <0.0001. There was a small statistical significance between the difference in potassium values in the SL group (mean 3.98meq/L) compared to the ED Group (mean 3.96meq/L) with a p value of 0.022. No significant difference was found between the creatinine values.

Conclusion : These results suggest that mean lactate values decreased when measured in an ED blood gas laboratory and may provide more accurate LA results than blood gas samples analyzed at an SL blood gas laboratory within the same institution. Hospitals may consider moving blood gas laboratories to the ED to improve accuracy of one of the most important early blood markers used in the definition of sepsis and in the identification of the critically ill.

Conclusion (proposition de traduction) : Ces résultats suggèrent que les valeurs moyennes de lactate ont diminué lorsqu'elles sont mesurées dans un laboratoire qui réalise l'analyse des gaz du sang aux urgences et peuvent fournir des résultats de taux d'acide lactique plus précis que les échantillons de gaz du sang analysés dans un laboratoire satellite du même établissement. Les hôpitaux peuvent envisager de transférer les laboratoires qui réalisent le dosage des gaz du sang dans le service des urgences afin d'améliorer l'exactitude de l'un des marqueurs sanguins précoces les plus importants utilisés dans la définition du sepsis et dans l'identification des patients devant être admis en réanimation.

Association of fentanyl use in rapid sequence intubation with post-intubation hypotension.
Takahashi J, Goto T, Okamoto H, Hagiwara Y, Watase H, Shiga T, Hasegawa K; Japanese Emergency Medicine Network Investigators. | Am J Emerg Med. 2018 Nov;36(11):2044-2049
DOI: https://doi.org/10.1016/j.ajem.2018.03.026
Keywords: Adverse events; Emergency department; Fentanyl; Post-intubation hypotension; Rapid sequence intubation

Original contribution

Introduction : The anesthesia literature has reported that pre-intubation fentanyl use is associated with post-intubation hypotension which is a risk factor of poor post-emergency department (ED) prognosis. However, little is known about the relations between fentanyl use for intubation and post-intubation hypotension in the ED. We aimed to determine whether pretreatment with fentanyl was associated with a higher risk of post-intubation hypotension in the ED.

Méthode : We conducted a secondary analysis of data of ED airway management collected from a multicenter prospective study of 14 Japanese EDs from February 2012 through November 2016. We included all adult non-cardiac-arrest patients who underwent rapid sequence intubation for medical indication. Patients were divided into fentanyl and non-fentanyl groups. The primary outcome was post-intubation hypotension (systolic blood pressure ≤90mmHg) in the ED.

Résultats : Of 1263 eligible patients, 466 (37%) patients underwent pretreatment with fentanyl. The fentanyl group had a higher risk of post-intubation hypotension (17% vs. 6%; unadjusted OR, 1.73; 95%CI, 1.01-2.97; P=0.048) compared to the non-fentanyl group. In the multivariable analysis adjusting for age, sex, weight, principal indication, sedatives, intubator's specialty, number of intubation attempts, and patient clustering within EDs, the fentanyl group had a higher risk of post-intubation hypotension (adjusted OR, 1.87; 95%CI, 1.05-3.34; P=0.03) compared to the non-fentanyl group. In the sensitivity analysis using propensity score matching, this association remained significant (OR, 3.17; 95%CI, 1.96-5.14; P<0.01).

Conclusion : In this prospective multicenter study of ED airway management, pretreatment with fentanyl in rapid sequence intubation was associated with higher risks of post-intubation hypotension.

Conclusion (proposition de traduction) : Dans cette étude prospective multicentrique sur la prise en charge des voies aériennes aux urgences, le prétraitement par fentanyl lors d'une intubation en séquence rapide était associé à des risques plus élevés d'hypotension post-intubation.

Reducing mortality in near-hanging patients with a novel early management protocol.
Tharmarajah M, Tharmarajah M, Ijaz H, Vallabhai M, Jena NN, LeSaux M, Smith JP, Chen C, Ma Y, Douglass KA, Meltzer AC. | Am J Emerg Med. 2018 Nov;36(11):2050-2053
DOI: https://doi.org/10.1016/j.ajem.2018.08.003
Keywords: Global health; India; Intubation; Near-hanging; Targeted temperature management; Trauma

Brief Reports

Introduction : Hanging is one of the most common causes of suicide world-wide, more prevalent in developing countries. There are no established protocols for early management of near-hanging patients who present to the emergency department (ED). The use of early intubation, strict blood pressure control and targeted temperature management has shown promise in small studies.
OBJECTIVE: To detect changes in mortality and neurological deficits in near-hanging patients before and after implementation of a novel early management protocol in a tertiary care hospital in India.

Méthode : Prospective cohort study conducted at a tertiary-care hospital in Tamil Nadu, India from August 2014-July 2016. For first year of study (pre-implementation), near-hanging patients were treated without a structured protocol. For second year of study (post-implementation), near-hanging patients were treated per a protocol including early intubation, strict blood pressure control and targeted temperature management. Primary outcomes included: (1) in-hospital mortality and (2) hospital discharge without neurological deficit.

Résultats : 65 patients were included (27 in the pre-implementation phase and 38 in the post-implementation phase.) At presentation, there was no difference between the two groups in mean heart rate, mean arterial pressure, mean oxygen saturation, Glasgow coma score, or mean respiratory rate. Protocol implementation decreased mortality (10/27 (37%) versus 2/38 (5%), P < 0.05) and increased the number of patients discharged without neurological deficit (10/27 (37%) versus 35/38 (92%), P < 0.05).

Conclusion : his novel early management protocol reduced mortality and increased the number discharged without neurological deficit in near-hanging patients in a single tertiary care center in India.

Conclusion (proposition de traduction) : Ce nouveau protocole de prise en charge précoce a permis de réduire la mortalité et d'augmenter le nombre de patients sans déficit neurologique chez les patients pris en charge pour quasi-pendaison dans un seul centre de soins tertiaires en Inde.

Urgent care peripheral nerve blocks for refractory trigeminal neuralgia.
Perloff MD, Chung JS. | Am J Emerg Med. 2018 Nov;36(11):2058-2060
DOI: https://doi.org/10.1016/j.ajem.2018.08.019
Keywords: Nerve block; Refractory trigeminal neuralgia; Trigeminal neuralgia

Brief reports

Introduction : After medication failure, patients with refractory trigeminal neuralgia (TGN) often present urgently and seek more potent or invasive therapies such as opioids or surgical options. Peripheral nerve blocks, safe and simple, may offer extended pain relief prior to opioid use or more invasive ganglion level procedures.

Méthode : We report a retrospective case-series (urgent care, at a large urban medical center, over a 2 year period) of nine patients with intractable primary TGN who underwent peripheral trigeminal nerve blocks after failing conservative medical therapy. After antiseptic skin preparation, a 30 g needle was inserted localizing to the supraorbital, infraorbital, and mental foramens. 0.5 mL of 0.25% bupivicaine:1% lidocaine was injected locally at all three foramens. Then, 1 mL of the above was injected in the region of the auriculotemporal nerve (see Video 1). All injections were done on the side with TGN pain.

Résultats : All nine patients experienced immediate pain relief of >50% with 7 of 9 being completely pain free or just mild paresthesia. Six of nine patients had lasting pain relief (1-8 months); three patients reporting pain now tolerable with adjunct medication and two patients were completely pain free.

Conclusion : The treatment paradigm for TGN remains unclear when a patient fails conservative medical therapy. In this case series, many patients achieved rapid and sustained TGN pain relief with peripheral trigeminal nerve blocks. This modality should be considered as a potential therapeutic option in the ED or urgent care setting.

Conclusion (proposition de traduction) : Le paradigme de traitement de la névralgie du trijumeau n'est pas clair lorsqu'un patient n'est pas soulagé par un traitement médical conservateur. Dans cette série de cas, plusieurs patients ont obtenu une antalgie rapide et persistante de la névralgie du trijumeau par des blocs nerveux périphérique.
Cette modalité d'antalgie doit être envisagée comme une option thérapeutique potentielle dans le service des urgences ou dans un établissement de soins d'urgence.

Predicting fluid responsiveness: A review of literature and a guide for the clinician.
Jalil BA, Cavallazzi R. | Am J Emerg Med. 2018 Nov;36(11):2093-2102
DOI: https://doi.org/10.1016/j.ajem.2018.08.037
Keywords: Fluid responsiveness; Hemodynamics; Resuscitation; Shock

Reviews

Editorial : Volume resuscitation is of utmost importance in the treatment of shock. It is imperative that this resuscitation be guided using a reliable method of ascertaining volume status to avoid the ill-effects of hypovolemia while also avoiding those of over-resuscitation. There are numerous tools and methods available in this era to aid the bedside physician in guiding volume resuscitation, many of which will be described in this review of literature. The methods to assess preload responsiveness are broadly divided into static and dynamic measurements. Static measurements involve 'snapshot' estimations of preload. Dynamic measurements rely on fluctuations in heart-lung interactions or a simulated volume challenge to predict whether increasing preload by volume loading will be beneficial. Dynamic measurements are favored over static measurements, however the conditions to be met for most dynamic measurements to be valid leave these methods to be used reliably in a very discrete critically-ill population. This issue is overcome by utilizing maneuvers that have been developed to assess fluid responsiveness that liberalize the conditions required for most dynamic measurements, such as passive leg raising, end expiratory occlusion, and mini-fluid boluses. This review of literature highlights the differences between static and dynamic measurements of fluid responsiveness, and proposes a guide to choosing the most reliable methods of ascertaining volume responsiveness individualized to each patient.

Discussion : In the resuscitation of shock, it is essential to determine fluid responsiveness to prevent unnecessary fluid administration and its associated risks. Froma physiologic stance, staticmeasurements are not reliable indicators of fluid responsiveness while dynamicmeasurements and maneuvers appear more useful. Most methods available require extensive prerequisites to be met, mechanical ventilation with higher tidal volumes being themost common, leaving fewer reliablemethods for spontaneously breathing patients. Of the methods reviewed, a passive leg raise coupled with a minimally-invasive cardiac output monitor has the least prerequisites and can be used in a variety of critically-ill patients.
It is important to note that fluid responsiveness ismerely an assessment of a patient's position on the Frank-Starling curve. It is very important to integrate the assessment of fluid responsiveness with parameters that assess fluid overload. These include physical examination, fluid balance,weight, and very importantly lung ultrasound. Ultrasound is being used increasingly and its ability to predict preload responsiveness is promising and the subject of ongoing study.

Conclusion : We acknowledge that most studies evaluating measures of fluid responsiveness are small, single center studies that lacked an assessment of reproducibility. It is unclear which of the dynamic measurements are superior and we cannot conclude an order of preference for the methods available. We recommend an individualized approach to the integration of different modalities to assess fluid responsiveness and guide fluid resuscitation in the critically-ill patient.
At the bedside, clinicians should be aware of the pitfalls and limitations of modalities available to ascertain fluid responsiveness.

Conclusion (proposition de traduction) : Nous reconnaissons que la plupart des études évaluant les mesures de la réponse à l'expansion volémique sont de petites études, monocentriques, sans évaluation de la reproductibilité. On ne sait pas quelles mesures dynamiques sont supérieures et nous ne pouvons pas conclure un ordre de préférence pour les méthodes disponibles. Nous recommandons une approche individualisée à l'intégration de différentes modalités pour évaluer la réponse à l'expansion volémique et guider la réanimation liquidienne chez les patients en phase critique.
Au chevet du patient, les cliniciens doivent être conscients des pièges et des limites des modalités disponibles pour déterminer la réponse à l'expansion volémique.

Sonographic diameter of optic nerve sheath in differentiation of ischemic and hemorrhagic strokes; a diagnostic accuracy study.
Manouchehrifar M, Lakestani M, Kashani P, Safari S. | Am J Emerg Med. 2018 Nov;36(11):2064-2067
DOI: https://doi.org/10.1016/j.ajem.2018.08.041
Keywords: Diagnosis, differential; Diagnostic imaging; Intracranial hypertension; Optic nerve; Stroke; Tomography, X-ray computed; Ultrasonography

Brief Reports

Introduction : Differentiating between ischemic and hemorrhagic types is of special importance in the treatment process of patients with stroke. The present study was designed with the aim of evaluating the diagnostic accuracy of ultrasonographic optic nerve sheath diameter (ONSD) in differentiation of ischemic from hemorrhagic stroke.

Méthode : The present research is a diagnostic accuracy study on patients with stroke presenting to emergency department during 1 year. Ultrasonographic diameter of optic nerve sheath of both eyes was measured for all the patients and its sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios in differentiating ischemic stroke from hemorrhagic type were calculated considering CT scan findings as the gold standard.

Résultats : 80 patients with stroke (40 hemorrhagic and 40 ischemic) were studied. Mean age of the patients was 65.0 ± 13.1 years (57.5% male). Mean ONSD was 5.5 ± 0.4 mm in the ischemic group and 6.1 ± 0.7 mm in the hemorrhagic group (p < 0.0001). Area under the curve of ONSD in differentiation of hemorrhagic and ischemic stroke was 0.75 (95% CI: 0.64-0.86). In 5.5 mm cut-off point, sensitivity and specificity of ONSD in identifying the type of stroke were 75.0% (95% CI: 58.5-86.8) and 52.5% (95% CI: 36.3-68.2), respectively. These values were 57.5% (95% CI: 41.0-68.2) and 90.0% (95% CI: 75.4-96.7), respectively, in the 6 mm cut-off point.

Conclusion : Findings of the present study showed that ultrasonographic diameter of optic nerve sheath has moderate accuracy in differentiation of hemorrhagic and ischemic stroke.

Conclusion (proposition de traduction) : Les résultats de la présente étude ont montré que le diamètre échographique de la gaine du nerf optique présente une précision moyenne dans la différenciation des accidents vasculaires cérébraux hémorragiques et ischémiques.

Is Peripheral Oxygen Saturation a Reliable Predictor of Upper Airways Air-Flow Limitation?.
Malagutti N, Di Laora A, Barbetta C, Groppo E, Tugnoli V, Sette E, Astolfi L, Beswick W, Borin M, Ciorba A, Pelucchi S, Stomeo F, Contoli M. | J Emerg Med. 2018 Nov;55(5):627-634
DOI: https://doi.org/10.1016/j.jemermed.2018.07.007
Keywords: dyspnea; oximetry; upper airflow limitation; upper airway obstruction

Brief Report

Introduction : Dyspnea secondary to acute upper airways airflow limitation (UAAFL) represents a clinical emergency that can be difficult to recognize without a suitable history; even when etiology is known, parameters to assess the severity are unclear and often improperly used.
OBJECTIVES: The aim of this study was to assess the role of peripheral oxygen saturation (SpO2) as a predictor of severity of upper airway obstruction.

Méthode : The authors propose an experimental model of upper airway obstruction by a progressive increase of UAAFL. Ten healthy volunteers randomly underwent ventilation for 6 min with different degrees of UAAFL. SpO2, heart rate, respiratory rate (RR), tidal volume, accessory respiratory muscle activation, and subjective dyspnea indexes were measured.

Résultats : In this model, SpO2 was not reliable as the untimely gravity index of UAAFL. Respiratory rate, visual analogue scale (VAS), and Borg dyspnea scale were statistically correlated with UAAFL (p < 0.0001 for RR and p < 0.05 for VAS and Borg scale). No significant changes were observed on heart rate (p > 0.05) and tidal volume (p > 0.05); a RR ≤ 7 breaths/min; VAS and Borg scale showed statistically significant parameters changes (p < 0.05).

Conclusion : RR, VAS, and Borg dyspnea scales are sensitive parameters to detect and stage, easily and quickly, the gravity of an upper airways impairment, and should be used in emergency settings for an early diagnosis of a UAAFL. SpO2 is a poorer predictor of the degree of upper airways flow limitation.

Conclusion (proposition de traduction) : La fréquence respiratoire, l'échelle visuelle analogique et les échelles de dyspnée de Borg sont des paramètres sensibles permettant de détecter et de déterminer facilement et rapidement la gravité d'une dégradation des voies respiratoires supérieures. Elles doivent être utilisées en situation d'urgence pour diagnostiquer rapidement une limitation du flux d'air dans les voies respiratoires supérieures. La SpO2 est un prédicteur plus pauvre du degré de limitation du débit des voies respiratoires supérieures.

Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature.
Long B, Koyfman A, Gottlieb M. | J Emerg Med. 2018 Nov;55(5):635-646
DOI: https://doi.org/10.1016/j.jemermed.2018.08.002
Keywords: diuretics; fluid overload; heart failure; nitroglycerine; noninvasive ventilation; pulmonary edema

Clinical Reviews in Emergency Medicine

Introduction : Acute heart failure (AHF) is a common presentation to the emergency department (ED), with the potential to cause significant morbidity and mortality. It is important to tailor treatments to the appropriate type of heart failure.

Méthode : This review provides an evidence-based summary of the current ED management of acute heart failure.

Discussion : Heart failure can present along a spectrum, especially in acute exacerbation. Treatment should focus on the underlying disease process, with guidelines focusing primarily on blood pressure and hemodynamic status. Treatment of patients with mild AHF exacerbations often focuses on intravenous diuretics. Patients with AHF with flash pulmonary edema should receive nitroglycerin and noninvasive positive pressure ventilation, with consideration of an angiotensin-converting enzyme inhibitor, while monitoring for hypotension. Patients with hypotensive AHF should receive emergent specialty consultation and an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors. Dobutamine is the inotrope of choice in these patients, with norepinephrine recommended if blood pressure support is needed. If noninvasive positive pressure ventilation is required, providers should monitor closely for acute decompensation. Mechanical circulatory support devices may be considered as a bridge to further therapeutic intervention. High-output heart failure can be managed acutely with vasoconstricting agents, with focus on treating the underlying etiology. Disposition is not always straightforward, and several risk scores may assist in this decision.

Conclusion : AHF is a condition that requires rapid assessment and ma

Conclusion (proposition de traduction) : L'insuffisance cardiaque aiguë est une affection qui nécessite une évaluation et une gestion rapides. Comprendre la stratégie de prise en charge appropriée peut permettre un traitement plus ciblé et de meilleurs résultats.

Malpractice in Emergency Medicine-A Review of Risk and Mitigation Practices for the Emergency Medicine Provider.
Ferguson B, Geralds J, Petrey J, Huecker M. | J Emerg Med. 2018 Nov;55(5):659-665
DOI: https://doi.org/10.1016/j.jemermed.2018.06.035
Keywords: emergency medicine; litigation; malpractice; risk mitigation; risk reduction

Clinical Reviews in Emergency Medicine

Introduction : Malpractice in emergency medicine is of high concern for medical providers, the fear of which continues to drive decision-making. The body of evidence evaluating risk specific to emergency physicians is disjointed, and thus it remains difficult to derive cohesive themes and strategies for risk minimization.

Méthode : This review evaluates the state of malpractice in emergency medicine and summarizes a concise approach for the emergency physician to minimize risk.

Discussion : The environment of the emergency department (ED) represents moderate overall malpractice risk and yields a heavy burden in finance and time. Key areas of relatively high litigation occurrence include missed acute myocardial infarction, missed fractures/foreign bodies, abdominal pain/appendicitis, wounds, intracranial bleeding, aortic aneurysm, and pediatric meningitis. Mitigation of risk is best accomplished through constructive communication, intelligent documentation, utilization of clinical practice guidelines and generalizable diagnoses, careful management of discharge against medical advice, and establishing follow-up for diagnostic studies ordered while in the ED (especially x-ray studies). Communication breakdown seems to be more predictive of malpractice litigation than injury experienced.

Conclusion : There are consistent diagnoses that are associated with increased litigation incidence. A combination of mitigation approaches may assist providers in mitigation of malpractice risk.

Conclusion (proposition de traduction) : Il y a des diagnostics cohérents qui sont associés à une augmentation de l'incidence des litiges. Une combinaison d'approches d'atténuation peut aider les urgentistes à atténuer le risque de faute professionnelle.

Commentaire : L'article identifie les domaines de diagnostic à risque élevé les plus fréquemment observés en cas de faute professionnelle aux urgences :
les douleurs thoraciques/infarctus du myocarde manqué, les douleurs abdominales/appendicite, les hémorragies intracrâniennes et la fièvre/méningite chez l'enfant.
Les diagnostics à faible risque sont dominés par les plaies avec des corps étrangers négligés et des fractures manquées.

Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis.
Mankowitz SL, Regenberg P, Kaldan J, Cole JB. | J Emerg Med. 2018 Nov;55(5):670-681
DOI: https://doi.org/10.1016/j.jemermed.2018.07.017
Keywords: acute behavioral disturbance (ABD); agitated; emergency department; excited delirium syndrome (ExDS); intubation; ketamine; laryngospasm; sedation

Selected Topics: Prehospital Care

Introduction : Rapid tranquilization of agitated patients can prevent injuries and expedite care. Whereas antipsychotics and benzodiazepines are commonly used for this purpose, ketamine has been suggested as an alternative.
OBJECTIVE: The aim of this systematic review is to determine the safety and effectiveness of ketamine to sedate prehospital and emergency department (ED) patients with undifferentiated agitation.

Méthode : Studies and case series of patients receiving ketamine for agitation were included. Studies were excluded if ketamine was used for analgesia, procedural sedation, asthma, or induction. Information sources included traditional and gray literature.

Résultats : The initial search yielded 1176 results from 14 databases. After review of titles and abstracts, 32 studies were reviewed and 18 were included in the analysis, representing 650 patient encounters. The mean dose of ketamine was 315 mg (SD 52) given intramuscularly, with adequate sedation achieved in 7.2 min (SD 6.2, range 2-500). Intubation occurred in 30.5% of patients (95% confidence interval [CI] 27.0-34.1%). In the majority of those patients, ketamine was administered by paramedics during ground transport and the patient was intubated on ED arrival. When ketamine was administered in the ED, the intubation rate was 1.8% (95% CI 0.0-4.4%); in air medical transport, the rate was 4.9% (95% CI 0.0-10.3%). Other reported side effects included: vomiting, 5.2% (2.3-8.1%); hypertension, 12.1% (5.7-18.6%); emergence reactions, 3.5% (1.4-5.6%); transient hypoxia, 1.8% (0.1-3.6%) and laryngospasm, 1.3% (0.3-2.3%).

Conclusion : Ketamine provides rapid sedation for undifferentiated agitated patients and is associated with higher intubation rates when used by ground Emergency Medical Services paramedics, compared with ED or air medical transport patients. Other side effects are common but usually self-limiting.

Conclusion (proposition de traduction) : La kétamine procure une sédation rapide aux patients agités quel que soit la cause de l'agitation et est associée à des taux d'intubation plus élevés lorsqu'elle est utilisée par les ambulanciers paramédicaux des services médicaux d'urgence au sol, comparativement aux patients des urgences ou du transport médical aérien. D'autres effets secondaires sont fréquents, mais habituellement spontanément résolutifs.