Prehospital Double Sequential Defibrillation: A Matched Case-Control Study.
Mapp JG, Hans AJ, Darrington AM, Ross EM, Ho CC, Miramontes DA, Harper SA, Wampler DA; Prehospital Research and Innovation in Military and Expeditionary Environments (PRIME) Research Group. | Acad Emerg Med. 2018 Dec 10.
DOI: https://doi.org/10.1111/acem.13672
Keywords: Aucun

Original Contribution

Introduction : The goal of our study was to determine whether prehospital double sequential defibrillation (DSD) is associated with improved survival to hospital admission in the setting of refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).

Méthode : This project is a matched case-control study derived from prospectively collected quality assurance/quality improvement data obtained from the San Antonio Fire Department out-of-hospital cardiac arrest (OHCA) database between January 2013 and December 2015. The cases were defined as OHCA patients with refractory VF/pVT who survived to hospital admission. The control group was defined as OHCA patients with refractory VF/pVT who did not survive to hospital admission. The primary variable in our study was prehospital DSD. The primary outcome of our study was survival to hospital admission.

Résultats : Of 3,469 consecutive OHCA patients during the study period, 205 OHCA patients met the inclusion criterion of refractory VF/pVT. Using a predefined algorithm, two blinded researchers identified 64 unique cases and matched them with 64 unique controls. Survival to hospital admission occurred in 48.0% of DSD patients and 50.5% of the conventional therapy patients (p > 0.99; odds ratio = 0.91, 95% confidence interval = 0.40-2.1).

Conclusion : Our matched case-control study on the prehospital use of DSD for refractory VF/pVT found no evidence of associated improvement in survival to hospital admission. Our current protocol of considering prehospital DSD after the third conventional defibrillation in OHCA is ineffective.

Conclusion (proposition de traduction) : Notre étude cas-témoin appariée sur l'utilisation préhospitalière de la double défibrillation séquentielle dans les FV/TV réfractaires n'a trouvé aucune preuve d'amélioration associée de la survie à l'admission à l'hôpital. Notre protocole actuel de prise en compte de la double défibrillation séquentielle préhospitalière après la troisième défibrillation conventionnelle en cas d'arrêt cardiaque extra-hospitalier est inefficace.

Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis.
Gottlieb M, Holladay D, Peksa GD. | Ann Emerg Med. 2018 Dec;72(6):627-636
DOI: https://doi.org/10.1016/j.annemergmed.2018.06.024
Keywords: Aucun

Airway

Introduction : Intubation is routinely performed in the emergency department, and rapid, accurate confirmation is essential to avoid potentially serious adverse outcomes. The number of studies assessing ultrasonography for the verification of endotracheal tube placement has expanded rapidly in recent years. We performed this systematic review and meta-analysis to determine the sensitivity and specificity of transtracheal ultrasonography for the verification of endotracheal tube location.

Méthode : PubMed, the Cumulative Index of Nursing and Allied Health, Scopus, Latin American and Caribbean Health Sciences Literature database, the Cochrane databases, and bibliographies of selected articles were assessed for all prospective and randomized controlled trials evaluating the accuracy of transtracheal ultrasonography for identifying endotracheal tube location. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Data were summarized and a meta-analysis was performed with subgroup analyses by location, specialty, experience, transducer type, and technique. Time to confirmation was assessed as a secondary outcome.

Résultats : This systematic review identified 17 studies (n=1,595 patients). Overall, transtracheal ultrasonography was 98.7% sensitive (95% confidence interval [CI] 97.8% to 99.2%) and 97.1% specific (95% CI 92.4% to 99.0%), with a positive likelihood ratio of 34.4 (95% CI 12.7 to 93.1) and a negative likelihood ratio of 0.01 (95% CI 0.01 to 0.02). Subgroup analyses did not demonstrate a significant difference by location, provider specialty, provider experience, transducer type, or technique. Mean time to confirmation was 13.0 seconds.

Conclusion : Transtracheal sonography is rapid to perform, with an acceptable degree of sensitivity and specificity for the confirmation of endotracheal intubation. Ultrasonography is a valuable adjunct and should be considered when quantitative capnography is unavailable or unreliable.

Conclusion (proposition de traduction) : L'échographie transtrachéale est rapide à effectuer, avec un degré acceptable de sensibilité et de spécificité pour la confirmation de placement lors de l'intubation endotrachéale. L'échographie est un complément précieux et doit être envisagée lorsque la capnographie quantitative est indisponible ou peu fiable.

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study.
April MD, Arana A, Pallin DJ, Schauer SG, Fantegrossi A, Fernandez J, Maddry JK, Summers SM, Antonacci MA, Brown CA 3rd; NEAR Investigators.. | Ann Emerg Med. 2018 Dec;72(6):645-653
DOI: https://doi.org/10.1016/j.annemergmed.2018.03.042  | Télécharger l'article au format  
Keywords: Aucun

Airway

Introduction : Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium.

Méthode : We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose.

Résultats : There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose.

Conclusion : In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events.

Conclusion (proposition de traduction) : Dans cette grande série d'observations, nous n'avons pas décelé d'association entre le choix de l'agent curarisant et le succès de l'intubation en séquence rapide à la première tentative ou les effets indésirables péri-intubatoires.

Man vs machine in emergency medicine - a study on the effects of manual and automatic vital sign documentation on data quality and perceived workload, using observational paired sample data and questionnaires.
Skyttberg N, Chen R, Koch S. | BMC Emerg Med. 2018 Dec 13;18(1):54
DOI: https://doi.org/10.1186/s12873-018-0205-2  | Télécharger l'article au format  
Keywords: Automated documentation; Data quality; Emergency department; Emergency medicine; Vital signs

Research article

Introduction : Emergency medicine is characterized by a high patient flow where timely decisions are essential. Clinical decision support systems have the potential to assist in such decisions but will be dependent on the data quality in electronic health records which often is inadequate. This study explores the effect of automated documentation of vital signs on data quality and workload.

Méthode : An observational study of 200 vital sign measurements was performed to evaluate the effects of manual vs automatic documentation on data quality. Data collection using questionnaires was performed to compare the workload on wards using manual or automatic documentation.

Résultats : n the automated documentation time to documentation was reduced by 6.1 min (0.6 min vs 7.7 min, p <  0.05) and completeness increased (98% vs 95%, p <  0.05). Regarding workflow temporal demands were lower in the automatic documentation workflow compared to the manual group (50 vs 23, p <  0.05). The same was true for frustration level (64 vs 33, p <  0.05). The experienced reduction in temporal demands was in line with the anticipated, whereas the experienced reduction in frustration was lower than the anticipated (27 vs 54, p < 0.05).

Conclusion : The study shows that automatic documentation will improve the currency and the completeness of vital sign data in the Electronic Health Record while reducing workload regarding temporal demands and experienced frustration. The study also shows that these findings are in line with staff anticipations but indicates that the anticipations on the reduction of frustration may be exaggerated among the staff. The open-ended answers indicate that frustration focus will change from double documentation of vital signs to technical aspects of the automatic documentation system.

Conclusion (proposition de traduction) : L'étude montre que la documentation automatique améliorera la validité et l'exhaustivité des données sur les signes vitaux contenues dans le dossier médical électronique, tout en réduisant la charge de travail liée aux demandes temporaires et aux frustrations éprouvées. L'étude montre également que ces résultats correspondent aux attentes du personnel, mais indique que les anticipations de réduction de la frustration peuvent être exagérées parmi le personnel. Les réponses ouvertes indiquent que la frustration ne va plus se focaliser sur la double documentation des signes vitaux mais sur les aspects techniques du système de documentation automatique.

Trajectories of early secondary insults correlate to outcomes of traumatic brain injury: results from a large, single centre, observational study.
Volpi PC, Robba C, Rota M, Vargiolu A, Citerio G. | BMC Emerg Med. 2018 Dec 5;18(1):52
DOI: https://doi.org/10.1186/s12873-018-0197-y  | Télécharger l'article au format  
Keywords: Outcome; Prehospital insults; Secondary injuries; Trajectory; Traumatic brain injury

Research article

Introduction : Secondary insults (SI), such as hypotension, hypoxia, and intracranial hypertension frequently occur after traumatic brain injury (TBI), and have a strong impact on patients' clinical outcomes. The aim of this study is to examine the trajectories of SI from the early phase of injury in the prehospital setting to hospital admission in a cohort of TBI patients.

Méthode : This is a retrospective, observational, single centre study on consecutive patients admitted from 1997 to 2016 to the Neuro Intensive Care Unit (NICU) at San Gerardo Hospital, in Monza, Italy. Trajectories of SI from the prehospital to hospital settings were defined as "sustained", "resolved", "new event", and "none". Univariate and multivariate logistic regression analyses were performed to correlate SI trajectories to a 6-months outcome.

Résultats : Nine hundred sixty-seven patients were enrolled in the final analysis. About 20% had hypoxic or hypotensive events and 30.7% of patients had pupillary abnormalities. Hypotension and hypoxia were associated with an unfavourable outcome when "sustained" and "resolved", while pupillary abnormalities were associated with a poor outcome when "sustained" and as "new events". After adjusting for confounding factors, 6-month mortality strongly correlated with "sustained" hypotension (OR 11.25, 95% CI, 3.52-35.99), "sustained" pupillary abnormalities (OR 2.8, 95% CI, 1.51-5.2) and "new event" pupillary abnormalities (OR 2.8, 95% CI, 1.16-6.76).

Conclusion : After TBI, sustained hypotension and pupillary abnormalities are important determinants for patients' outcomes. Early trajectories define the dynamics of SI and contribute to a better understanding of how early recognition and treatments in emergency settings could impact on 6-month outcomes and mortality.

Conclusion (proposition de traduction) : Après une agression cérébrale traumatique, une hypotension prolongée et des anomalies pupillaires sont des facteurs déterminants pour les résultats des patients. Les trajectoires précoces définissent la dynamique des agressions cérébrales secondaires et contribuent à une meilleure compréhension de la manière dont la reconnaissance précoce et les traitements en situation d'urgence pourraient avoir une incidence sur les résultats à 6 mois et la mortalité.

Ear measurement of temperature is only useful for screening for fever in an adult emergency department.
Mogensen CB, Vilhelmsen MB, Jepsen J, Boye LK, Persson MH, Skyum F. | BMC Emerg Med. 2018 Dec 3;18(1):51
DOI: https://doi.org/10.1186/s12873-018-0202-5  | Télécharger l'article au format  
Keywords: Fever; Rectal temperature; Temperature measurement; Tympanic

Research article

Introduction : A new generation of ear thermometers with preheated tips and several measurements points should allow a more precise temperature measurement. The aim of the study was to evaluate if the ear temperature measured by this ear thermometer can be used to screen for fever and whether the thermometer is in agreement with the rectal temperature and if age, use of hearing devices or time after admission influences the temperature measurements.

Méthode : Open cross-sectional clinical single site study patients, > 18 years old, who were acutely admitted to the short stay unit at the ED. A sample size of 99 patient per subgroup was recruited as random convenience series. As ear thermometer Braun Thermoscan Pro 4000® and as rectal thermometer Omron Flex Temp Smart ® was used. For different cut off of temperature the AUC was calculated and Bland-Altman analysis for calculation of 95% limits of agreement with rectal temperature, with subgroup analysis concerning age, time span from admission time and use of hearing aid.

Résultats : Among 599 patients the sensitivity to detect fever with an ear thermometer varied between 68 and 70% with AUC from 0.88-0.97. If the ear temperature was ≥37.5 oC, the sensitivity to detect patients with ≥38.0 oC rectally was 95% which raised to 100% for a rectal temperature of ≥38.3 oC. For the ear thermometer's ability to determine the exact temperature the 95% limits of agreement were +/- 0.8 oC. with no influence from age, duration of hospital stay or hearing aids.

Conclusion : The examined ear thermometer is able to detect fever, defined as ≥38 oC rectally in an adult ED population by using an ear cut-point of 37.5 oC, but not to measure the exact temperature. Used in this way around a fifth of the patients will still be in need of a rectal temperature measurement, but less than 5% with fever ≥38.0 oC will remain undetected and none with fever ≥38.3 oC. Age, admission time and use of hearing aid did not influence the temperature measurements.

Conclusion (proposition de traduction) : Le thermomètre auriculaire utilisé était capable de détecter la fièvre, définie comme étant ≥ 38° C par voie rectale dans une population adulte au service des urgences, en utilisant un seuil de 37,5° C pour l'oreille, mais ne permet pas de mesurer la température exacte. Ainsi utilisé, environ un cinquième des patients auront toujours besoin d'une mesure de la température rectale, mais moins de 5 % des patients avec une fièvre ≥ 38,0° C resteront non détectés et aucun avec une fièvre ≥ 38,3° C. L'âge, l'heure d'admission et l'utilisation d'un appareil auditif n'influencent pas les mesures de température.

Seven versus fourteen Days of Antibiotic Therapy for uncomplicated Gram-negative Bacteremia: a Non-inferiority Randomized Controlled Trial.
Yahav D, Yahav D, Franceschini E, Koppel F, Turjeman A, Babich T, Bitterman R, Neuberger A, Ghanem-Zoubi N, Santoro A, Eliakim-Raz N, Pertzov B, Steinmetz T, Stern A, Dickstein Y, Maroun E, Zayyad H, Bishara J, Alon D, Edel Y, Goldberg E, Venturelli C, Mussini C, Leibovici L, Paul M; Bacteremia Duration Study Group. | Clin Infect Dis. 2018 Dec 11, ciy1054
DOI: https://doi.org/10.1093/cid/ciy1054
Keywords: Aucun

CORRECTED PROOF

Introduction : Gram-negative bacteremia is a major cause of morbidity and mortality in hospitalized patients. Data to guide the duration of antibiotic therapy are limited.

Méthode : Randomized, multicenter, open-label, non-inferiority trial. Inpatients with Gram-negative bacteremia, afebrile and hemodynamically stable for at least 48 hours, were randomized to receive 7 (intervention) or 14 days (control) of covering antibiotic therapy. Patients with uncontrolled focus of infection were excluded. The primary outcome at 90 days was a composite of all-cause mortality; relapse, suppurative or distant complications; and re-admission or extended hospitalization (>14 days). The non-inferiority margin was set at 10%.

Résultats : We included 604 patients (306 intervention, 298 control) between January 2013 and August 2017 in three centers in Israel and Italy. The source of the infection was urinary in 411/604 (68%); causative pathogens were mainly Enterobacteriaceae (543/604, 90%). A 7-day difference in the median duration of covering antibiotics was achieved. The primary outcome occurred in 140/306 (45.8%) patients in the 7 days group versus 144/298 (48.3%) in the 14 days group (risk difference [RD] -2.6%, 95% confidence interval [CI] -10.5% to 5.3%). No significant differences were observed in all other outcomes and adverse events, except for a shorter time to return to baseline functional status in the short therapy arm.

Conclusion : In patients hospitalized with Gram-negative bacteremia achieving clinical stability before day 7, an antibiotic course of 7 days was non-inferior to 14 days. Reducing antibiotic treatment for uncomplicated Gram-negative bacteremia to 7 days is an important antibiotic stewardship intervention.

Conclusion (proposition de traduction) : Chez les patients hospitalisés pour une bactériémie à Gram négatif retrouvant une stabilité clinique avant le septième jour, un traitement antibiotique de sept jours était non inférieur à 14 jours. La réduction du traitement antibiotique pour la bactériémie à Gram négatif non compliquée à 7 jours est une intervention importante de la gestion des antibiotiques.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Pas plus de 7 jours d’antibiothérapie pour traiter les bactériémies à entérobactérie. Des preuves solides.  . Rédigé par le Dr Jean-Pierre Bru.
Voir aussi les articles :
- Chotiprasitsakul D and al. Comparing the Outcomes of Adults With Enterobacteriaceae Bacteremia Receiving Short-Course Versus Prolonged-Course Antibiotic Therapy in a Multicenter, Propensity Score-Matched Cohort.Clin Infect Dis. 2018 Jan 6;66(2):172-177  .
- Giannella M and al. Treatment duration for Escherichia coli bloodstream infection and outcomes: retrospective single-centre study. Clin Microbiol Infect. 2018 Oct;24(10):1077-1083  .

Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study).
van der Does Y, Limper M, Jie KE, Schuit SCE, Jansen H, Pernot N, van Rosmalen J, Poley MJ, Ramakers C, Patka P, van Gorp ECM, Rood PPM. | Clin Microbiol Infect. 2018 Dec;24(12):1282-1289
DOI: https://doi.org/10.1016/j.cmi.2018.05.011
Keywords: Antibiotics; Biomarkers; Emergency department; Fever; Procalcitonin

Original Articles

Introduction : Overuse of broad-spectrum antibiotics in emergency departments (EDs) results in antibiotic resistance. We determined whether procalcitonin (PCT) -guided therapy can be used to reduce antibiotic regimens in EDs by investigating efficacy, safety and accuracy.

Méthode : This was a non-inferiority multicentre randomized clinical trial, performed in two Dutch hospitals. Adult patients with fever ≥38.2°C (100.8°F) in triage were randomized between standard diagnostic workup (control group) and PCT-guided therapy, defined as standard workup with the addition of one single PCT measurement. The treatment algorithm encouraged withholding antibiotic regimens with PCT <0.5 μg/L, and starting antibiotic regimens at PCT ≥0.5 μg/L. Exclusion criteria were immunocompromised conditions, pregnancy, moribund patients, patients <72 h after surgery or requiring primary surgical intervention. Primary outcomes were efficacy, defined as number of prescribed antibiotic regimens; safety, defined as combined safety end point consisting of 30 days mortality, intensive-care unit admission, ED return visit within 2 weeks; accuracy, defined as sensitivity, specificity and area-under-the-curve (AUC) of PCT for bacterial infections. Non-inferiority margin for safety outcome was 7.5%.

Résultats : Between August 2014 and January 2017, 551 individuals were included. In the PCT-guided group (n = 275) 200 (73%) patients were prescribed antibiotic regimens, in the control group (n = 276) 212 (77%) patients were prescribed antibiotics (p 0.28). There was no significant difference in combined safety end point between the PCT-guided group, 29 (11%), and control group, 46 (16%) (p 0.16), with a non-inferiority margin of 0.46% (n = 526). AUC for confirmed bacterial infections for PCT was 0.681 (95% CI 0.633-0.730), and for CRP was 0.619 (95% CI 0.569-0.669).

Conclusion : PCT-guided therapy was non-inferior in terms of safety, but did not reduce prescription of antibiotic regimens in an ED population with fever. In this heterogeneous population, the accuracy of PCT in diagnosing bacterial infections was poor.

Conclusion (proposition de traduction) : L'innocuité du traitement guidé par la PCT n'a pas été inférieure, mais elle n'a pas réduit la prescription de schémas thérapeutiques antibiotiques dans une population de patients atteints de fièvre aux urgences. Dans cette population hétérogène, la précision de la PCT dans le diagnostic des infections bactériennes était faible.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : L’utilisation de la PCT aux urgences n’a pas d’intérêt chez le patient fébrile  . Rédigé par le Dr Philippe Lesprit.

Liberal Versus Conservative Fluid Therapy in Adults and Children With Sepsis or Septic Shock.
Li D, Li X, Cui W, Shen H, Zhu H, Xia Y. | Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593
DOI: https://doi.org/10.1002/14651858.cd010593.pub2  | Télécharger l'article au format  
Keywords: Aucun

Review

Introduction : Sepsis and septic shock are potentially life-threatening complications of infection that are associated with high morbidity and mortality in adults and children. Fluid therapy is regarded as a crucial intervention during initial treatment of sepsis. Whether conservative or liberal fluid therapy can improve clinical outcomes in patients with sepsis and septic shock remains unclear.
Objectives: To determine whether liberal versus conservative fluid therapy improves clinical outcomes in adults and children with initial sepsis and septic shock.

Méthode : We searched CENTRAL, MEDLINE, Embase, intensive and critical care conference abstracts, and ongoing clinical trials on 16 January 2018, and we contacted study authors to try to identify additional studies.
Selection criteria: We planned to include all randomized controlled trials (RCTs), quasi-RCTs, and cluster RCTs comparing liberal fluid therapy versus conservative fluid therapy for adults and children with sepsis or septic shock.
Data collection and analysis: We used the standard methodological procedures expected by Cochrane. We assessed risk of bias of all included trials by using the Cochrane risk of bias tool. When appropriate, we calculated risk ratios (RRs) and 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) and 95% CIs for continuous outcomes. Our primary outcomes were all-cause mortality in hospital and at follow-up. Secondary outcomes included adverse events (organ dysfunction, allergic reaction, and neurological sequelae). We used GRADE to assess the quality of evidence for each outcome.

Résultats : We identified no adult studies that met our selection criteria.This review included three paediatric RCTs (N = 3402), but we were able to extract data from only two of the three trials (n = 3288). These trials were conducted in India (two studies) and Africa. Participants were children from one month to 12 years old with sepsis or septic shock. All three included trials investigated liberal versus conservative fluid therapy, although definitions of liberal and conservative fluid therapy varied slightly across included studies. Results of the two trials included in the analyses show that liberal fluid therapy may increase risk of in-hospital mortality by 38% (2 studies; N = 3288; RR 1.38, 95% CI 1.07 to 1.77; number needed to treat for an additional harmful outcome (NNTH) = 34; moderate-quality evidence) and may increase risk of mortality at follow-up (at four weeks) by 39% (1 study; N = 3141; RR 1.39, 95% CI 1.11 to 1.74; NNTH = 29; high-quality evidence). The third study reported inconclusive results for in-hospital mortality (very low-quality evidence).We are uncertain whether there is a difference in adverse events between liberal and conservative fluid therapy because the single-study results are imprecise (organ dysfunction - hepatomegaly: RR 0.95, 95% CI 0.60 to 1.50; n = 147; low-quality evidence; organ dysfunction - need for ventilation: RR 1.17, 95% CI 0.83 to 1.65; n = 147; low-quality evidence; allergic reaction: RR 1.74, 95% CI 0.36 to 8.37; n = 3141; low-quality evidence; neurological sequelae: RR 1.03, 95% CI 0.61 to 1.75; n = 2983; low-quality evidence). Results are also uncertain for other adverse events such as desaturation, tracheal intubation, increased intracranial pressure, and severe hypertension.

Conclusion : No studies compared liberal versus conservative fluid therapy in adults. Low- to high-quality evidence indicates that liberal fluid therapy might increase mortality among children with sepsis or septic shock in hospital and at four-week follow-up. It is uncertain whether there are any differences in adverse events between liberal and conservative fluid therapy because the evidence is of low quality. Trials including adults, patients in other settings, and patients with a broader spectrum of pathogens are needed. Once published and assessed, three ongoing studies may alter the conclusions of this review.

Conclusion (proposition de traduction) : Aucune étude n'a comparé le remplissage vasculaire libérale versus conservateur chez l'adulte. Des preuves de faible à haute qualité indiquent que le remplissage vasculaire libérale pourrait augmenter la mortalité chez les enfants en sepsis ou en choc septique à l'hôpital et lors d'un suivi de quatre semaines. Il n'est pas certain qu'il y ait des différences d'effets indésirables entre le remplissage vasculaire libérale et le conservateur, car les preuves sont de faible qualité. Des essais incluant des adultes, des patients dans d'autres contextes et des patients présentant un spectre plus large d'agents pathogènes sont nécessaires. Une fois publiées et évaluées, trois études en cours pourraient modifier les conclusions de cette révision.

Commentaire : Feissel M, Vieillard-Baron A. Évaluation de la volémie par échocardiographie à l’aide des interactions cardiopulmonaires; Réanimation. 2003;12(2):145–52  .
(…) Au cours d’un état de choc, l’échocardiographie augmente la performance diagnostique de l’examen clinique.
• Une vélocité de l’onde E effondrée (< 0,7 m/s) associée à une ITV sous aortique basse (<14 cm) et/ou à un collapsus de la veine cave inférieure sont des bons critères pour administrer un remplissage vasculaire.
• Lorsque ces critères ne sont pas réunis, il faut suivre la variation d’ITV sous aortique sous remplissage. Tant que cette valeur augmente de 15 % après une expansion volémique de 250 à 500 ml, il est licite de poursuivre le remplissage.
• Le rapport E/E’ est surtout utile pour le diagnostic d’hypervolémie et de surcharge pulmonaire. Une valeur > 15 doit conduire à arrêter le remplissage vasculaire et envisager une déplétion volémique (…)

Evaluation of the provision of helicopter emergency medical services in Europe.
Jones A, Donald MJ, Jansen JO. | Emerg Med J. 2018 Dec;35(12):720-725
DOI: https://doi.org/10.1136/emermed-2018-207553
Keywords: emergency care systems; global health; prehospital care, doctors in PHC; prehospital care, helicopter retrieval; trauma, majot trauma management

CARDIOLOGY

Introduction : Helicopter emergency medical services (HEMS) are a useful means of reducing inequity of access to specialist emergency care. The aim of this study was to evaluate the variations in HEMS provision across Europe, in order to inform the further development of emergency care systems.

Méthode : This is a survey of primary HEMS in the 32 countries of the European Economic Area and Switzerland. Information was gathered through internet searches (May to September 2016), and by emailing service providers, requesting verification and completion of data (September 2016 to July 2017). HEMS provision was calculated as helicopters per million population and per 1000 km2 land area, by day and by night, and per US$10 billion of gross domestic product (GDP), for each country.

Résultats : In 2016, the smallest and least prosperous countries had no dedicated HEMS provision. Luxembourg had the highest number of helicopters by area and population, day and night. Alpine countries had high daytime HEMS coverage and Scandinavia had good night-time coverage. Most helicopters carried a doctor. Funding of services varied from public to charitable and private. Most services performed both primary (from the scene) and secondary (interfacility) missions.

Conclusion : Within Europe, there is a large variation in the number of helicopters available for emergency care, regardless of whether assessed with reference to population, land area or GDP. Funding of services varied, and did not seem to be clearly related to the availability of HEMS.

Conclusion (proposition de traduction) : En Europe, le nombre d’hélicoptères disponibles pour les soins d’urgence varie considérablement, qu’il soit évalué en fonction de la population, du territoire ou du PIB. Le financement des services variait et ne semblait pas être clairement lié à la disponibilité des SMUH.

Diagnostic performance of CT for pediatric patients with suspected appendicitis in various clinical settings: a systematic review and meta-analysis.
Kim DW, Yoon HM, Lee JY, Kim JH, Jung AY, Lee JS, Cho YA. | Emerg Radiol. 2018 December;25(6):627-637
DOI: https://doi.org/10.1007/s10140-018-1624-9
Keywords: Appendicitis; Appendix; Child; X-ray computed tomography

Original Article

Introduction : To assess the diagnostic performance of CT for pediatric patients with suspected appendicitis in various clinical settings and the proportion of acute appendicitis on final diagnosis among equivocal CT findings.

Méthode : MEDLINE and EMBASE databases were searched until October 21, 2017, for studies investigating diagnostic performance of CT for acute appendicitis in pediatric patients confirmed by histopathologic findings and/or clinical follow-up. Pooled estimates of sensitivity and specificity were calculated using a hierarchical logistic regression modeling. The proportion of true appendicitis among patients with inconclusive CT results was obtained using fixed and random effects meta-analyses.

Résultats : Twenty-two articles with 3396 patients were included. The pooled sensitivity and specificity were 95% (95% CI, 93-97%) and 94% (95% CI, 90-96%), respectively, and the area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.98 (95% CI, 0.96-0.99). Subgroup analyses revealed a comparable diagnostic performance in the low-dose CT group (sensitivity, 97%; specificity, 96%) and the unenhanced group (sensitivity, 95%; specificity, 95%). Other subgroups (publication year, study design, enrolled population, true appendicitis proportion, CT channel number, and slice thickness) also showed good diagnostic performance. Six studies reporting the true appendicitis proportion among patients with equivocal CT findings had pooled proportion of 17% (95% CI, 9-29%).

Conclusion : CT showed good performance for suspected appendicitis in pediatric patients under various clinical settings, including in cases with dose reduction or absence of IV contrast. The prevalence of true appendicitis among patients with equivocal appendicitis results on CTs was not low; therefore, clinical attention should not be disregarded in this population.

Conclusion (proposition de traduction) : La tomodensitométrie a montré de bonnes performances pour la suspicion d'appendicite chez les patients de pédiatrie dans divers contextes cliniques, y compris dans les cas de réduction de la dose ou d'absence de contraste IV. La prévalence de l'appendicite vraie chez les patients avec des résultats d'appendicite équivoque sur les scanners n'était pas faible; par conséquent, l'attention clinique ne doit pas être négligée dans cette population.

Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study.
Inukai K, Uehara S, Furuta Y, Miura M. | Emerg Radiol. 2018 Dec;25(6):647-652
DOI: https://doi.org/10.1007/s10140-018-1627-6
Keywords: Liver injury; Nonoperative management; Transcatheter arterial embolization; Trauma

Original Article

Introduction : The success rate of nonoperative management (NOM) of traumatic liver injury is approximately 90%. Although NOM has become the standard treatment when patients' vital signs are stable, open surgical hemostasis is often selected when these signs are unstable. At our hospital, we extensively use NOM along with transcatheter arterial embolization (TAE) to treat patients with severe abdominal trauma, as per our original protocol. We also apply NOM for severe liver injury with unstable hemodynamics. This retrospective study aimed to investigate the efficacy of NOM for blunt liver injury in hemodynamically stable and unstable patients.

Méthode : We retrospectively examined 23 patients with severe liver injuries who underwent NOM after visiting our emergency outpatient department between 2007 and 2017. Patients were assigned to either the stable group with stable hemodynamics or the unstable group with unstable hemodynamics.

Résultats : The stable group comprised 13 patients, and the unstable group comprised 10 patients. All patients underwent TAE. While all patients in the stable group were discharged alive, one patient in the unstable group died during the hospital stay. The response rate to NOM was 90%, and no patient switched from NOM to open surgery. A higher rate of complications with a significantly longer average stay in the intensive care unit was observed in the unstable group.

Conclusion : Even in the unstable group, NOM with TAE performed under careful general management facilitated avoidance of open surgery and provided high survival rates.

Conclusion (proposition de traduction) : Même dans le groupe instable, une prise en charge non chirurgicale avec embolisation artérielle par transcathéter réalisée sous une prise en charge générale soigneuse a permis d'éviter la chirurgie à ciel ouvert et fourni des taux de survie élevés.

Imaging of acute ischemic stroke.
Rudkin S, Cerejo R, Tayal A, Goldberg MF. | Emerg Radiol. 2018 Dec;25(6):659-672
DOI: https://doi.org/10.1007/s10140-018-1623-x
Keywords: ASPECTS; Acute ischemic stroke; Core; Endovascular therapy; Multi-phase CTA; Penumbra; Perfusion

Review Article

Editorial : For decades, imaging has been a critical component of the diagnostic evaluation and management of patients suspected of acute ischemic stroke (AIS). With each new advance in the treatment of AIS, the role of imaging has expanded in scope, sophistication, and importance in selecting patients who stand to benefit from potential therapies. Although the field of stroke imaging has been evolving for many years, there have been several major recent changes. Most notably, in late 2017, the window for treatment expanded to 24 h from onset of stroke symptoms in selected patients. Furthermore, for those patients in expanded time windows, guidelines issued in early 2018 now recommend the use of "advanced" imaging techniques in the acute setting, including CT perfusion and MRI, to guide therapeutic decision-making. With these and other changes, the emergency radiologist must be prepared to handle a growing volume and complexity of AIS imaging. This article reviews the various imaging modalities and techniques employed in the imaging of AIS patients, with an emphasis on recommendations from recent randomized controlled trials and national consensus guidelines.

Conclusion : The evaluation and treatment of acute ischemic stroke are rapidly evolving fields, with major new national guidelines issued in early 2018. The clinical trials demonstrating efficacy of acute therapy have made it clear that appropriate patient selection, by clinical and imaging criteria, is essential to achieving desirable outcomes, i.e., identifying patients who are likely to benefit from treatment and excluding patients who may be unaffected or adversely affected by treatment. A critical component of the patient selection process, especially in expanded time windows, is the use of imaging to distinguish core from penumbra. As imaging has become the dominant factor in this process, the terms "tissue window" and "imaging is brain" have become part of the lexicon of stroke diagnosis, in addition to the well-known "time window" and "time is brain" expressions. Making the distinction between core and penumbra will largely fall to the emergency radiologist. Furthermore, with patients now potentially eligible for therapy up to 24 h after onset of symptoms, the emergency radiologist should expect to see a marked increase in imaging for stroke. The emergency radiologist must therefore be able to optimize imaging protocols and provide accurate, thorough, and timely interpretations to assist the clinical team with the information needed for appropriate treatment decisions. Although Non-contrast head computed tomography and computed tomography angiogram continue to form the bedrock of the imaging evaluation of acute ischemic stroke patients, more advanced imaging techniques, especially computed tomography perfusion, are quickly becoming standard of care for these patients.

Conclusion (proposition de traduction) : L'évaluation et le traitement de l'AVC ischémique aigu sont des domaines en évolution rapide. De nouvelles recommandations nationales majeures ont été publiées au début de 2018. Les essais cliniques démontrant l'efficacité de la thérapeutique aiguë ont clairement montré qu'une sélection appropriée des patients, en fonction de critères cliniques et d'imagerie, était essentielle pour atteindre les objectifs suivants : résultats souhaitables, c’est-à-dire identifier les patients susceptibles de bénéficier du traitement et exclure les patients qui pourraient ne pas être affectés ou être affectés négativement par le traitement.
Un élément essentiel du processus de sélection des patients, en particulier dans les fenêtres temporelles étendues, est l’utilisation de l’imagerie pour distinguer la zone de pénombre. L'imagerie étant devenue le facteur dominant dans ce processus, les termes "fenêtre tissulaire" et "imagerie cérébrale" sont devenus partie intégrante du lexique du diagnostic des accidents vasculaires cérébraux, en plus des expressions "fenêtres temporelles" et "le temps cérébral". Faire la distinction entre l'ischémie et la pénombre dépendra en grande partie du radiologue d’urgence. De plus, avec les patients potentiellement admissibles au traitement jusqu'à 24 h après l'apparition des symptômes, le radiologue d'urgence devrait s'attendre à voir une nette augmentation du nombre d'imagerie pour un AVC. Le radiologue d'urgence doit donc être en mesure d'optimiser les protocoles d'imagerie et de fournir des interprétations précises, complètes et opportunes pour aider l'équipe clinique à obtenir les informations nécessaires aux décisions de traitement appropriées. Bien que la tomodensitométrie sans produit de contraste et l'angiographie par tomodensitométrie continuent de constituer le fondement de l'évaluation par imagerie des patients ayant subi un AVC ischémique aigu, des techniques d'imagerie plus avancées, notamment la perfusion par tomodensitométrie, deviennent rapidement la norme de soins pour ces patients.

Vitamin K antagonists and emergencies.
Lapostolle F, Siguret V, Martin AC, Pailleret C, Vigué B, Zerbib Y, Tazarourte K. | Eur J Emerg Med. 2018 Dec;25(6):378-386
DOI: https://doi.org/10.1097/MEJ.0000000000000541
Keywords: Aucun

REVIEW ARTICLE

Editorial : The recent emergence of 'non-VKA' oral anticoagulants may have led to some forgetting that vitamin K antagonists (VKA) are by far the most widely prescribed oral anticoagulants worldwide. Consequently, we decided to summarize the information available on them. This paper presents the problems facing emergency physicians confronted with patients on VKAs in 10 points, from pharmacological data to emergency management. Vitamin K antagonists remain preferable in many situations including in the elderly, in patients with extreme body weights, severe chronic kidney or liver disease or valvular heart disease, and in patients taking VKAs with well-controlled international normalized ratios (INRs). Given the way VKAs work, a stable anticoagulant state can only be achieved at the earliest 5 days after starting therapy. The induction phase of VKA treatment is associated with the highest risk of bleeding; validated algorithms based on INR values have to be followed. VKA asymptomatic overdoses and 'non-severe' hemorrhage are managed by omitting a dose or stopping treatment plus administering vitamin K depending on the INR. Major bleeding is managed using a VKA reversal strategy. A prothrombin complex concentrate infusion plus vitamin K is preferred to rapidly achieve an INR of up to 1.5 and maintain a normal coagulation profile. The INR must be measured 30 min after the infusion. Before an invasive procedure, if an INR of less than 1.5 (<1.3 in neurosurgery) is required, it can be achieved by combining prothrombin complex concentrate and vitamin K. A well-codified strategy is essential for managing patients requiring emergency invasive procedures or presenting bleeding complications.

Conclusion : Vitamin K anticoagulants that have been used for more than 60 years are still the most prescribed anticoagulants worldwide. They therefore constitute the reference ther- apy for long-term anticoagulation. Emergency physicians will continue to be confronted with patients presenting with asymptomatic overdose and having to deal with patients requiring emergency invasive procedures or pre- senting with bleeding complications. A properly codified management strategy is essential for improving prognosis.

Conclusion (proposition de traduction) : Les AVK utilisés depuis plus de 60 ans sont toujours les anticoagulants les plus prescrits dans le monde. Ils constituent donc la thérapeutique de référence pour l'anticoagulation à long terme. Les médecins urgentistes continueront d'être confrontés à des patients présentant un surdosage asymptomatique et devant faire face à des patients nécessitant des procédures invasives d'urgence ou présentant des complications hémorragiques. Une stratégie de gestion correctement codifiée est essentielle pour améliorer le pronostic.

Utility of SOFA and Δ-SOFA scores for predicting outcome in critically ill patients from the emergency department.
García-Gigorro R, Sáez-de la Fuente I, Marín Mateos H, Andrés-Esteban EM, Sanchez-Izquierdo JA, Montejo-González JC. | Eur J Emerg Med. 2018 Dec;25(6):387-393
DOI: https://doi.org/10.1097/MEJ.0000000000000472
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : The condition of critically ill patients in the emergency department (ED) varies from moment to moment. The aims of this study are to quantify sequential organ failure assessment (SOFA) and changes in SOFA scores over time and determine its prognostic impact.

Méthode : This is a prospective observational cohort study. We included 269 patients consecutively admitted to the ICU from the ED over 18 months. The SOFA scores at ED admission (ED-SOFA) and ICU admission (ICU-SOFA) were obtained. Relative changes in SOFA scores were calculated as follows: Δ-SOFA=ICU-SOFA-ED-SOFA. Patients were divided into two groups depending on the Δ-SOFA score: (a) Δ-SOFA=0-1; and (b) Δ-SOFA more than or equal to 2.

Résultats : The median ED-SOFA score was two points (interquartile range: 1-4.5) and the Δ-SOFA score was 2 points (interquartile range: 0-3). The Δ-SOFA score was more powerful (area under the curve: 0.81) than the ED-SOFA score (area under the curve: 0.75) in predicting hospital mortality. Sixteen (6%) patients had a Δ-SOFA score less than 0, 116 (43%) patients had a Δ-SOFA=0-1, and 137 (51%) patients had a Δ-SOFA of at least 2 points. The probability of being alive at hospital discharge was 51 and 86.5% in Δ-SOFA of at least 2 and Δ-SOFA=0-1 groups, respectively (P<0.001). Risk factors for an increase of two or more SOFA points were age, cirrhosis, a diagnosis of sepsis, and a prolonged ED stay.

Conclusion : SOFA and changes in the SOFA score over time are potentially useful tools for risk stratification when applied to critically ill patients admitted to ICUs from the ED.

Conclusion (proposition de traduction) : SOFA et les changements dans le score SOFA au fil du temps sont des outils potentiellement utiles pour la stratification du risque lorsqu'ils sont appliqués à des patients gravement malades admis dans des unités de soins intensifs à partir des urgences.

Management of chest pain in the French emergency healthcare system: the prospective observational EPIDOULTHO study.
Charpentier S, Beaune S, Joly LM, Khoury A, Duchateau FX, Briot R, Renaud B, Ageron FX; IRU Network. | Eur J Emerg Med. 2018 Dec;25(6):404-410
DOI: https://doi.org/10.1097/MEJ.0000000000000481
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : The aim of this paper was to describe the epidemiology, and diagnostic and therapeutic strategies that emergency physicians use to manage patients presenting with chest pain at all three levels of the French emergency medical system - that is, dispatch centres (SAMUs: the medical emergency system), which operate the mobile intensive care units (MICUs), and hospitals' emergency departments (EDs), with a focus on acute coronary syndrome (ACS).

Méthode : All patients with chest pain who contacted a SAMU and/or were managed by a MICU and/or were admitted into an ED were included in a 1-day multicentre prospective study carried out in January 2013. Data on diagnostic and therapeutic management and disposition were collected. An in-hospital follow-up was performed.

Résultats : In total, 1339 patients were included: 537 from SAMU, 187 attended by a MICU and 615 in EDs. Diagnosing ACS was the main diagnostic strategy of the French emergency care system, diagnosed in 16% of SAMU patients, 25% of MICU patients and 10% of ED patients. Among patients calling the SAMU, 76 (14%) received only medical advice, 15 (8%) patients remained at home after being seen by a MICU and 454 (74%) were discharged from an ED.

Conclusion : Management of chest pain at the three levels of the French medical emergency system is mainly oriented towards ruling out ACS. The strategy of diagnostic management is based on minimizing missed diagnoses of ACS.

Conclusion (proposition de traduction) : La prise en charge des douleurs thoraciques aux trois niveaux du système d’urgence médical français est principalement orientée vers l’élimination du SCA. La stratégie de gestion des diagnostics repose sur la minimisation des diagnostics manqués de SCA.

Commentaire : Consulter également le déroulement et les résultats de cette étude par diaporama : Epidémiologie en SMUR (187) - SFMU
  

Safe discharge and outpatient investigation of ureteric colic: a retrospective analysis.
Stewart M | Eur J Emerg Med. 2018 Dec;25(6):429-433
DOI: https://doi.org/10.1097/MEJ.0000000000000489
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : Computed tomography of the kidneys, ureters and bladder is the recommended imaging modality for suspected urolithiasis. Early scanning is advised in guidelines, but there is limited published evidence to support this recommendation.

Méthode : In a retrospective study, we reviewed patients managed according to a local guideline. Patients without high-risk features were either imaged during their initial visit (if in the daytime) or discharged for outpatient scans. Complications, unplanned returns, final diagnosis, and intervention rates were compared between groups.

Résultats : Fifty-four patients were scanned during their initial visit and 151 were scanned as an outpatient at a median interval of 10 days. Unplanned return rates were lower in those scanned as outpatients (7.3 vs. 24.1%), with no significant difference in complications (2.0 vs. 3.7%; none leading to permanent harm). Those scanned as outpatients were less likely to have a stone proven by imaging (39.7 vs. 64.8%), but did not have a significantly higher rate of proven alternative diagnosis (9.3 vs. 13.0%).

Conclusion : There is no evidence in this cohort that discharging patients for outpatient imaging is associated with poorer outcomes, provided that an appropriate clinical risk assessment is carried out.

Conclusion (proposition de traduction) : Il n'y a aucune preuve dans cette cohorte que le fait de faire sortir des patients pour une imagerie en consultation externe soit associé à des résultats plus médiocres, à condition qu'une évaluation appropriée des risques cliniques soit réalisée.

Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers.
Maissan IM, Ketelaars R, Vlottes B, Hoeks SE, den Hartog D, Stolker RJ. | Eur J Emerg Med. 2018 Dec;25(6):e24-e28
DOI: https://doi.org/10.1097/MEJ.0000000000000490
Keywords: Aucun

Original articles

Introduction : Rigid cervical collars are known to increase intracranial pressure (ICP) in severe traumatic brain injury (TBI). Cerebral blood flow might decrease according to the Kellie Monroe doctrine. For this reason, the use of the collar in patients with severe TBI has been abandoned from several trauma protocols in the Netherlands. There is no evidence on the effect of a rigid collar on ICP in patients with mild or moderate TBI or indeed patients with no TBI. As a first step we tested the effect in healthy volunteers with normal ICPs and intact autoregulation of the brain.

Méthode : In this prospective blinded cross-over study, we evaluated the effect of application of a rigid cervical collar in 45 healthy volunteers by measuring their optical nerve sheath diameter (ONSD) by transocular sonography. Sonographic measurement of the ONSD behind the eye is an indirect noninvasive method to estimate ICP and pressure changes.

Résultats : We included 22 male and 23 female volunteers. In total 360 ONSD measurements were performed in these 45 volunteers. Application of a collar resulted in a significant increase in ONSD in both the left (β=0.06, 95% confidence interval: 0.05-0.07, P<0.001) and the right eye (β=0.01, 95% confidence interval: 0.00-0.02, P=0.027)

Conclusion : Application of a rigid cervical collar significantly increases the ONSD in healthy volunteers with intact cerebral autoregulation. This suggests that ICP may increase after application of a collar. In healthy volunteers, this seems to be of minor importance. On the basis of our findings the effect of a collar on ONSD and ICP in patients with mild and moderate TBI needs to be determined.

Conclusion (proposition de traduction) : La mise en place d'un collier cervical rigide augmente considérablement le diamètre de la gaine du nerf optique chez des volontaires en bonne santé présentant une autorégulation cérébrale intacte. Cela suggère que la pression intracrânienne peut augmenter après la mise en place d'un collier. Chez les volontaires en bonne santé, cela semble être d'une importance mineure. Sur la base de nos résultats, il convient de déterminer l’effet d’un collier sur le diamètre de la gaine du nerf optique et la pression intracrânienne chez les patients présentant une lésion cérébrale traumatique légère ou modérée.

Applying the Ottawa subarachnoid haemorrhage rule on a cohort of emergency department patients with headache.
Chu KH, Keijzers G, Furyk JS, Eley RM, Kinnear FB, Thom ON, Howell TE, Mahmoud I, Ting JYS, Brown AFT. | Eur J Emerg Med. 2018 Dec;25(6):e29-e32
DOI: https://doi.org/10.1097/MEJ.0000000000000523
Keywords: Aucun

Original articles

Introduction : The Ottawa subarachnoid haemorrhage (SAH) rule suggests that alert patients older than 15 years with a severe nontraumatic headache reaching maximum intensity within 1 h and absence of high-risk variables effectively have a SAH ruled out. We aimed to determine the proportion of emergency department (ED) patients with any headache fulfilling the entry criteria for the Ottawa SAH rule.

Méthode : The Ottawa SAH rule was applied retrospectively in a substudy of a prospective snapshot of 34 EDs in Queensland, Australia, carried out over 4 weeks in September 2014. Patient aged 18 years and older with a nontraumatic headache of any potential cause were included. Clinical data and results of investigations were collected.

Résultats : Data were available for 644 (76%) patients. A total of 149 (23.1%, 95% confidence interval: 20.0-26.5%) fulfilled and 495 (76.9%, 95% confidence interval: 73.5-80.0%) did not fulfil the entry criteria. In patients who fulfilled the entry criteria, 30 (<5% overall) did not have any high-risk variables for SAH. In patients who fulfilled the entry criteria and had at least 1 high-risk feature, almost half (46%) received a computed tomographic brain. No SAH were missed.

Conclusion : In this descriptive observational study, the majority of ED patients presenting with a headache did not fulfil the entry criteria for the Ottawa SAH rule. Less than 5% of the patients in this cohort could have SAH excluded on the basis of the rule. More definitive studies are needed to determine an accepted benchmark for the proportion of patients receiving further work-up (computed tomographic brain) after fulfilling the entry criteria for the Ottawa SAH rule.

Conclusion (proposition de traduction) : Dans cette étude observationnelle descriptive, la majorité des patients des services d'urgence présentant une céphalée ne remplissaient pas les critères d'entrée pour la règle Ottawa sur l'hémorragie sous-arachnoïdienne. Moins de 5 % des patients de cette cohorte pourraient avoir une hémorragie sous-arachnoïdienne exclue sur la base de la règle. Des études plus définitives sont nécessaires pour déterminer un point de référence acceptable pour la proportion de patients nécessitant un bilan plus approfondi (scanner cérébral) après avoir rempli les critères d'entrée pour la règle Ottawa sur l'hémorragie sous-arachnoïdienne.

Boussuge A, Boidevézi A, Vogel T, Schmitt E, Lefebvre F, Bilbault P, Lang PO. | Geriatr Psychol Neuropsychiatr Vieil. 2018 Décembre;16(4):349-58
DOI: https://doi.org/10.1684/pnv.2018.0765
Keywords: Aucun

Gériatrie et gérontologie. Articles originaux

Introduction : Le diagnostic d’une embolie pulmonaire (EP) reste difficile. L’objectif de cette étude était d’analyser l’effet de l’âge sur son mode de présentation clinique, paraclinique et la sensibilité des scores diagnostiques.

Méthode : Rétrospectivement, tous les patients sortis avec une EP documentée du service des urgences adultes du Centre hospitalier régional universitaire de Strasbourg sur une année ont été considérés. Selon 4 catégories d’âge (< 70, 70-74, 75-80 et > 80 ans), les données des dossiers médicaux ont été analysées et comparées.

Résultats : 117 patients remplissaient les critères d’inclusion. La douleur thoracique était moins fréquente après 80 ans ; aucune différence n’a été observée concernant la syncope ou la dyspnée. Un patient sur quatre a eu une scintigraphie pulmonaire, avec une augmentation du recours avec l’âge. L’angioscanner thoracique concernait 79 % des patients avec une diminution significative de son utilisation avec l’âge. La sensibilité des scores diagnostiques était basse mais augmentait avec l’âge.

Conclusion (proposition de traduction) : Cette étude confirme la faible spécificité des signes cliniques et la faible sensibilité des scores diagnostiques de l’EP après 70 ans.

Bérard C, McCambridge C, Sourdet S, Piau A, Rouch L, Chicoulaa B, Vellas B, Cestac P. | Geriatr Psychol Neuropsychiatr Vieil. 2018 Décembre;(16)4:359-66
DOI: https://doi.org/10.1684/pnv.2018.0755
Keywords: Aucun

Gériatrie et gérontologie. Articles originaux

Introduction : La prescription chronique de benzodiazépines (BZD) chez la personne âgée (PA) est potentiellement inappropriée. À l’hôpital de jour (HDJ) d’évaluation des fragilités de Toulouse, l’optimisation thérapeutique est une des mesures utilisées pour lutter contre la perte d’autonomie. L’objectif de cette étude était d’évaluer l’impact d’une intervention standardisée sur l’optimisation du traitement par BZD de ces patients.

Méthode : Après remise d’une brochure informative sur les BZD aux patients évalués à l’HDJ, une optimisation du traitement était proposée (diminution de posologie, prise intermittente, arrêt, prise d’une molécule à demi-vie courte). Un suivi téléphonique mensuel sur 6 mois était ensuite réalisé.

Résultats : 18 patients ont été inclus dans l’étude ; 50 % prenaient une BZD depuis plus de 10 ans, et 39 % avaient une BZD à demi-vie longue ; 50 % de la population était fragile et 44 % pré-fragile selon les critères de Fried. Après 6 mois, 33 % des patients avaient optimisé leur traitement, dont 17 % d’arrêt.

Conclusion (proposition de traduction) : Chez les patients âgés fragiles, une intervention standardisée peut contribuer à optimiser les traitements par BZD. Pour s’assurer de la pérennité de cette intervention, la collaboration avec le médecin traitant et le suivi prolongé des patients sont indispensables.

The impact of prothrombin complex concentrates when treating DOAC-associated bleeding: a review.
Hoffman M, Goldstein JN, Levy JH. | Int J Emerg Med. 2018 December;11(1):1-18
DOI: https://doi.org/10.1186/s12245-018-0215-6  | Télécharger l'article au format  
Keywords: Anticoagulants, Haemorrhage, Non-vitamin K antagonist oral anticoagulants, Dabigatran, Rivaroxaban, Edoxaban, Apixaban, Prothrombin complex concentrates, Anticoagulant reversal

REVIEW

Introduction : Bleeding complications are a risk associated with all anticoagulants. Currently, the treatment options for the management of direct oral anticoagulant (DOAC)-associated bleeding are limited. Prothrombin complex concentrates (PCCs) have been proposed as a potential therapeutic option, and evidence regarding their use is increasing.

Méthode : Many studies supporting PCC have used preclinical models and healthy volunteers; however, more recently, observational studies have further improved insight into current DOAC reversal strategies. Multiple clinical practice guidelines now specifically suggest use of PCCs for this indication. Specific reversal agents for Factor Xa inhibitors may become available in the near future, but data on their efficacy are still emerging.

Conclusion : Ultimately, a multimodal approach may be the optimal strategy to restore haemostasis in patients presenting with DOAC-associated coagulopathy.

Conclusion (proposition de traduction) : En fin de compte, une approche multimodale pourrait être la stratégie optimale pour rétablir l'hémostase chez les patients présentant une coagulopathie associée au AOD.

Rodrigues A | Prat Anesth Reanim. 2018 December;22(6):361-364
DOI: https://doi.org/10.1016/j.pratan.2018.08.010
Keywords: Multiple trauma; Spinal cord blood flow; Spinal cord injury

Short communication

Editorial : Les lésions médullaires s'observent le plus souvent chez les sujets jeunes victimes d'accidents à cinétique élevée et les sujets âgés dans les suites d'une chute. Le diagnostic doit être réalisé de manière précoce de manière à mettre rapidement en oeuvre les thérapeutiques adaptées. La gestion de ces patients est multidisciplinaire et vise à limiter la survenue de lésions secondaires, dans le but de limiter le handicap. Elle est réalisée dans des centres spécialisés. Elle associe l'immobilisation rachidienne, l'optimisation du débit sanguin et de l'oxygénation médullaire, la chirurgie et la réhabilitation précoce.

Conclusion (proposition de traduction) : De nombreux progrès restent à faire sur la gestion des blessés médullaires. Actuellement, leur prise en charge implique de nombreux professionnels et vise à limiter le handicap en évitant l’aggravation ou la survenue de lésions secondaires. Plusieurs axes de recherches sont à développer : monitorage dans le but d’individualisation des thérapeutiques, techniques neuro protectrices ou « neuro régénératives » associées à la réhabilitation.

Lécuyer H, Nassif X, Coureuil M. | Med Sci (Paris). 2018 Dec;34(12):1038-1041
DOI: https://doi.org/10.1051/medsci/2018288  | Télécharger l'article au format  
Keywords: Aucun

NOUVELLE

Editorial : Neisseria meningitidis, plus communément appelé méningocoque, est une bactérie de la flore normale du nasopharynx, totalement inféodée à l’être humain (elle ne colonise que l’homme et ne survit pas dans l’environnement extérieur). Cet hôte intime fait très rarement parler de lui. Cependant, dans de très rares cas, le méningocoque traverse l’épithélium du pharynx et se retrouve dans la circulation sanguine. Comme d’autres pathogènes extracellulaires cette bactérie possède une capsule polysacccharidique et exprime plusieurs facteurs de virulence qui la protègent de l’action bactéricide du complément et qui limitent sa phagocytose.
Une caractéristique fondamentale le distingue cependant des autres bactéries : il est capable d’adhérer aux cellules endothéliales, de s’y développer sous forme de microcolonies, et ce y compris en dépit des forces de cisaillement générées par le flux sanguin à la surface des cellules. La bactérie est ainsi capable de littéralement coloniser l’endothélium. Ce sont les pili de type IV, fibre protéique bactérienne, qui permettent son adhérence aux cellules endothéliales et sont à l’origine de signaux intracellulaires. Notre équipe a montré que l’adhérence aux cellules endothéliales des microvaisseaux cérébraux et l’activation par les pili du récepteur bêta-2 adrénergique induisait la délocalisation des protéines de jonction serrées et le franchissement de la barrière hémato-encéphalique (BHE)

Conclusion (proposition de traduction) : Si la physiopathologie du PF méningococcique est complexe et certainement multifactorielle, il est très probable que l’atteinte de la voie anticoagulante de la protéine C que nous avons décrite joue un rôle important dans la formation des thromboses. Ce travail ouvre ainsi de nouvelles voies de recherche pour l’élaboration de thérapeutiques innovantes pour ce syndrome qui est encore aujourd’hui associé à une mortalité élevée et à des séquelles importantes chez les survivants.

Implementation of a 2-Day Simulation-Based Course to Prepare Medical Graduates on Their First Year of Residency.
Bragard I, Seghaye MC, Farhat N, Solowianiuk M, Saliba M, Etienne AM, Schumacher K. | Pediatr Emerg Care. 2018 Dec;34(12):857-861
DOI: https://doi.org/10.1097/PEC.0000000000000930
Keywords: Aucun

Original Articles

Introduction : Residents beginning their specialization in pediatrics and emergency medicine (EM) are rapidly involved in oncall duties. Early acquisition of crisis resource management by novice residents is essential for patient safety, but traditional training may be insufficient. Our aim was to investigate the impact of a 2-day simulation-based course on residents to manage pediatric and neonatal patients.

Méthode : First year residents participated in the course. They completed two questionnaires concerning perceived stress and self-efficacy in technical skills (TSs) and non-TSs (NTSs) at 3 times: before (T0), after (T1), and 6 weeks after the course (T2).

Résultats : Eleven pediatric and 5 EM residents participated. At T0, stress about "communicating with parents" (P = 0.022) and "coordinating the team" (P = .037) was significantly higher among pediatric compared with EM residents; self-efficacy was not different between the specialities. After training, perceived stress about "managing a critical ill child" and perceived stress total significantly decreased among EM residents, whereas it remained the same among pediatricians (respectively, P = 0.001 and P = 0.016). Regarding self-efficacy, it had significantly increased in both groups (P < 0.001). Specifically, the increase in TSs self-efficacy was significant after the training (p = .008) and after 6 weeks (p < .001), and the increase in NTs self-efficacy was only significant after 6 weeks (P = 0.014).

Conclusion : Our course improved perceived stress, TSs, and NTSs self-efficacy of residents. This encourages us to formalize this as a prerequisite for admission to the pediatric and EM residency.

Conclusion (proposition de traduction) : Notre cours a amélioré le stress perçu, les compétences techniques et les compétences non techniques d'efficacité personnelle des résidents. Cela nous encourage à formaliser cela comme une condition préalable à l'admission au résidanat en pédiatrie et en médecine d'urgence.

Why Are Newborns Brought to the Emergency Department?.
Ferreira H, Ferreira C, Tavares C, Aguiar I. | Pediatr Emerg Care87. 2018 Dec;34(12):883-887
DOI: https://doi.org/10.1097/PEC.0000000000001680
Keywords: Aucun

Original articles

Introduction : Neonatal period is a peculiar life stage. This study aimed to characterize newborns' visits to the emergency department (ED) of a secondary care hospital.

Méthode : Retrospective analysis of infants up to 28 days, who resorted to the ED between January and December of 2014, was performed. The data included newborn and maternal demographic characteristics and characterization of visits in the ED.

Résultats : From 378 newborns' visits in the ED, 77 were excluded because the visits did not meet the inclusion criteria. From the remaining 301 visits, corresponding to 266 newborns, 56 newborns were referred to hospital care by another doctor, and 34 returned to ED in the neonatal period. The majority of newborns were full term (94%), born by vaginal delivery (55.1%), and had an appropriate birth weight for gestational age (94%). The main reasons for ED visits were gastrointestinal symptoms (33.8%), mucocutaneous lesions (21.4%), and jaundice (16.2%). Half (53%) of the newborns' visits were considered nonurgent. Emergency department visits for reasons justifying medical evaluation were higher in those referred by another doctor (P < 0.001). The rate of hospitalization or guidance for consultation was higher in newborns referred by another doctor (P = 0.017), in those whose color attributed by Manchester Triage System was yellow or orange (P = 0.029) and in newborns older than 7 days (P = 0.035).

Conclusion : The majority of ED visits is owing to insufficient caretaker knowledge or benign symptoms without necessity of immediate medical evaluation. These results emphasize the need for parents' education by health professionals.

Conclusion (proposition de traduction) : La majorité des consultations aux urgences sont dues à des connaissances insuffisantes du soignant (médecin adresseur) ou à des symptômes bénins sans qu'une évaluation médicale ne soit immédiatement nécessaire.
Ces résultats soulignent le besoin d'éducation des parents par les professionnels de la santé.

An Update on End-Tidal CO2 Monitoring.
Selby ST, Abramo T, Hobart-Porter N. | Pediatr Emerg Care. 2018 Dec;34(12):888-892
DOI: https://doi.org/10.1097/PEC.0000000000001682
Keywords: Aucun

CME Review Article

Editorial : End-tidal CO2 (ETCO2) monitoring is not a new modality in the pediatric emergency department (PED) and emergency department. It is the standard of care during certain procedures such as intubations and sedations and can be used in variety of clinical situations. However, ETCO2 may be underused in the PED setting. The implementation of ETCO2 monitoring may be accomplished many ways, but a foundation of capnography principles specifically in ventilation, cardiac output, and current literature regarding its application is essential to successful implementation. It is the intention of this article to briefly review the principles of ETCO2 monitoring and its clinical applications in the PED setting.

Conclusion : End-tidal CO2 monitoring is a helpful tool in the PED setting. It is essential in pediatric airway management and has been accepted universally; however, the utility of this tool in other clinical scenarios has not been as readily adopted. New research and further education regarding the use and interpretation of this tool in various clinical scenarios should be done to help clinicians and their patients who will benefit from the implementation of this invaluable tool.

Conclusion (proposition de traduction) : La surveillance de l'EtCO2 est un outil utile dans le cadre des services d’urgence pédiatriques. C'est essentiel dans la gestion des voies respiratoires pédiatriques et a été accepté universellement ; toutefois, l'utilité de cet outil dans d'autres situations cliniques n'a pas été aussi facilement adoptée. De nouvelles recherches et une formation supplémentaire concernant l'utilisation et l'interprétation de cet outil dans divers situations cliniques doivent être effectuées pour aider les cliniciens et leurs patients qui bénéficieront de la mise en œuvre de cet outil inestimable.

Evaluation of Bacterial Contamination on Prehospital Ambulances Before and After Disinfection.
Farhadloo R, Goodarzi Far J, Azadeh MR, Shams S, Parvaresh-Masoud M. | Prehosp Disaster Med. 2018 Dec;33(6):602-606
DOI: https://doi.org/10.1017/S1049023X1800095X
Keywords: EMS Emergency Medical Service; PHMB polyhexamethylene biguanide; QAC quaternary ammonium compound; Iran; ambulances; bacteria; disinfectants

Original Research

Introduction : The contamination of the environment, ambulance equipment, and staff hands consequently are major factors which create nosocomial infections in emergency patients. The contamination of equipment and devices plays an important role in nosocomial infections.
OBJECTIVES: The aim of this study was to determine the effectiveness of a disinfectant on the rate of microbial contamination of ambulances in Qom Emergency Medical Services (EMS), Qom, Iran.

Méthode : This is a quasi-experimental study with a before-after design in order to determine microbial contaminations at the rear and front cabin of ambulances, as well as medical equipment being utilized in Qom EMS. Saya sept-HP-2% solution was used for disinfection. Bacteriological standard methods were used to identify the contaminations.

Résultats : The contamination rates before and after use of disinfection solution were 52% and eight percent, respectively. Coagulase-negative staphylococci were the most commonly isolated bacterial agent from the equipment (53%). In all equipment, the contamination level has shown a significant reduction after applying disinfectant.

Conclusion : In spite of the fact that the rate of infection from ambulance equipment is high, the results showed that the use of the suitable disinfectant had an effective role in the reduction of bacteria.

Conclusion (proposition de traduction) : Bien que le taux d'infection par le matériel ambulancier soit élevé, les résultats ont montré que l'utilisation d'un désinfectant approprié avait joué un rôle efficace dans la réduction du nombre de bactéries.

Impact of pre-hospital vital parameters on the neurological outcome of out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry.
Javaudin F, Desce N, Le Bastard Q, De Carvalho H, Le Conte P, Escutnaire J, Hubert H, Montassier E, Leclere B; GR-RéAC. | Resuscitation. 2018 Dec;133:5-11
DOI: https://doi.org/10.1016/j.resuscitation.2018.09.016
Keywords: Hemodynamic monitoring; Out of hospital cardiac arrest; Prehospital emergency care; Ventilation; Vital signs

Clinical Papers

Introduction : The targets for vital parameters following return of spontaneous circulation (ROSC) from an out-of-hospital cardiac arrest (OHCA) are based on studies carried out predominantly in intensive care units. Therefore, we studied the pre-hospital phase.

Méthode : We included all adult OHCA from the French OHCA Registry. Vital parameters [peripheral oxygen saturation level (SpO2), end-tidal carbon dioxide (ETCO2) and systolic blood pressure (SBP)] documented during the pre-hospital phase by mobile medical team, were evaluated with regard to the neurological outcome on day 30 (classified as good for Cerebral Performance Category (CPC) 1 - 2, and poor for CPC 3 - 5 or death).

Résultats : When compared with a reference range of 94-98%, SpO2 values less than 94% were associated with a worse outcome on univariate analysis [relative risk (RR) = 1.108(1.069 - 1.147)]. An SpO2 of 99 - 100% did not appear to be harmful [RR = 0.9851(0.956-1.015)]. ETCO2 values that deviated from the reference of 30 - 40 mmHg were associated with a worse outcome on univariate analysis [<20, RR = 1.191(1.143 - 1.229); 20 - 29, RR = 1.092(1.061 - 1.123); 41 - 50, RR = 1.075(1.039 - 1.110); >50, RR = 1.136(1.085 - 1.179)]. When compared with a reference range of 100 - 130, higher or lower values of SBP were associated with a worse outcome on univariate analysis [<80, RR = 1.203(1.158 - 1.243); 80 - 99, RR = 1.069(1.033 - 1.105); 131 - 160, RR = 1.076(1.043 - 1.110); >160, RR = 1.168(1.126 - 1.208)]. The multivariate analysis yielded similar results.

Conclusion : In comatose patients who have achieved ROSC after OHCA, vital parameters in the pre-hospital phase appear to have a real impact on the 30-day neurological outcome. We found that an SpO2 ≥ 94%, an ETCO2 of 30 - 40 mmHg, and an SBP of 100 - 130 mmHg were associated with a better prognosis.

Conclusion (proposition de traduction) : Chez les patients comateux après une RACS dans les suites d'un arrêt cardiaque extra-hospitalier, les paramètres vitaux en phase pré-hospitalière semblent avoir un impact réel sur le résultat neurologique à 30 jours. Nous avons constaté qu'un SpO2 ≥ 94 %, un ETCO2 de 30 à 40 mmHg et une PAS de 100 à 130 mmHg étaient associés à un meilleur pronostic.

'We're going to do CPR': A linguistic study of the words used to initiate dispatcher-assisted CPR and their association with caller agreement.
Riou M, Ball S, Whiteside A, Bray J, Perkins GD, Smith K, O'Halloran KL, Fatovich DM, Inoue M, Bailey P, Cameron P, Brink D, Finn J. | Resuscitation. 2018 Dec;133:95-100
DOI: https://doi.org/10.1016/j.resuscitation.2018.10.011  | Télécharger l'article au format  
Keywords: Bystander cardiopulmonary resuscitation; Communication; Conversation analysis; Dispatch; Emergency calls; Emergency medical services; Linguistics; Out-of-hospital cardiac arrest.

CLINICAL PAPER

Introduction : In emergency ambulance calls for out-of-hospital cardiac arrest (OHCA), dispatcher-assisted cardiopulmonary resuscitation (CPR) plays a crucial role in patient survival. We examined whether the language used by dispatchers to initiate CPR had an impact on callers' agreement to perform CPR.

Méthode : We analysed 424 emergency calls relating to cases of paramedic-confirmed OHCA where OHCA was recognised by the dispatcher, the caller was with the patient, and resuscitation was attempted by paramedics. We investigated the linguistic choices used by dispatchers to initiate CPR, and the impact of those choices on caller agreement to perform CPR.

Résultats : Overall, CPR occurred in 85% of calls. Caller agreement was low (43%) when dispatchers used terms of willingness ("do you want to do CPR?"). Caller agreement was high (97% and 84% respectively) when dispatchers talked about CPR in terms of futurity ("we are going to do CPR") or obligation ("we need to do CPR"). In 38% (25/66) of calls where the caller initially declined CPR, the dispatcher eventually secured their agreement by making several attempts at initiating CPR.

Conclusion : There is potential for increased agreement to perform CPR if dispatchers are trained to initiate CPR with words of futurity and/or obligation.

Conclusion (proposition de traduction) : Il est possible que l'on accepte davantage de pratiquer la RCP si les assistants de régulation sont formés à initier la RCP avec des expressions conjuguées au temps futur et/ou en terme d'obligation.

Low-dose (2-mSv) computed tomography for suspected appendicitis: Applicability in an emergency department.
Woo JH, Jeon JJ, Choi SJ, Choi JY, Jang YS, Lim YS, Shim YS, Ahn SJ, Park JH, Lee SS. | Am J Emerg Med. 2018 Dec;36(12):2139-2143
DOI: https://doi.org/10.1016/j.ajem.2018.03.031
Keywords: Appendicitis; Computer assisted; ROC curve; Tomography; X-ray computed

Original Contribution

Introduction : To document the level of interobserver agreement and compare the diagnostic performances of emergency physicians and radiologists at interpreting low radiation CT images of acute appendicitis in adolescents and young adults.

Méthode : One hundred and seven adolescents and young adult patients (aged 15 to 44years) that underwent 2-mSv low-dose CT for suspected acute appendicitis between June and December in 2013 were enrolled in this retrospective study. Three emergency physicians and three radiologists with different experiences of low-dose CT independently reviewed CT images. These six physicians rated the likelihood of acute appendicitis using a 5-point Likert scale. We calculated interobserver agreement and compared the diagnostic performances between emergency physicians and radiologists. And diagnostic confidence was also assessed using the likelihood of acute appendicitis.

Résultats : Acute appendicitis was pathologically confirmed in 42 patients (39%); the remaining 65 patients were considered not to have appendicitis. Fleiss' Kappa for reliability of agreement between emergency physicians and radiologists for the diagnosis of acute appendicitis was 0.720 (95% confidence intervals (CI), 0.685-0.726). Pooled areas under the receiver operating characteristics curve (AUC) for a diagnosis of appendicitis were 0.904 and 0.944 for emergency physicians and radiologists, respectively, and these AUC values were not significantly different (95% confidence interval, -0.087, 0.007; p=0.0855).

Conclusion : The emergency physicians and radiologists showed good interobserver agreement and comparable diagnostic performances for appendicitis in adolescents and adults using low-dose CT images. Low-dose CT could be a useful tool for the diagnosis of appendicitis by emergency physicians.

Conclusion (proposition de traduction) : Les médecins urgentistes et les radiologues ont montré un bon accord entre observateurs et des performances diagnostiques comparables pour l'appendicite chez les adolescents et les adultes en utilisant des images tomodensitométriques à faible dose. Le scanner à faible dose pourrait être un outil utile pour le diagnostic de l'appendicite par les médecins des urgences.

Heart failure education in the emergency department markedly reduces readmissions in un- and under-insured patients.
Asthana V, Sundararajan M, Ackah RL, Karun V, Misra A, Pritchett A, Bugga P, Siler-Fisher A, Peacock WF. | Am J Emerg Med. 2018 Dec;36(12):2166-2171
DOI: https://doi.org/10.1016/j.ajem.2018.03.057
Keywords: Disease management; Emergency department; Heart failure; Patient education; Uninsured

Original contribution

Introduction : Heart failure (HF) readmissions are a longstanding national healthcare issue for both hospitals and patients. Our purpose was to evaluate the efficacy of a structured, educational intervention targeted towards un- and under-insured emergency department (ED) HF patients.

Méthode : HF patients presenting to the ED for care were enrolled between July and December 2015 as part of an open label, interventional study, using a parallel observational control group. Eligible patients provided informed consent, had an established HF diagnosis, and were hemodynamically stable. Intervention patients received a standardized educational intervention in the ED waiting room before seeing the emergency physician, and a 30-day telephone follow-up. Primary and secondary endpoints were 30- and 90-day ED and hospital readmission rates, as well as days alive and out of hospital (DAOH) respectively.

Résultats : Of the 94 patients enrolled, median age was 58.4 years; 40.4% were female, and 54.3% were African American. Intervention patients (n = 45) experienced a 47.8% and 45.3% decrease in ED revisits (P = 0.02 &P < 0.001), and 60.0% and 47.4% decrease in hospital readmissions (P = 0.049 &P = 0.007) in the 30 and 90 days pre- versus post-intervention respectively. Control patients (n = 49) had no change in hospital readmissions or 30-day ED revisits, but experienced a 36.6% increase in 90-day ED revisits (P = 0.03). Intervention patients also saw a 59.2% improvement in DAOH versus control patients (P = 0.03).

Conclusion : An ED educational intervention markedly decreases ED and hospital readmissions in un- and under-insured HF patients.

Conclusion (proposition de traduction) : Une éducation thérapeutique aux urgences réduit considérablement les réadmissions aux urgences et dans les services hospitaliers chez les patients insuffisants cardiaques non assurés et sous-assurés.

Displaced anterior pelvic fracture on initial pelvic radiography predicts massive hemorrhage.
Tanizaki S, Maeda S, Sera M, Nagai H, Nakanishi , Hayashi M, Azuma H, Kano KI, Watanabe H2, Ishida H. | Am J Emerg Med. 2018 Dec;36(12):2172-2176
DOI: https://doi.org/10.1016/j.ajem.2018.03.058
Keywords: Massive hemorrhage; Pelvic radiography; Pelvic trauma

Original contribution

Introduction : Massive hemorrhage is often associated with unstable pelvic fractures with posterior ring injury. Initial pelvic radiography alone may not detect these posterior lesions. We examined whether the presence of an anterior pelvic fracture on initial pelvic radiography alone may identify patients who are at a high risk of major hemorrhage.

Méthode : A total of 288 patients with pelvic fractures were admitted to the Fukui Prefectural Hospital during an 11-year period. After excluding 33 patients who were in cardiopulmonary arrest on arrival and nine with concomitant abdominal organ injuries requiring emergency laparotomy, 246 eligible patients were retrospectively reviewed. Anterior pelvic fractures were defined as displacement of the obturator ring, obturator ring with laterality, or displacement of the pubic symphysis on pelvic radiography.

Résultats : Massive hemorrhage was identified in 106 of 246 patients. Patients with massive hemorrhage had a higher frequency of anterior pelvic fractures on pelvic radiography and higher frequency of posterior pelvic fractures on computed tomography than those without massive hemorrhage. Logistic regression analysis identified displacement of the obturator ring by ≥5mm, obturator ring with laterality of ≥5mm, and displacement of the pubic symphysis by ≥4mm on pelvic radiography as predictors of massive pelvic hemorrhage.

Conclusion : The results of the present study suggested that the presence of displaced anterior lesions of the pelvic ring on pelvic radiography alone, without the use of computed tomography during the initial treatment stage, may promptly identify patients at high risk of massive pelvic hemorrhage who require intervention for hemorrhage control.

Conclusion (proposition de traduction) : Les résultats de la présente étude suggèrent que la présence de lésions antérieures déplacées de l'anneau pelvien sur la seule radiographie pelvienne, sans l'utilisation de la tomodensitométrie au stade initial du traitement, peut permettre d'identifier rapidement les patients à risque élevé d'hémorragie pelvienne massive nécessitant une intervention chirurgicale pour contrôler une hémorragie.

Factors associated with absent microhematuria in symptomatic urinary stone patients.
Kim TH, Oh SH, Park KN, Kim HJ, Youn CS, Kim SH, Lim J, Moon HK, Kim HJ. | Am J Emerg Med. 2018 Dec;36(12):2187-2191
DOI: https://doi.org/10.1016/j.ajem.2018.03.069
Keywords: Hematuria; Prediction; Urinalysis; Urinary calculi

Original contribution

Introduction : he aim of this study was to identify factors associated with absent hematuria in patients with symptomatic urinary stones.

Méthode : This retrospective study analyzed the clinical and imaging findings of emergency department patients who underwent computed tomography (CT) for suspected ureteral colic over the past 2years. All patients also underwent a microscopic urinalysis, and the presence of 4 or more red blood cells/high-power field was defined as microhematuria.

Résultats : A total of 798 patients were included in this study. Of these patients, 750 (94.0%) presented with hematuria, while 48 (6.0%) urine samples did not have evidence of hematuria. The group with an absence of hematuria was more likely to have a lower stone location (located in an area from the distal ureter to the bladder) and perinephric stranding on CT than the hematuria group (75.0% vs. 54.3%, p=0.005; 47.9% vs. 30.5%, p=0.012, respectively). The degree of hematuria at each stone location was significantly different (p=0.001). In multivariate analysis, perinephric stranding (odds ratios (OR) 1.87 [95% confidence interval (CI) 1.01-3.46], p=0.047), a lower stone location (OR 2.72 [95% CI 1.37-5.36], p=0.004), and elevated serum blood urea nitrogen (BUN) levels (OR 1.06 [95% CI 1.01-1.12], p=0.026) were associated with absent hematuria.

Conclusion : In this large cohort of patients with renal colic, 6% had no microhematuria. Although some CT findings and elevated BUN were independently associated with hematuria absence, there was no difference in the demographics, time of presentation and degree and location of pain between the groups.

Conclusion (proposition de traduction) : Dans cette importante cohorte de patients atteints de colique néphrétique, 6 % n'avaient pas d'hématurie microscopique. Bien que certains résultats de la tomodensitométrie et l'augmentation de l'urée aient été associés de manière indépendante à l'absence d'hématurie, il n'y avait pas de différence dans les données démographiques, l'heure de la présentation, le degré et l'emplacement de la douleur entre les groupes.

Diagnostic value of QRS and S wave variation in patients with suspicion of acute pulmonary embolism.
Çağdaş M, Karakoyun S, Rencüzoğulları İ, Karabağ Y, Artaç İ, İliş D, Hamideyin Ş, Karayol S, Çiftçi H, Çınar T. | Am J Emerg Med. 2018 Dec;36(12):2197-2202
DOI: https://doi.org/10.1016/j.ajem.2018.03.074
Keywords: Acute pulmonary embolism; Electrocardiogram; QRS variation; S wave variation

Original contribution

Introduction : This study aimed to investigate the diagnostic value of QRS and S wave variation in patients admitted to the emergency department with suspicion of acute pulmonary embolism (APE).

Méthode : Computerized tomographic pulmonary angiography (CTPA) was performed in 118 consecutive patients to evaluate patients with suspected APE, and 106 subjects with appropriate electrocardiogram and CT images constituted the study population.

Résultats : Using CTPA, APE was diagnosed in 48.1% (n:51) of the study population. The comparison of patients with APE and those without APE revealed that increased heart rate, right axis deviation of QRS axis, complete or incomplete right bundle branch block, prominent S wave in lead D1, increased QRS duration, percentage of QRS (9,8[4,8-19,0] vs 3,8[2,7-71]; p<0,001), S wave variation (22,3[9,6-31,9] vs 4,8 [2-8]; p<0,001) and ΔS wave amplitude (1.1[0.5-1.5] vs 0.2[0.1-0.5]; p<0.001) were significantly associated with APE, but no relationship was detected with respect to the presence of atrial arrhythmias, clockwise rotation of the horizontal axis, fragmentation, ST segment deviation, T wave inversion, and S1Q3T3 and S1S2S3 patterns. The percentage of S wave variation (OR: 1072 per 1% increase, 95% CI:1011-1137) was found to be an independent predictor of APE. ΔS wave amplitude>0.5mm predicted APE with a sensitivity of 72.6% and a specificity of 74.6% (AUC:0.805, 95% CI: 0.717-0.876; p<0.001).

Conclusion : The present study demonstrated that QRS and S wave variation could be useful electrocardiographic signs for the diagnosis of APE.

Conclusion (proposition de traduction) : Cette étude a démontré que la modification des ondes QRS et S pourrait être un signe électrocardiographique utile pour le diagnostic d'une embolie pulmonaire aiguë.

Commentaire : Dans cette étude les conclusions sont les suivantes :
L’analyse des ECG a mis en évidence que la présence d’une augmentation de la fréquence cardiaque, d’une déviation axiale droite des QRS, d’un bloc de branche complet ou incomplet, d’une onde S importante dans D1 et de la durée de QRS étaient significativement associées à l'embolie pulmonaire, alors qu’aucune relation retrouvée en ce qui concerne la présence d'arythmies auriculaires, la fragmentation (NDLR : dédoublements de l’onde R ou l’onde S en l'absence de bloc de branche [QRS < 0,12 s]), la rotation de l'axe horizontal dans le sens des aiguilles d'une montre, la déviation du segment ST, l'inversion de l'onde T et les aspects S1Q3T3 et S1S2S3.

The early chain of care in bacteraemia patients: Early suspicion, treatment and survival in prehospital emergency care.
Andersson H, Axelsson C, Larsson A, Bremer A, Gellerstedt M, Bång A, Herlitz J, Ljungström L. | Am J Emerg Med. 2018 Dec;36(12):2211-2218
DOI: https://doi.org/10.1016/j.ajem.2018.04.004
Keywords: Bacteraemia; Emergency Medical Services; Emergency care; Infection; Prehospital emergency care; Sepsis

Original contribution

Introduction : Bacteraemia is a first stage for patients risking conditions such as septic shock. The primary aim of this study is to describe factors in the early chain of care in bacteraemia, factors associated with increased chance of survival during the subsequent 28days after admission to hospital. Furthermore, the long-term outcome was assessed.

Méthode : This study has a quantitative design based on data from Emergency Medical Services (EMS) and hospital records.

Résultats : In all, 961 patients were included in the study. Of these patients, 13.5% died during the first 28days. The EMS was more frequently used by non-survivors. Among patients who used the EMS, the suspicion of sepsis already on scene was more frequent in survivors. Similarly, EMS personnel noted the ESS code "fever, infection" more frequently for survivors upon arriving on scene. The delay time from call to the EMS and admission to hospital until start of antibiotics was similar in survivors and non-survivors. The five-year mortality rate was 50.8%. Five-year mortality was 62.6% among those who used the EMS and 29.5% among those who did not (p<0.0001).

Conclusion : This study shows that among patients with bacteraemia who used the EMS, an early suspicion of sepsis or fever/infection was associated with improved early survival whereas the delay time from call to the EMS and admission to hospital until start of treatment with antibiotics was not. 50.8% of all patients were dead after five years.

Conclusion (proposition de traduction) : Cette étude montre que chez les patients présentant une bactériémie ayant eu recours aux services médicaux d'urgence, une suspicion précoce de sepsis ou de fièvre/infection était associée à une amélioration de la survie précoce, tandis que les antibiotiques ne l'étaient pas. 50,8 % de tous les patients étaient décédés après cinq ans.

Air pollutants and atmospheric pressure increased risk of ED visit for spontaneous pneumothorax.
Park JH, Lee SH, Yun SJ, Ryu S, Choi SW, Kim HJ, Kang TK, Oh SC, Cho SJ. | Am J Emerg Med. 2018 Dec;36(12):2249-2253
DOI: https://doi.org/10.1016/j.ajem.2018.04.020
Keywords: Air pollution; Atmospheric pressure; Epidemiology; Meteorology; Primary spontaneous pneumothorax

Original contribution

Introduction : To investigate the impact of short-term exposure to air pollutants and meteorological variation on ED visits for primary spontaneous pneumothorax (PSP).

Méthode : We retrospectively identified PSP cases that presented at the ED of our tertiary center between January 2015 and September 2016. We classified the days into three types: no PSP day (0 case/day), sporadic days (1-2 cases/day), and cluster days (PSP, ≥3 cases/day). Association between the daily incidence of PSP with air pollutants and meteorological data were determined using Poisson generalized-linear-model to calculate incidence rate ratio (IRRs) and the use of time-series (lag-1 [the cumulative air pollution level on the previous day of PSP], lag-2 [two days ago], and lag-3 [three days ago]).

Résultats : Using multivariate logistic regression analysis, O3 (p = 0.010), NO2 (p = 0.047), particulate matters (PM)10 (p = 0.021), and PM2.5 (p = 0.008) were significant factors of PSP occurrence. When the concentration of O3, NO2, PM10, and PM2.5 were increased, PSP IRRs increased approximately 15, 16, 3, and 5-fold, respectively. With the time-series analyses, atmospheric pressure in lag-3 was significantly lower and in lag-2, was significantly higher in PSP days compared with no PSP days. Among air pollutant concentrations, O3 in lag-1 (p = 0.017) and lag-2 (p = 0.038), NO2 in lag-1 (p = 0.015) and lag-2 (p = 0.009), PM10 in lag-1 (p = 0.012), and PM2.5 in lag-1 (p = 0.021) and lag-2 (p = 0.032) were significantly different between no PSP and PSP days.

Conclusion : Increased concentrations of air pollutants and abrupt change in atmospheric pressure were significantly associated with increased IRR of PSP.

Conclusion (proposition de traduction) : L'augmentation des concentrations de polluants atmosphériques et une modification brutale de la pression atmosphérique étaient significativement associées à une augmentation du taux d'incidence du pneumothorax spontané inaugural.

Survival of trauma patients needing CPR shortly after arrival: The NationalTrauma Data Bank Research Data Set.
Elkbuli A, Flores R, Dowd B, Hai S, Boneva D, McKenney M. | Am J Emerg Med. 2018 Dec;36(12):2276-2278
DOI: https://doi.org/10.1016/j.ajem.2018.09.031
Keywords: Aggressive resuscitation; Post-resuscitation survival; The National Trauma Data Bank; Trauma outcomes; Trauma quality

Brief reports

Introduction : Cardio Pulmonary Resuscitation (CPR) for traumatized patients in the field portends poor survival but the outcome of trauma patients who arrive in-extremis and undergo CPR shortly after arrival has not been well studied. The purpose of our review is to evaluate survival to discharge for trauma patients with CPR from 1 to 120 minutes (min) after arrival.

Méthode : The NTDB Research Data Set (RDS) was reviewed. Patients with vitals in the field who underwent CPR from 1 to 120 min after arrival were divided according to injury type and Injury Severity Score (ISS). Survival to discharge outcomes were determined in patients that underwent CPR from 1-60 min and 61-120 min after arrival.

Résultats : The RDS contained 968,665 patients and 9,365 (0.96%) had CPR from 1 to 120 min after arrival. For blunt injuries with CPR from 1 to 60 min, survival was similar for all levels of ISS (8.5-10.2%, p > 0.05). Blunt injury patients with CPR 61-120 min and ISS 1-15 had significantly higher survival rate compared to ISS >25 (36.1% vs 8.7%, p < 0.00003). For penetrating injuries and CPR from 1 to 60 min, survival was similar for all levels of ISS (4.3-6.8%, p > 0.05); Blunt and penetrating patients with CPR from 61 to 120 min, and ISS 1-15 had the highest survivals at 36.1 and 36.4%.

Conclusion : Trauma patients who undergo CPR shortly after arrival have a survival rate of (4.3%-36.4%). Over one-third of blunt and penetrating injuries and low ISS who had CPR from 61 to 120 min after arrival survived. Trauma patients who arrest shortly after arrival warrant an aggressive approach.

Conclusion (proposition de traduction) : Les patients traumatisés qui bénéficient une RCP peu de temps après leur arrivée ont un taux de survie de 4,3 % à 36,4 %. Plus du tiers des lésions traumatiques fermées et/ou pénétrantes et de faible score de gravité des blessures qui ont bénéficié d'une RCP de 61 à 120 minutes après leur arrivée ont survécu. Les patients traumatisés qui s'arrêtent peu de temps après leur arrivée méritent une réanimation agressive.

Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis.
White L, Melhuish T, Holyoak R, Ryan T, Kempton H, Vlok R. | Am J Emerg Med. 2018 Dec;36(12):2298-2306
DOI: https://doi.org/10.1016/j.ajem.2018.09.045
Keywords: Advanced airway management; Cardiac arrest; Intubation; Laryngeal mask; Laryngeal tube

Reviews

Introduction : To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA).

Méthode : A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state.

Résultats : Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I2 = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I2 = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I2 = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I2 = 0%; p < 0.00001).

Conclusion : The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.

Conclusion (proposition de traduction) : L'avantage hétérogène global sur le plan de la survie avec la sonde endotrachéale n'a pas été reproduit dans les essais contrôlés randomisés à faible risque, sans différence significative sur le plan de la survie ou du résultat neurologique. En présence de compressions thoraciques automatisées, l'intubation par sonde endotrachéale peut avoir des effets bénéfiques sur la survie.

Commentaire : Voir l'article de Jabre P and all :
Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018 Feb 27;319(8):779-787
  

Sepsis Core Measures - Are They Worth the Cost?.
Esposito A, Silverman ME, Diaz F, Fiesseler F, Magnes G, Salo D. | J Emerg Med. 2018 Dec;55(6):751-757
DOI: https://doi.org/10.1016/j.jemermed.2018.07.033
Keywords: CMS sepsis core measures; SIRS; sepsis

Original Contributions

Introduction : In 2015, the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission launched the sepsis core measures in an attempt to decrease sepsis morbidity and mortality. Recent studies call into question the multiple treatment measures in early goal-directed therapy on which these CMS measures are based.
OBJECTIVES: The purpose of this study is to compare the utilization of resources due to the implementation of the sepsis core measures while examining whether complying with these treatment guidelines decreases patient mortality.

Méthode : Data were collected on patients suspected of sepsis in a suburban academic emergency department. These data were collected over the course of 3 consecutive years. The data collected included lactates, blood cultures, and antibiotics (vancomycin, piperacillin/tazobactam) ordered. The mortality rate of patients with a final diagnosis of sepsis present on arrival was calculated for a 3-month period of each year and compared.

Résultats : There was no difference in the mortality rates of patients with sepsis across the 3 years. There was an increase in the amount of piperacillin/tazobactam and vancomycin administered. There was a significant increase in the number of lactates and blood cultures ordered per patient across all 3 years.

Conclusion : There was no difference in the mortality rate of patients with a final diagnosis of sepsis. However, there was a significant increase in the utilization of resources to care for these patients. As a result of the overutilization of these resources, the cost for both patients and hospitals has increased without improvement in mortality.

Conclusion (proposition de traduction) : Il n'y avait pas de différence dans le taux de mortalité des patients avec un diagnostic final de septicémie. Cependant, il y a eu une augmentation significative de l'utilisation des ressources pour soigner ces patients. En raison de la surutilisation de ces ressources, les coûts pour les patients et les hôpitaux ont augmenté sans amélioration de la mortalité.

Acute Pancreatitis: Updates for Emergency Clinicians.
Waller A, Long B, Koyfman A, Gottlieb M. | J Emerg Med. 2018 Dec;55(6):769-779
DOI: https://doi.org/10.1016/j.jemermed.2018.08.009
Keywords: alcohol; fluids; gallstones; imaging; lipase; necrosis; pancreatitis

Clinical Reviews

Introduction : Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis.

Méthode : This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis.

Discussion : Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe.

Conclusion : Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.

Conclusion (proposition de traduction) : La pancréatite est une maladie potentiellement mortelle qui consulte généralement dans la plupart des services d'urgence. Il est important que les cliniciens soient au courant des des données probantes actuelles concernant le diagnostic, le traitement et le traitement réservé à ces patients.