Bibliographie de Médecine d'Urgence

Mois de janvier 2019


Academic Emergency Medicine

Safety of the Combination of PERC and YEARS Rules in Patients With Low Clinical Probability of Pulmonary Embolism: A Retrospective Analysis of Two Large European Cohorts.
Gorlicki J, Penaloza A, Germeau B, Moumneh T, Philippon AL, Truchot J, Douillet D, Steinier C, Soulié C, Bloom B, Cachanado M, Roy PM, Freund Y. | Acad Emerg Med. 2019 Jan;26(1):23-30
DOI: https://doi.org/10.1111/acem.13508  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : This study aimed to determine the failure rate of a combination of the PERC and the YEARS rules for the diagnosis of pulmonary embolism (PE) in the emergency department (ED).

Méthode : We performed a retrospective analysis of two European cohorts of emergency patients with low gestalt clinical probability of PE (PROPER and PERCEPIC). All patients we included were managed using a conventional strategy (D-dimer test, followed, if positive, by computed tomographic pulmonary angiogram (CTPA). We tested a diagnostic strategy that combined PERC and YEARS to rule out PE. The primary endpoint was a thromboembolic event diagnosed in the ED or at 3-months follow-up. Secondary endpoints included a thromboembolic event at baseline in the ED and a CTPA in the ED. Ninety-five percent confidence intervals (CIs) of proportions were calculated with the use of Wilson's continuity correction.

Résultats : We analyzed 1,951 patients (mean ± SD age = 47 ± 18 years, 56% women) with an overall proportion of patients with PE of 3.5%. Both PERC and YEARS strategies were associated with 11 missed PE in the ED: failure rate 0.57 (95% CI = 0.32-1.02). At 3-month follow-up, the overall failure rate was 0.83% (95% CI = 0.51-1.35). Among the 503 patients who underwent a CTPA (26%), the use of the PERC-YEARS combination would have ruled out PE without CTPA in 249 patients (50% [95%CI = 45%-54%], absolute reduction 13% (95% CI = 11%-14%]).

Conclusion : The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA.

Conclusion (proposition de traduction) : L'association des scores PERC et YEARS était associée à un faible risque d'échec du diagnostic d'embolie pulmonaire et aurait entraîné une réduction relative de près de la moitié des angio-scanners thoraciques.

Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department.
Yadav K | Acad Emerg Med. . 2019 Jan;26(1):51-59
DOI: https://doi.org/10.1111/acem.13492  | Télécharger l'article au format  
Keywords: Aucun

original contributions

Introduction : Current guideline recommendations for optimal management of nonpurulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is a lack of evidence to guide emergency physicians regarding selection of patients for oral versus intravenous antibiotic therapy. The primary objective was to identify predictors associated with oral antibiotic treatment failure.

Méthode : We performed a health records review of adults (age ≥ 18 years) with nonpurulent SSTIs treated at two tertiary care emergency departments (EDs). Oral antibiotic treatment failure was defined as any of the following after a minimum of 48 hours of oral therapy due to worsening infection: 1) hospitalization, 2) change in class of oral antibiotic, or 3) switch to intravenous therapy. Multivariable logistic regression was used to identify predictors independently associated with oral antibiotic treatment failure.

Résultats : We identified 500 patients (mean ± SD age = 64 ± 19 years, 279 male [55.8%], and 126 [25.2%] with diabetes). Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR] = 6.31, 95% confidence interval [CI] = 1.80 to 22.08), chronic ulcers (OR = 4.90, 95% CI = 1.68-14.27), history of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection (OR = 4.83, 95% CI = 1.51 to 15.44), and cellulitis in the past 12 months (OR = 2.23, 95% CI = 1.01 to 4.96) were independently associated with oral antibiotic treatment failure.

Conclusion : This is the first study to evaluate predictors of oral antibiotic treatment failure for nonpurulent SSTIs treated in the ED. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection, and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for outpatient management of nonpurulent SSTIs.

Conclusion (proposition de traduction) : Il s'agit de la première étude à évaluer les facteurs prédictifs d'échec du traitement antibiotique par voie orale pour les infections non purulentes de la peau et des tissus mous traitées dans le service des urgences. Les tachypnées au triage, les ulcères chroniques, les antécédents de colonisation ou d'infection par Staphylococcus aureus résistant à la méthicilline et la cellulite au cours de l'année écoulée ont été associés de manière indépendante à un échec du traitement antibiotique par voie orale. Les urgentologues doivent prendre en compte ces facteurs de risque lors du choix d’un traitement antimicrobien oral ou intraveineux lors de la prise en charge en ambulatoire des infections non purulentes de la peau et des tissus mous.

Clinical Predictors of Acute Brain Injury in Carbon Monoxide Poisoning Patients With Altered Mental Status at Admission to Emergency Department.
Kim YJ, Sohn CH, Seo DW, Oh BJ, Lim KS, Kim WY. | Acad Emerg Med. 2019 Jan;26(1):60-67
DOI: https://doi.org/10.1111/acem.13510  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : Objective screening tool for patients at a high risk of developing acute brain injury (ABI) is necessary for the proper treatment of carbon monoxide (CO) poisoning patients. The aim of this study is to identify clinical factors that could predict ABI due to CO poisoning in patients with an altered mental status.

Méthode : A prospectively collected CO poisoning registry at a single academic medical center was retrospectively analyzed. CO poisoning patients with an altered mental status at the emergency department, defined as unalert on the alert/responsive to voice/responsive to pain/unresponsive scale and underwent diffusion-weighted magnetic resonance imaging (DW-MRI) between January 1, 2013, and December 31, 2015, were included. ABI was defined as the presence of acute hypoxic brain lesions. Clinical predictors of ABI were identified by multivariate logistic regression analysis.

Résultats : Of 180 patients, 67 (37.2%) had ABI as revealed by DW-MRI. Multivariate analysis showed that CO exposure duration > 5 hours (adjusted odds ratio [AOR] = 7.082; 95% confidence interval [CI] = 3.463-15.014; p < 0.001) defined as the time between CO exposure and rescue, abnormal white blood cell count (AOR = 2.568, 95% CI = 1.188-5.700, p = 0.02), and abnormal creatinine concentration (AOR = 2.667, 95% CI = 1.110-6.605, p = 0.03) were predictors of ABI. CO exposure duration had the highest predictive value (area under the curve, 0.815), and the optimal cutoff value was 5 hours. Moreover, increasing exposure durations (quartile) indicated a stepwise increase in the risk of ABI.

Conclusion : In CO poisoning patients with an altered mental status, CO exposure duration was useful for predicting ABI, which may help clinicians or paramedics identify high-risk patients and provide treatment on priority.

Conclusion (proposition de traduction) : Chez les patients intoxiqués par le monoxyde de carbone et dont l'état mental était altéré, la durée d'exposition au monoxyde de carbone était utile pour prédire les lésions cérébrales aiguës, ce qui pourrait aider les cliniciens ou les ambulanciers paramédicaux à identifier les patients à haut risque et à qui proposer un traitement prioritaire.

Parenteral Antipsychotic Choice and Its Association With Emergency Department Length of Stay for Acute Agitation Secondary to Alcohol Intoxication.
Cole JB, Klein LR, Martel ML. | Acad Emerg Med. 2019 Jan;26(1):79-84
DOI: https://doi.org/10.1111/acem.13486  | Télécharger l'article au format  
Keywords: Aucun

Brief Report

Introduction : Acute agitation secondary to alcohol intoxication frequently requires parenteral sedatives for patient and caregiver safety. Antipsychotics play a prominent role; however, no consensus exists regarding the ideal agent. One important consideration when evaluating the choice of antipsychotic is its association with emergency department (ED) length of stay (LOS).
OBJECTIVES: We sought to determine the median ED LOS for patients receiving a single parenteral dose of an antipsychotic for acute agitation secondary to alcohol intoxication in an urban Level I trauma center.

Méthode : This was a retrospective review of patients receiving a single parenteral dose of droperidol, haloperidol, or olanzapine who were acutely intoxicated on alcohol from 2011 to 2016. Patients needing psychiatric assessment in our ED are discharged to a geographically separate department; thus, ED LOS is minimally impacted by waits for psychiatric assessment. Data were abstracted from the electronic medical record and are presented descriptively.

Résultats : A total of 40,601 patients were identified and screened; 24,319 patients were intoxicated but received no sedation. Of those remaining 4,495 received multiple drugs and/or benzodiazepines leaving 11,787 for analysis. Median age was 42 years, 76% were male, and 5% of patients were admitted. Mean breath ethanol concentration was 227 mg/dL. Antipsychotics administered were as follows: droperidol (n = 3,790), haloperidol (n = 1,449), and olanzapine (n = 6,548). Median ED LOS was shortest for droperidol (499 minutes, 95% confidence interval [CI] = 493-506 minutes), which was significantly shorter than both haloperidol (524 minutes, 95% CI = 515-537 minutes) and olanzapine (533 minutes, 95% CI = 528-539 minutes). No cases of sudden cardiac death occurred.

Conclusion : Droperidol, when given as monotherapy for sedation of acute agitation secondary to alcohol intoxication, was associated with significantly shorter ED LOS than either parenteral haloperidol or parenteral olanzapine. No difference in ED LOS was observed between haloperidol and olanzapine.

Conclusion (proposition de traduction) : Lorsque le dropéridol était administré en monothérapie pour calmer l'agitation aiguë secondaire à une intoxication alcoolique, il était associé à une durée de séjour en service d'urgence considérablement plus courte que l'halopéridol par voie injectable ou l'olanzapine par voie injectable. Aucune différence dans la durée du séjour à l'urgence n'a été observée entre l'halopéridol et l'olanzapine.

Commentaire : Pour mémoire : dropéridol = DROLEPTAN 5 mg/2 ml (par voie intra-musculaire), halopéridol = HALDOL 5 mg/ml (par voie intramusculaire uniquement) et olanzapine = ZYPREXA 10 mg (une seule injection intramusculaire).
L'article n'aborde pas l'utilisation de la Loxapine 50 mg/2ml (par voie intra-musculaire), pourtant largement utilisé dans les services d'urgence.

Benefits of Rhythm Control and Rate Control in Recent-onset Atrial Fibrillation: The HERMES-AF Study.
Martín A, Coll-Vinent B, Suero C, Fernández-Simón A, Sánchez J, Varona M, Cancio M, Sánchez S, Carbajosa J, Malagón F, Montull E, Del Arco C; HERMES-AF investigators.. | Acad Emerg Med. 2019 Jan 31
DOI: https://doi.org/10.1111/acem.13703
Keywords: Aucun

Original Contribution

Introduction : Although rhythm control has failed to demonstrate long-term benefits over rate control in longstanding episodes of atrial fibrillation (AF), there is little evidence concerning recent-onset ones. We analyzed the benefits of rhythm and rate control in terms of symptoms alleviation and need for hospital admission in patients with recent-onset AF.

Méthode : This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 emergency departments (EDs). Clinical variables, treatment effectiveness, and outcomes (control of symptoms, final disposition) were analyzed in stable patients with recent-onset AF consulting for AF-related symptoms.

Résultats : Of 421 patients included, rhythm control was chosen in 352 patients (83.6%), a global effectiveness of 84%. Rate control was performed in 69 patients (16.4%) and was achieved in 67 (97%) of them. Control of symptoms was achieved in 396 (94.1%) patients and was associated with a heart rate after treatment ≤ 110 beats/min (odds ratio [OR] = 14.346, 95% confidence interval [CI] = 3.90 to 52.70, p < 0.001) and a rhythm control strategy (OR = 2.78, 95% CI = 1.02 to 7.61, p = 0.046). Sixty patients (14.2%) were admitted: discharge was associated with a rhythm control strategy (OR = 2.22, 95% CI = 1.20-4.60, p = 0.031) and admission was associated with a heart rate > 110 beats/min after treatment (OR = 29.71, 95% CI = 7.19 to 123.07, p < 0.001) and acute heart failure (OR = 9.45, 95% CI = 2.91 to 30.65, p < 0.001).

Conclusion : In our study, recent-onset AF patients in whom rhythm control was attempted in the ED had a high rate of symptoms' alleviation and a reduced rate of hospital admissions.

Conclusion (proposition de traduction) : Dans notre étude, les patients présentant une FA paroxystique chez qui un contrôle du rythme cardiaque avait été tenté au service des urgences présentaient un taux élevé d'atténuation des symptômes et un taux réduit d'hospitalisations.

AEM Education and Training

A Mixed-methods Comparison of Participant and Observer Learner Roles in Simulation Education.
Bullard MJ, Weekes AJ, Cordle RJ, Fox SM, Wares CM, Heffner AC, Howley LD, Navedo D. | AEM Educ Train. 2019 January;3(1):20-32
DOI: https://doi.org/10.1002/aet2.10310
Keywords: Aucun

ORIGINAL CONTRIBUTIONS

Introduction : Traditional simulation-based education prioritizes participation in simulated scenarios. The educational impact of observation in simulation-based education compared with participation remains uncertain. Our objective was to compare the performances of observers and participants in a standardized simulation scenario.

Méthode : We assessed learning differences between simulation-based scenario participation and observation using a convergent, parallel, quasi-experimental, mixed-methods study of 15 participants and 15 observers (N = 30). Fifteen first-year residents from six medical specialties were evaluated during a simulated scenario (cardiac arrest due to critical hyperkalemia). Evaluation included predefined critical actions and performance assessments. In the first exposure to the simulation scenario, participants and observers underwent a shared postevent debriefing with predetermined learning objectives. Three months later, a follow-up assessment using the same case scenario evaluated all 30 learners as participants. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare participants and observers at 3-month follow-up. In addition, we used case study methodology to explore the nature of learning for participants and observers. Data were triangulated using direct observations, reflective field notes, and a focus group.

Résultats : Quantitative data analysis comparing the learners' first and second exposure to the investigation scenario demonstrated participants' time to calcium administration as the only statistically significant difference between participant and observer roles (316 seconds vs. 200 seconds, p = 0.0004). Qualitative analysis revealed that both participation and observation improved learning, debriefing was an important component to learning, and debriefing closed the learning gap between observers and participants.

Conclusion : Participants and observers had similar performances in simulation-based learning in an isolated scenario of cardiac arrest due to hyperkalemia. Findings support current limited literature that observation should not be underestimated as an important opportunity to enhance simulation-based education. When paired with postevent debriefing, scenario observers and participants may reap similar educational benefits.

Conclusion (proposition de traduction) : Les participants et les observateurs ont présenté des performances similaires dans le cadre d'un apprentissage basé sur la simulation dans un scénario isolé d'arrêt cardiaque dû à une hyperkaliémie. Les résultats corroborent la documentation limitée actuelle selon laquelle l'observation ne doit pas être sous-estimée comme une opportunité importante d'améliorer la formation par simulation. Lorsqu'ils sont associés à un débriefing après la fin de l'événement, les observateurs du scénario et les participants peuvent bénéficier d'avantages éducatifs similaires.

Performance Standards of Comprehensive Airway Management for Emergency Medicine Residents.
Panchal AR, Way DP, King AM, Yudkowsky R, Terndrup TE; Airway Mastery Collaborative (AMC). | AEM Educ Train. 2019 January;3(1):39-49
DOI: https://doi.org/10.1002/aet2.10127
Keywords: Aucun

ORIGINAL CONTRIBUTIONS

Introduction : The Emergency Medicine (EM) Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Although milestones provide a general structure for assessment, they do not define performance standards. The objective of this project was to establish comprehensive airway management performance standards for EM trainees at both novice and mastery levels of proficiency.

Méthode : Comprehensive airway management standards were derived using standard-setting procedures. A panel of residency education and airway management experts was convened to determine how trainees would be expected to perform on 51 individual tasks in a standardized airway management simulation encompassing preparation, endotracheal intubation, backup airway use, and ventilation. Experts participated in facilitated exercises in which they were asked to 1) define which items were critical for patient safety, 2) predict the performance of a "novice" learner, and 3) predict the performance of a "mastery" learner nearing independent practice. Experts were given a worksheet to complete and descriptive statistics were calculated using STATA 14.

Résultats : Experts identified 39 of 51 (76%) airway management items as critical for patient safety. Experts also noted that novice trainees do not need to complete all the items deemed to be critical prior to starting practice since they will be supervised by a board-certified EM physician. In contrast, mastery-level trainees would be expected to successfully complete not only the critical tasks, but also nearly all the items in the assessment (49/51, 96%) since they are nearing independent practice.

Conclusion : In this study, we established EM resident performance standards for comprehensive airway management during a simulation scenario. Future work will focus on validating these performance standards in current resident trainees as they move from simulation to actual patient care.

Conclusion (proposition de traduction) : Dans cette étude, nous avons établi des normes de performance des résidents en médecine d'urgence pour une gestion complète des voies respiratoires lors d'un scénario de simulation. Les travaux futurs porteront sur la validation de ces normes de performance chez les stagiaires résidents actuels, qui passeront de la simulation aux soins réels aux patients.

Annales Françaises de Médecine d'Urgence

Taboulet P, Vincent-Cassy C, Squara PA, Resche-Rigon M. | Ann Fr Med Urgence. 2019 janv;9:10-16
DOI: https://doi.org/10.3166/afmu-2018-0099
Keywords: Triage; Nurse; Emergency medicine; France

Article original / Original article

Introduction : La Société française de médecine d’urgence a créé en 2016 une échelle de tri pour les infirmier( ière)s d’accueil dans une structure d’urgences. Cette échelle appelée FRENCH (FRench Emergency Nurses Classification in Hospital) classe les tris de 5 à 1 (du moins urgent au plus urgent) en fonction du pronostic et de la complexité/ sévérité des motifs de recours aux soins. Le tri 3, groupe hétérogène dans les échelles de tri internationales, a été subdivisé en deux niveaux pour prioriser les patients qui ont une comorbidité en rapport avec le motif de recours aux soins ou qui sont adressés par un médecin et qui sont prioritaires (3A) par rapport aux autres patients (3B).

Méthode : Évaluer la pertinence de la FRENCH.
Méthode : Nous avons analysé les données démographiques, les paramètres vitaux, les examens complémentaires prescrits et les durées de prise en charge de tous les patients accueillis dans un hôpital universitaire sur une période de neuf mois consécutifs. Le critère de jugement était l’existence d’une relation croissante entre le niveau de complexité/ sévérité des patients — reflétée par le taux d’hospitalisation et la prescription d’examens complémentaires—et le niveau de priorité du tri.

Résultats : L’étude a inclus 27 598 patients. La répartition des patients par niveaux de tri était : 0,4 (tri 1), 6,7 (tri 2), 13,3 (tri 3A), 29,4 (tri 3B), 43,1 (tri 4) et 7,1 % (tri 5). Le taux d’hospitalisation était croissant quand l’ordre de priorité augmentait. La relation entre les niveaux de tri et le taux d’hospitalisation mesurée par l’aire sous la courbe (0,83 : intervalle de confiance à 95 % : [0,82–0,83]) était bonne. La prescription des examens complémentaires était croissante quand l’ordre de priorité augmentait. La corrélation entre les niveaux de tri et un indice global d’examens complémentaires prescrits était modérée (K = 0,51).

Conclusion : This study validates the relevance of the sixlevel FRENCH triage scale by its good ability to classify patients according to their complexity/severity. New assessments might be needed in other emergency departments to confirm its performance and promote its evolution.

Conclusion (proposition de traduction) : Cette étude monocentrique valide la pertinence de l’échelle de tri FRENCH à six niveaux par sa bonne capacité à classer les patients selon leur complexité/sévérité. De nouvelles évaluations sont nécessaires dans d’autres structures d’urgences pour confirmer sa performance et favoriser son évolution.

Commentaire : Retrouvez la grille FRENCH sur la page « Score » du site  , onglet « Réanimation & urgences ».

Adt C, Salignon J, Freund Y, Espinasse E, Ray P, Avondo A. | Ann Fr Med Urgence. 2019 janv;9:17-23
DOI: https://doi.org/10.3166/afmu-2018-0073
Keywords: Cardiac arrest; Age; Prognostic; Duration of resuscitation

Article original / Original article

Introduction : L’objectif de notre étude est de déterminer si l’âge des patients en arrêt cardiaque (AC) a une influence sur les durées de réanimation cardiopulmonaire (RCP) par les équipes préhospitalières.

Méthode : Nous avons réalisé une étude monocentrique, prospective, à partir des données de notre centre hospitalier universitaire, issues du Registre électronique des arrêts cardiaques. Ont été inclus tous les patients ayant présenté un AC, hormis ceux retrouvés en état de rigidité cadavérique ou qui avaient préalablement exprimé des directives anticipées sur leur fin de vie. Les patients ont été séparés en deux groupes selon leur âge : les moins de 75 ans et ceux de 75 ans et plus. Le critère de jugement principal était la durée de RCP spécialisée décidée par le médecin de l’équipe préhospitalière.

Résultats : Du 1er janvier au 31 décembre 2015, sur 253 patients victimes d’AC, 188 (74 % d’hommes, 78 % d’asystolie) ont bénéficié d’une RCP par une équipe du Service mobile d’urgence et de réanimation. Il y a eu 39 % de récupération d’une activité cardiaque spontanée (RACS). Seuls 31 % des patients étaient admis vivants à l’hôpital, ils étaient 6 % à j30. La durée de RCP était plus importante pour les patients de moins de 75 ans (29 ± 15 vs 23 ± 19 minutes ; p < 0,01). Mais pour les patients ayant une RACS, la durée de RCP était identique entre les deux groupes (16 ± 10 vs 14 ± 9 minutes ; p = 0,34). La survie des patients de 75 ans et plus était de 10 vs 22 % pour les moins de 75 ans (p = 0,35).

Conclusion : Our study suggests that as the patient’s age increases, the medical teams reduce the duration of resuscitation.

Conclusion (proposition de traduction) : Notre étude suggère que l’âge des patients influence négativement les durées de réanimation des équipes préhospitalières.

Commentaire : Article à rapprocher des études sur la durée « optimale » d'une RCP :
· Funada A and al. Duration of cardiopulmonary resuscitation in patients without prehospital return of spontaneous circulation after out-of-hospital cardiac arrest: Results from a severity stratification analysis. Resuscitation. 2018 Mar;124:69-75   ;
· Nagao K and al. Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest. Circulation. 2016 Apr 5;133(14):1386-96   ;
· Reynolds JC and al. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? Circulation. 2013 Dec 3;128(23):2488-94   ;
· Goldberger ZD and al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study.Lancet. 2012 Oct 27;380(9852):1473-81  .

Annals of Emergency Medicine

Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial.
Gaspari RJ, Sanseverino A, Gleeson T. | Ann Emerg Med. 2019 Jan;73(1):1-7
DOI: https://doi.org/10.1016/j.annemergmed.2018.05.014
Keywords: Aucun

Infectious Disease

Introduction : We hypothesize that clinical failure rates will be lower in patients treated with point-of-care ultrasonography and incision and drainage compared with those who undergo incision and drainage after physical examination alone.

Méthode : We performed a prospective randomized clinical trial of patients presenting with a soft tissue abscess at a large, academic emergency department. Patients presenting with an uncomplicated soft tissue abscess requiring incision and drainage were eligible for enrollment and randomized to treatment with or without point-of-care ultrasonography. The diagnosis of an abscess was by physical examination, bedside ultrasonography, or both. Patients randomized to the point-of-care ultrasonography group had an incision and drainage performed with bedside ultrasonographic imaging of the abscess. Patients randomized to the non-point-of-care ultrasonography group had an incision and drainage performed with physical examination alone. Comparison between groups was by comparing means with 95% confidence intervals. The primary outcome was failure of therapy at 10 days, defined as a repeated incision and drainage, following a per-protocol analysis. Multivariate analysis was performed to control for study variables. Our study was designed to detect a clinically important difference between groups, which we defined as a 13% difference.

Résultats : A total of 125 patients were enrolled, 63 randomized to the point-of-care ultrasonography group and 62 to physical examination alone. After loss to follow-up and misallocation, 54 patients in the ultrasonography group and 53 in the physical examination alone group were analyzed. The overall failure rate for all patients enrolled in the study was 10.3%. Patients who were evaluated with ultrasonography were less likely to fail therapy and have repeated incision and drainage, with a difference between groups of 13.3% (95% confidence interval 0.0% to 19.4%). Abscess locations were predominantly torso (21%), buttocks (21%), lower extremity (18%), and axilla or groin (16%). There was no difference in baseline characteristics between groups relative to abscess size, duration of symptoms before presentation, percentage with cellulitis, and treatment with antibiotics.

Conclusion : Patients with soft tissue abscesses who were undergoing incision and drainage with point-of-care ultrasonography demonstrated less clinical failure compared with those treated without point-of-care ultrasonography.

Conclusion (proposition de traduction) : Les patients présentant des abcès des tissus mous qui subissaient une incision et un drainage sous échographie au point d'intervention ont présenté moins d'échecs cliniques par rapport à ceux traités sans échographie au point d'intervention.

Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis..
Gottlieb M, DeMott JM, Hallock M, Peksa GD. | Ann Emerg Med. 2019 Jan;73(1):8-16
DOI: https://doi.org/10.1016/j.annemergmed.2018.02.011
Keywords: Aucun

Infectious Disease

Introduction : The addition of antibiotics to standard incision and drainage is controversial, with earlier studies demonstrating no significant benefit. However, 2 large, multicenter trials have recently been published that have challenged the previous literature. The goal of this review was to determine whether systemic antibiotics for abscesses after incision and drainage improve cure rates.

Méthode : PubMed, the Cumulative Index of Nursing and Allied Health Literature, Scopus, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all randomized controlled trials comparing adjuvant antibiotics with placebo in the treatment of drained abscesses, with an outcome of treatment failure assessed within 21 days. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Cochrane Risk of Bias tool.

Résultats : Four studies (n=2,406 participants) were identified. There were 89 treatment failures (7.7%) in the antibiotic group and 150 (16.1%) in the placebo group. The calculated risk difference was 7.4% (95% confidence interval [CI] 2.8% to 12.1%), with an odds ratio for clinical cure of 2.32 (95% CI 1.75 to 3.08) in favor of the antibiotic group. There was also a decreased incidence of new lesions in the antibiotic group (risk difference -10.0%, 95% CI -12.8% to -7.2%; odds ratio 0.32, 95% CI 0.23 to 0.44), with a minimally increased risk of minor adverse events (risk difference 4.4%, 95% CI 1.0% to 7.8%; odds ratio 1.29, 95% CI 1.06 to 1.58).

Conclusion : The use of systemic antibiotics for skin and soft tissue abscesses after incision and drainage resulted in an increased rate of clinical cure. Providers should consider the use of antibiotics while balancing the risk of adverse events.

Conclusion (proposition de traduction) : L'utilisation d'antibiotiques systémiques dans les abcès de la peau et des tissus mous après une incision et un drainage a entraîné une augmentation du taux de guérison clinique. Les prestataires devraient envisager l'utilisation d'antibiotiques tout en équilibrant le risque d'événements indésirables.

Should Adults With Mild Head Injury Who Are Receiving Direct Oral Anticoagulants Undergo Computed Tomography Scanning? A Systematic Review.
Fuller GW, Evans R, Preston L, Woods HB, Mason S. | Ann Emerg Med. 2019 Jan;73(1):66-75
DOI: https://doi.org/10.1016/j.annemergmed.2018.07.020
Keywords: Aucun

Trauma

Introduction : Patients receiving direct oral anticoagulant medications commonly undergo computed tomography head scanning after mild traumatic brain injury, regardless of symptoms or signs. International guidelines have noted a lack of evidence to support management decisions for such patients. This systematic review aims to identify, appraise, and synthesize the current evidence for the risk of adverse outcome in patients receiving direct oral anticoagulants after mild head injury.

Méthode : A protocol was registered with PROSPERO and review methodology followed Cochrane Collaboration recommendations. Studies of adult patients with mild head injury (Glasgow Coma Scale score 13 to 15) and who were receiving direct oral anticoagulants that reported the risk of adverse outcome after the head injury were eligible for inclusion. A comprehensive range of bibliographic databases and gray literature was examined with a sensitive search strategy. Selection of eligible studies, data extraction, and risk of bias were evaluated independently by separate reviewers. A random-effects meta-analysis was used to provide a pooled estimate of the risk of adverse outcome. The overall quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation Working Group approach.

Résultats : A total of 4,886 articles were screened for inclusion, of which 7 cohort studies including 346 patients met inclusion criteria. All studies were at high or unclear risk of bias as a result of selection and information bias. Estimates of adverse outcome (any death, intracranial hematoma, or neurosurgery) ranged from 0.0% to 8.3%. A random-effects meta-analysis showed a weighted composite outcome risk of 3.7% (95% confidence interval 1.7% to 5.8%; I2=3.3%). The overall quality of the body of evidence was low as a result of imprecision, indirectness, and risk of bias.

Conclusion : There are limited data available to characterize the risk of adverse outcome in patients receiving direct oral anticoagulants after mild traumatic brain injury. A sufficiently powered prospective cohort study is required to validly define this risk, identify clinical features predictive of adverse outcome, and inform future head injury guidelines.

Conclusion (proposition de traduction) : Les données disponibles pour caractériser le risque d'évolution défavorable chez les patients recevant des anticoagulants oraux directs après une lésion cérébrale traumatique légère sont limitées. Une étude de cohorte prospective suffisamment puissante est nécessaire pour définir valablement ce risque, identifier les caractéristiques cliniques prédictives de résultats défavorables et informer les futures recommandations relatives aux traumatisme crânien.

Annals of Intensive Care

Current use of vasopressors in septic shock.
Scheeren TWL, Bakker J, De Backer D, Annane D, Asfar P, Boerma EC, Cecconi M, Dubin A, Dünser MW, Duranteau J, Gordon AC, Hamzaoui O, Hernández G, Leone M, Levy B, Martin C, Mebazaa A, Monnet X, Morelli A, Payen D, Pearse R, Pinsky MR, Radermacher P, Reuter D, Saugel B, Sakr Y, Singer M, Squara P, Vieillard-Baron A, Vignon P, Vistisen ST, van der Horst ICC, Vincent JL, Teboul JL. | Ann Intensive Care. 2019 Jan 30;9(1):20
DOI: https://doi.org/10.1186/s13613-019-0498-7  | Télécharger l'article au format  
Keywords: Arterial blood pressure; Norepinephrine; Resuscitation; Sepsis; Septic shock; Shock; Vasoactive agonists; Vasopressor

Research

Introduction : Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use.

Méthode : From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 17 questions focused on the profile of respondents, triggering factors, first choice agent, dosing, timing, targets, additional treatments, and effects of vasopressors. We investigated whether the answers complied with current guidelines. In addition, a group of 34 international ESICM experts was asked to formulate recommendations for the use of vasopressors based on 6 questions with sub-questions (total 14).

Résultats : A total of 839 physicians from 82 countries (65% main specialty/activity intensive care) responded. The main trigger for vasopressor use was an insufficient mean arterial pressure (MAP) response to initial fluid resuscitation (83%). The first-line vasopressor was norepinephrine (97%), targeting predominantly a MAP > 60-65 mmHg (70%), with higher targets in patients with chronic arterial hypertension (79%). The experts agreed on 10 recommendations, 9 of which were based on unanimous or strong (≥ 80%) agreement. They recommended not to delay vasopressor treatment until fluid resuscitation is completed but rather to start with norepinephrine early to achieve a target MAP of ≥ 65 mmHg.

Conclusion : Reported vasopressor use in septic shock is compliant with contemporary guidelines. Future studies should focus on individualized treatment targets including earlier use of vasopressors.

Conclusion (proposition de traduction) : L’utilisation déclarée de vasopresseurs en cas de choc septique est conforme aux directives actuelles. Les futures études devraient se concentrer sur des cibles de traitement individualisées, y compris l'utilisation antérieure de vasopresseurs.

Commentaire : 

British Medical Journal

Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial.
Kortekangas T, Kortekangas T, Haapasalo H, Flinkkilä T, Ohtonen P, Nortunen S, Laine HJ, Järvinen TL, Pakarinen H. | BMJ. 2019 Jan 23;364:k5432
DOI: https://doi.org/10.1136/bmj.k5432  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : OBJECTIVE: To determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces non-inferior outcomes compared with conventional immobilisation in a cast for six weeks.
DESIGN : Randomised, pragmatic, non-inferiority, clinical trial with blinded outcome assessment.
SETTING : Two major trauma centres in Finland, 22 December 2012 to 6 June 2016.

Méthode :  PARTICIPANTS : 247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs.
INTERVENTIONS : Participants were randomly allocated to conventional six week cast immobilisation (n=84) or three week treatment either in a cast (n=83) or in a simple orthosis (n=80).
MAIN OUTCOME MEASURES: The primary, non-inferiority, intention-to-treat outcome was the Olerud-Molander Ankle Score at 12 months (OMAS; range 0-100; higher scores indicate better outcomes and fewer symptoms). The predefined non-inferiority margin for the primary outcome was -8.8 points. Secondary outcomes were ankle function, pain, quality of life, ankle motion, and radiographic outcome. Follow-up assessments were performed at 6, 12, and 52 weeks.

Résultats : 212 of 247 randomised participants (86%) completed the study. At 52 weeks, the mean OMAS was 87.6 (SD 18.3) in the six week cast group, 91.7 (SD 12.9) in the three week cast group, and 89.8 (SD 18.4) in the three week orthosis group. The between group difference at 52 weeks for the three week cast versus six week cast was 3.6 points (95% confidence interval -1.9 to 9.1, P=0.20), and for the three week orthosis versus six week cast was 1.7 points (-4.0 to 7.3, P=0.56). In both comparisons, the confidence intervals did not include the predefined inferiority margin of -8.8 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three week orthosis group versus six week cast group.

Conclusion : Immobilisation for three weeks with a cast or orthosis was non-inferior to conventional cast immobilisation for six weeks in the treatment of an isolated stable Weber B type fracture.

Conclusion (proposition de traduction) : L'immobilisation pendant trois semaines avec un plâtre ou une orthèse (attelle) n'était pas inférieure à l'immobilisation par plâtre conventionnelle pendant six semaines dans le traitement d'une fracture isolée de type Weber B stable.

Commentaire : La fracture Weber B est une fracture uni-malléolaire de la cheville.

Canadian Journal of Emergency Medicine

Sex-specific, high-sensitivity cardiac troponin T cut-off concentrations for ruling out acute myocardial infarction with a single measurement.
McRae A, Graham M, Abedin T, Ji Y, Yang H, Wang D, Southern D, Andruchow J, Lang E, Innes G, Seiden-Long I, DeKoning L, Kavsak P. | CJEM. 2019 Jan;21(1):26-33
DOI: https://doi.org/10.1017/cem.2018.435
Keywords: acute coronary syndrome; cardiac biomarkers; myocardial infarction

Original Research

Introduction : L’établissement de valeurs-seuils diagnostiques selon le sexe pourrait améliorer les caractéristiques des dosages ultrasensibles de la troponine en vue du diagnostic d’infarctus du myocarde (IM). L’étude visait donc à quantifier les caractéristiques des valeurs-seuils selon le sexe d’un seul dosage ultrasensible de la troponine T cardiaque (TnTc) chez les patients souffrant de douleurs thoraciques, sur une période de 7 jours.

Méthode : Il s’agit d’une étude observationnelle de cohorte, menée chez des patients consécutifs, examinés dans 4 services des urgences (SU), au Canada, pour des douleurs thoraciques évocatrices d’un IM et chez qui a été effectué un dosage de la TnTc dans les 60 minutes suivant leur arrivée à l’hôpital. Le principal critère d’évaluation consistait en la possibilité d’un IM au bout de 7 jours. Les caractéristiques de dosage (sensibilité, valeur prédictive négative, rapport de vraisemblance, proportion de patients éliminés) de différentes combinaisons de seuils d’élimination selon le sexe ont été quantifiées, et l’indice de reclassification net a été calculé par rapport aux seuils d’élimination généralement utilisés.

Résultats : L’incidence de l’IM relevée au bout de 7 jours chez 7130 patients (3931 hommes et 3199 femmes) était de 7,38 % chez les hommes et de 3,78 % chez les femmes. Les seuils optimaux selon le sexe (hommes : < < 8 ng/l; femmes : < 7 ng/l) avaient une sensibilité de 98,5 % à l’égard de l’IM et ils ont été utilisés pour éliminer la possibilité d’un IM chez 55,8 % des patients. Leur application permettrait une augmentation absolue de la proportion de patients chez qui a été éliminée la possibilité d’un IM à l’aide d’un seul dosage de la TnTc, augmentation qui passerait de 13,2 % à 22,2 % selon les seuils d’élimination généralement reconnus, utilisés comme comparateur.

Conclusion : Sex-specific hs-cTnT cut-offs for ruling out MI at ED arrival may improve classification performance, enabling more patients to be safely ruled out at ED arrival. However, differences between sex-specific and universal cut-off con- centrations are within the variation of the assay, limiting the clinical utility of this approach. These findings should be confirmed in other data sets.

Conclusion (proposition de traduction) : L’application des seuils d’élimination d’un IM selon le sexe, à l’aide de la mesure de la TnTc à l’arrivée des malades au SU, pourrait améliorer la performance de classement du dosage, ce qui permettrait d’écarter, en toute sécurité, la possibilité d’un IM chez plus de patients qu’actuellement à leur arrivée au SU. Toutefois, comme les différences entre les seuils d’élimination selon le sexe et les seuils d’élimination généralement utilisés se situent dans la plage de variations du dosage, elles en limitent l’utilité clinique. Il faudrait que les résultats obtenus soient confirmés dans d’autres ensembles de données.

How do I rule out aortic dissection?.
Ohle R, McIsaac S, Atkinson P. | CJEM. 2019 Jan;21(1):34-36
DOI: https://doi.org/10.1017/cem.2018.484
Keywords: Aucun

Just the Facts

Editorial : CLINICAL SCENARIO
A 75-year-old male presents with gradual onset central chest pain radiating to his back. Past medical history is significant for hypertension. Does he need a computed tomography (CT) scan to rule out acute aortic dissection?
CASE RESOLUTION
An electrocardiogram and troponins are negative. You get a chest X-ray that is also normal. An aortic dissection is possible, but the probability is so low that no further workup is required.

Conclusion : KEY POINTS
1. There is no current validated clinical decision rule that, in isolation, can rule out the presence of acute aortic dissection.
2. Clinical features can help decide which patients are low risk; however, definitive investigation by a CT is required if an acute aortic dissection is under serious consideration, and there is not an alternative diagnosis that could explain the patient’s symptoms.
3. Acute aortic dissection is a rare presentation to the emergency department that should be considered in your differential, because the mortality rate is significant if not diagnosed in a timely manner.

Conclusion (proposition de traduction) : Points clés
1. Il n'existe actuellement aucune règle de décision clinique validée qui puisse, à elle seule, exclure la présence d'une dissection aortique aiguë.
2. Les caractéristiques cliniques peuvent aider à décider quels patients présentent un risque faible. Cependant, une analyse définitive par un scanner est nécessaire si une dissection aortique aiguë est sérieusement envisagée et si aucun autre diagnostic ne peut expliquer les symptômes du patient.
3. La dissection aortique aiguë est une présentation rare au service des urgences qui doit être prise en compte dans votre différentiel, car le taux de mortalité est important s'il n'est pas diagnostiqué à temps.

An innovative short-stay health care model for treatment of uncomplicated vaso-occlusive crisis in adult sickle cell disease patients in Canada to reduce emergency department utilization.
Binding A, Ward R, Phua C, Naessens V, O'Brien T4 Bhatia S, Baranek H, Marani H, Mukerji G. | CJEM. 2019 Jan;21(1):55-62
DOI: https://doi.org/10.1017/cem.2017.413
Keywords: emergency room diversion; short-stay model; sickle cell disease; vaso-occlusive crisis

Original Research

Introduction : Patients with sickle cell disease (SCD) with vaso-occlusive crises (VOC) often visit the emergency department (ED) for management of painful episodes. The primary objective of this pilot study was to evaluate the acceptability of a short-stay model for treatment of VOC in SCD outside of the ED in Toronto, Canada. Secondary objectives were to assess patient satisfaction of this model, barriers to its use and comparison of clinical outcomes to a historical control.

Méthode : Adult SCD patients with symptoms of an uncomplicated VOC between October 2014 to July 2016 were managed according to best practice recommendations in a short-stay unit as an alternative to the local emergency room. Primary outcome of time to first analgesia, and secondary outcome of discharge rate were compared to a historical control at a local ED from 2009-2012. Satisfaction and barriers to use of the ambulatory care delivery model were assessed by patient survey.

Résultats : Twenty-one visits were recorded at the short-stay unit during the study period. Average time to first opiate dose was 23.5 minutes in the short-stay unit compared to 100.3 minutes in the ED (p4/5 on Likert scale) except for geographic accessibility (85% response rate, n=18).

Conclusion : This study demonstrated high patient satisfaction and acceptability of a short-stay model for treatment of uncomplicated VOC in adult SCD patients in Toronto, the first of its kind in Canada.

Conclusion (proposition de traduction) : Cette étude a démontré une grande satisfaction des patients et l'acceptabilité d'un modèle de séjour de courte durée pour le traitement de crises vaso-occlusives non compliquées chez des patients atteints de drépanocytose chez l'adulte à Toronto, le premier du genre au Canada.

Dog bites in the emergency department: a descriptive analysis.
Morzycki A, Simpson A, Williams J. | CJEM. 2019 Jan;21(1):63-70.
DOI: https://doi.org/10.1017/cem.2018.2
Keywords: dog bite; epidemiology; wound

Original Research

Introduction : L’étude visait à évaluer les types de morsure de chien, observés chez les adultes, dans un service des urgences (SU) de taille moyenne, situé en milieu urbain, au Canada.

Méthode : Tous les adultes (≥16 ans) ayant consulté au SU, dans la région, pour des morsures de chien, sur une période de 30 mois (janvier 2013 à juin 2015) ont été recensés. A suivi un examen des données démographiques, des types de blessure et des caractéristiques des chiens.

Résultats : Au total, 475 morsures de chien ont été relevées. La plupart des morsures se sont produites en été (140; 30 %) et la race de chiens incriminée le plus souvent était de type pitbull (27 %). La majorité des patients était des femmes (295; 62 %) et les morsures touchaient surtout les mains (264; 56 %). Celles concernant la tête et le cou représentaient 11 % des blessures. Dans 50 % des cas, un bon lavage des plaies et la pose de pansements ont suffi mais, dans 15 cas (3 %), il a fallu procéder à une suture primitive complexe. Par ailleurs, l’utilisation d’une salle d’opération s’est imposée dans 8 cas de pertes de substance (2 %), pour reconstruction. Il y a eu 4 réparations de tendon (1 %), 1 réparation de nerfs (0,2 %) et 1 greffe de peau (0,2 %). Trois patients ont dû être hospitalisés. Le taux général d’infection s’est élevé à 10 %.

Conclusion : Dog bites most commonly occurred in the hands and upper extremities, and carried an infection risk of approximately 10%. Large, muscular breeds were the most frequently implicated. The effectiveness of breed-specific legislation remains unclear, but educational programs for dog owners, children, and health care workers may help decrease the number and severity of attacks.

Conclusion (proposition de traduction) : Les morsures de chien touchaient surtout les mains et les membres supérieurs, et elles comportaient un risque d’infection d’environ 10 %. Les chiens incriminés le plus souvent étaient de grosse taille et bien musclés. Si l’efficacité des lois visant des races particulières de chien reste à démontrer, des programmes de formation à l’intention des propriétaires de chien, des enfants et des professionnels de la santé pourraient, eux, réduire le nombre d’attaques et la gravité des morsures.

ULTRASIM: Ultrasound in trauma simulation.
McLean D, Hewitson L, Atkinson P, Lewis D, Fraser J, Verheul G, Mekwan J, Robinson B. | CJEM. 2019 Jan;21(1):125-128
DOI: https://doi.org/10.1017/cem.2018.56
Keywords: education; point-of-care ultrasound; simulation; trauma

Original Research

Introduction : L’essai visait à évaluer l’efficacité des simulations d’échographie comme moyen de représentation réaliste de traumas, dans l’amélioration de la compétence diagnostique de résidents et de médecins traitants qui avaient participé à des études de cas factices de trauma.

Méthode : Au total, 12 résidents et 20 médecins traitants ont participé à 114 simulations de trauma. Les sujets ont dressé une liste ordonnée de diagnostics différentiels après un examen physique et une autre après une échographie simulée E-FAST. Il y a ensuite eu comparaison des rapports afin de déterminer si l’ajout de l’échographie avait permis d’améliorer la performance relative à l’exactitude diagnostique.

Résultats : L’exactitude diagnostique initiale s’est améliorée de manière significative avec l’ajout des simulations d’écho- graphie (p < 0,0001). Il y a également eu une amélioration des résultats médians relatifs au classement des diagnostics (p<0,0001). En outre, les participants ont fait état d’un plus grand degré de confiance personnelle dans l’exactitude diagnostique (p < 0,0001) et ont raccourci leur liste de diagnostics différentiels (p < 0,0001).

Conclusion : We demonstrated that a low-cost ultrasound simulator can be successfully integrated into trauma simula- tions, resulting in an associated improvement in measures of diagnostic accuracy, confidence, and precision for participat- ing resident and attending physicians.

Conclusion (proposition de traduction) : Les résultats de l’étude démontrent que l’utilisa- tion d’un simulateur d’échographie à bas coût peut donner de bons résultats dans l’étude de cas factices de trauma; en effet, une amélioration des mesures de l’exactitude et de la précision diagnostiques ainsi que de la confiance personnelle a été observée chez les résidents et les médecins traitants qui avaient participé à des séances de formation.

A new way to look at simulation-based assessment: the relationship between gaze-tracking and exam performance.
Szulewski A, Egan R, Gegenfurtner A, Howes D, Dashi G, McGraw NCJ, Hall AK, Dagnone D, van Merrienboer JJG. | CJEM. 2019 Jan;21(1):129-137
DOI: https://doi.org/10.1017/cem.2018.391
Keywords: assessment; emergency medicine; gaze-tracking; medical education; simulation

Original Research

Introduction : Une des tâches importantes du chef d’équipe en médecine d’urgence est la collecte efficace de renseignements, et le port de lunettes de monitorage oculaire permet d’étudier rapidement et facilement les différents modes de collecte visuelle de renseignements. Les chercheurs ont donc eu recours à cette technique pour émettre des hypothèses selon lesquelles il existerait une relation entre la performance des résidents et la saisie de champs visuels d’intérêt présumés tels par des experts, dans des scénarios d’examen de réanimation axés sur la simulation, en médecine.

Méthode : Des résidents en médecine d’urgence ont porté des lunettes de monitorage oculaire au cours de deux séances d’examen par simulation (n = 29 et n = 13, respectivement). Des experts tenus dans l’ignorance ont évalué le comportement des résidents enregistré sur vidéo, à l’aide d’un outil d’évaluation de la performance axée sur la simulation, dont la validité avait déjà fait ses preuves dans le contexte. Il y a eu analyse de relations entre la collecte visuelle de renseignements et la performance ainsi qu’émission d’hypothèses. Quatre scénarios ont été évalués dans l’étude : l’acidocétose diabétique, une bradycardie consécutive à un surdosage de bêta-bloquants, une rupture d’anévrisme de l’aorte abdominale et une acidose métabolique causée par la consommation d’antigel.

Résultats : Des corrélations ont été établies entre certaines manières de recueillir visuellement les renseignements et la performance objective. Ainsi, ceux qui ont le mieux réussi avaient davantage tendance à se concentrer sur les stimulus pertinents, relatifs aux tâches et à ne pas tenir compte, à juste titre, des stimulus non pertinents comparativement à ceux qui ont moins bien réussi. Par exemple, un temps d’attente raccourci dans la collecte visuelle de renseignements sur les signes vitaux dans le cas de l’acidocétose diabétique s’est révélé en corrélation positive avec la performance (r = 0,70; p < 0,05), tandis que le temps total écoulé à glaner des renseignements sur les résultats d’examens de laboratoire dans le cas de la rupture d’anévrisme de l’aorte abdominale était en corrélation négative avec la performance (r = −0,50; p < 0,05).

Conclusion : There are differences between the visual patterns of high and low-performing residents. These findings may allow for better characterization of expertise development in resuscitation medicine and provide a framework for future study of visual behaviours in resuscitation cases.

Conclusion (proposition de traduction) : Il existe donc des différences entre la manière de glaner visuellement les renseignements et la performance, bonne ou mauvaise, des résidents. Les résultats pourraient permettre une meilleure caractérisation de l’acquisition de la compétence en matière de médecine de réanimation, et fournir un cadre de travail en vue d’études futures sur les comportements visuels dans les cas de réanimation.

Cognitive load theory as a framework for simulation-based, ultrasound-guided internal jugular catheterization training: Once is not enough.
McGraw R, Chaplin T, Rocca N, Rang L, Jaeger M, Holden M, Keri Z, Fichtinger G. | CJEM.. 2019 Jan;21(1):141-148
DOI: https://doi.org/10.1017/cem.2018.456
Keywords: cognitive load theory; competency; medical education; simulation

Original Research

Introduction : L’étude avait pour objectif principal d’appliquer les principes de la théorie des capacités cognitives dans l’élaboration d’un programme d’apprentissage visant à intégrer la méthode de la pratique progressive-fractionnée à l’enseignement du cathétérisme échoguidé de la jugulaire interne (JI) à des débutants. L’étude avait également pour objectif secondaire de comparer la compétence technique des résidents formés selon le nouveau programme avec celle des résidents formés selon la formule habituelle d’enseigne- ment, appliquée à l’échelle locale, consistant en une seule séance de simulation.

Méthode : Le groupe expérimental comptait 16 résidents, qui ont participé à 3 séances de pratique progressive-fractionnée, de 2 heures chacune, dans un laboratoire de simulation; le groupe témoin, quant à lui, comptait 46 résidents, qui ont participé à 1 seule séance de simulation, d’une durée de 2 heures, juste avant leur stage au service de soins intensifs, selon la méthode habituelle d’enseignement. L’habileté technique des participants a été évaluée à l’aide d’une analyse des mouvements de la main et du temps d’exécution de l’examen.

Résultats : Après 3 séances de formation, les résultats médians relatifs aux mouvements de la main droite (MMD) (34,5 [27,0-49,0]), à ceux de la main gauche (MMG) (35,5 [20,0- 45,0]) et au temps total d’exécution (TT) (117,0 s [82,7-140,0]) dans le groupe expérimental étaient significativement meilleurs que ceux obtenus dans le groupe témoin (p < 0,001). Par ailleurs, 8 résidents dans le groupe expérimental, soumis à une évaluation de la capacité de rappel des gestes à une date ultérieure, ont obtenu les résultats médians suivants: MMD (45,0 [32,0-58,0]), MMG (33,5 [20,0-63,0]) et TT d’exécution (150,0 s [103,0-399,6]); ces chiffres sont nette- ment meilleurs que ceux enregistrés dans le groupe témoin (p = 0,01, p < 0,01 et p = 0,02, respectivement).

Conclusion : These results support multiple sessions of progressive part practice in a simulation lab as an effective competency-based approach to teaching USG IJC in prepara- tion for the clinical setting.

Conclusion (proposition de traduction) : Les résultats obtenus confirment l’efficacité des séances fractionnées de pratique progressive, en laboratoire de simulation, comme méthode d’enseignement du cathétérisme échoguidé de la JI, axée sur les compétences, en vue de la préparation des étudiants au milieu clinique.

Emergency Care Journal

Determinants of troponin T and I elevation in old patients without acute coronary syndrome.
Di Micoli A, Scarciello C, De Notariis S, Cavazza M, Muscari A. | Emerg Care J. 2019;15:7798
DOI: https://doi.org/10.4081/ecj.2019.7798  | Télécharger l'article au format  
Keywords: Aucun

Original Articles

Introduction : Cardiac troponins T and I (cTnT and cTnI) are the main markers of acute myocardial cell damage and then of Acute Coronary Syndrome (ACS) if associated with compatible symptoms. Although their cardio-specificity, the cTn may be increased in various clinical conditions but only few recent studies have reported their trends with age.

Méthode : This is a single-center retrospective observational study on two groups of adults consecutive patients, with age ≥65 years, admitted to the Emergency Department of the Sant’Orsola-Malpighi Hospital of Bologna, Italy, with chest pain as chief complaint.

Résultats : In the first group was dosed cTnT (N=617), in the second group cTnI (N=569). The patients with final ACS’s diagnosis (N=255) or an incomplete report of blood tests (N=17) were excluded. The definitive database included 471 patients in the first group and 443 in the second one. The observed differences between clinical parameters, patients with cTnT≤14ng/L and those with cTnT>14ng/L (N=207, 44%) are: older age, greater prevalence of diabetes, lower values of Hb e ALT, higher values of white blood cells, INR, glycemia, urea, creatinine, BNP e PCR. In multiple logistics regression (N=333) only 4 variables resulted independently associated to cTnT increase: age (P<0.0001), PCR (P=0.01), creatinine (P=0.02) and urea (P=0.04), R2=0.30. The differences between patients with cTnI≤40ng/L and those with cTnI>40ng/L (N=46, 10%) are: older age, Hb values equal and higher values of white blood cells, INR, glycemia, urea, creatinine, total bilirubin, AST, BNP e PCR. In multiple logistics regression (N=259) the only 4 variables independently associated to increase of cTnI are age (P<0.0001), glycemia (P=0.004), PCR (P=0.01) and white blood cells (P=0.02), R2=0.17. Furthermore, the number of patients with high level of cTn significantly increase by age (cTnT: 65-74 years 22.2%, 75-84 years 48.5%, ≥85 years 79.5%; cTnI: 65-74 years 4.3%, 75-84 years 8.1%, ≥85 years 22.5%, P<0.0001).

Conclusion : In our study, cTnI showed fewer false positives than cTnT and seems to be less influenced by kidney failure. Furthermore, the acute phase of inflammation was associated with the rise of troponins. High cTn values were found in elderly subjects, without acute coronary syndromes, particularly cTnT. Then the age seems to be the most important factor related to this highelevated troponin levels.

Conclusion (proposition de traduction) : Dans notre étude, la troponine cardiaque I (cTnI) a montré moins de faux positifs que la troponine cardiaque T (cTnT) et semble être moins influencé par une insuffisance rénale. En outre, la phase aiguë d'une inflammation a été associée à une augmentation des troponines. Des valeurs de troponine cardiaque élevées ont été trouvées chez des sujets assez âgés, sans syndromes coronaires aigus, particulièrement pour la troponine cardiaque T (cTnT). Enfin, l'âge semble être le facteur le plus important lié à ce taux élevé de troponine.

Emergency Medicine Journal (EMJ)

Accuracy of NEXUS II head injury decision rule in children: a prospective PREDICT cohort study.
Babl FE, Oakley E, Dalziel SR, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Donath S, Hearps S, Crowe LM, Arpone M, Bressan S, Lyttle MD; Paediatric Research in Emergency Department International Collaborative (PREDICT). | Emerg Med J. 2019 Jan;36(1):4-11
DOI: https://doi.org/10.1136/emermed-2017-207435  | Télécharger l'article au format  
Keywords: emergency departments; imaging, ct/mri; paediatrics, paediatric emergency medicine; trauma, head

ORIGINAL ARTICLES

Introduction : The National Emergency X-Radiography Utilisation Study II (NEXUS II) clinical decision rule (CDR) can be used to optimise the use of CT in children with head trauma. We set out to externally validate this CDR in a large cohort.

Méthode : We performed a prospective observational study of patients aged <18 years presenting with head trauma of any severity to 10 Australian/New Zealand EDs. In a planned secondary analysis, we assessed the accuracy of the NEXUS II CDR (with 95% CI) to detect clinically important intracranial injury (ICI). We also assessed clinician accuracy without the rule.

Résultats : Of 20 137 total patients, we excluded 28 with suspected penetrating injury. Median age was 4.2 years. CTs were obtained in ED for 1962 (9.8%), of whom 377 (19.2%) had ICI as defined by NEXUS II. 74 (19.6% of ICI) patients underwent neurosurgery.Sensitivity for ICI based on the NEXUS II CDR was 379/383 (99.0 (95% CI 97.3% to 99.7%)) and specificity was 9320/19 726 (47.2% (95% CI 46.5% to 47.9%)) for the total cohort. Sensitivity in the CT-only cohort was similar. Of the 18 022 children without CT in ED, 49.4% had at least one NEXUS II risk criterion. Sensitivity for ICI by the clinicians without the rule was 377/377 (100.0% (95% CI 99.0% to 100.0%)) and specificity was 18 147/19 732 (92.0% (95% CI 91.6% to 92.3%)).

Conclusion : NEXUS II had high sensitivity, similar to the derivation study. However, approximately half of unimaged patients were positive for NEXUS II risk criteria; this may result in an increased CT rate in a setting with high clinician accuracy.

Conclusion (proposition de traduction) : NEXUS II présentait une sensibilité élevée, semblable à celle de l'étude de dérivation. Toutefois, environ la moitié des patients non imagés étaient positifs pour les critères de risque de NEXUS II, ce qui pourrait entraîner une augmentation du taux de TDM dans un contexte où la précision du clinicien est élevée.

Analgesia in the emergency department: why is it not administered?.
Kant J, Dombagolla M, Lai F, Hendarto A, Taylor DM. | Emerg Med J. 2019 Jan;36(1):12-17
DOI: https://doi.org/10.1136/emermed-2018-207629
Keywords: analgesia/pain control; emergency department

ORIGINAL ARTICLES

Introduction : Pain management in the ED is often suboptimal, with many patients not receiving analgesia. We aimed to determine why some patients refuse it, why others do not receive it, and whether these variables impact on patient satisfaction with their pain management.

Méthode : We undertook a prospective, observational study in a large, Australian, tertiary referral ED (February-May 2017). A convenience sample of consecutive adult patients with a triage pain score of ≥4 were examined. Data were collected from the medical record and the treating nurses. At follow-up at least 48 hours postdischarge, patients were asked if they received analgesia in the ED (if not, then why not) and how satisfied they were with their pain management (very dissatisfied/dissatisfied/slightly dissatisfied/slightly satisfied/satisfied/very satisfied). The primary outcome was why patients refuse analgesia.

Résultats : Of the 651 enrolled patients, 171 (26.3%) did not receive analgesia; for 30 (17.5%), patients and their nurses agreed that analgesia was refused. Patients mainly refused analgesia because their pain was not bad enough, they had recent analgesia intake, and concerns about side effects and interactions. Patients who received analgesia were more likely to be 'very satisfied' with their pain management (difference in proportions 10.8%, 95% CI 2.1 to 19.4). The satisfaction of patients who refused analgesia and those who did not receive analgesia for other reasons did not differ.

Conclusion : Patient refusal is the most common reason for patients not receiving analgesia. Analgesia receipt is associated with greater patient satisfaction. However, a patient's knowledge of their analgesia receipt status may be incorrect. Disregard of the reasons for patients not receiving analgesia may underestimate the number offered analgesia.

Conclusion (proposition de traduction) : Le refus du patient est la raison la plus courante pour laquelle les patients ne reçoivent pas d'analgésie. L'analgésie est associée à une plus grande satisfaction du patient. Cependant, la connaissance qu'a le patient de l'état de l'administration de son analgésie peut être incorrecte. Si l'on ne tient pas compte des raisons pour lesquelles les patients ne reçoivent pas d'analgésie, on peut sous-estimer le nombre d'analgésiques proposés.

Commentaire : Article complémentaire :
Ricard-Hibon A, Chareyron A. État des lieux de la prise en charge de la douleur. Ann. Fr. Med. Urgence (2018) 8:S2-S5  

Near-infrared spectroscopy monitoring during out-of-hospital cardiac arrest: can the initial cerebral tissue oxygenation index predict ROSC?.
Tsukuda J, Fujitani S, Morisawa K, Shimozawa N, Lohman BD, Okamoto K, Kawaguchi T, Takamatsu Y, Fujii S, Ozaki M, Rahman M, Taira Y. | Emerg Med J. 2019 Jan;36(1):33-38
DOI: https://doi.org/10.1136/emermed-2018-207533
Keywords: cardiac arrest; resuscitation

Original articles

Introduction : Near-infrared spectroscopy is a modality that can monitor tissue oxygenation index (TOI) and has potential to evaluate return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). This study's objectives were to evaluate whether TOI could be associated with ROSC and used to help guide the decision to either terminate CPR or proceed to extracorporeal CPR (ECPR).

Méthode : In this observational study, we assessed the patients with out-of-hospital cardiac arrest with non-traumatic cause receiving CPR on arrival at our ED between 2013 and 2016. TOI monitoring was discontinued either on CPR termination after ROSC was reached or on patient death. Patients were classified into two groups: ROSC and non-ROSC group.

Résultats : Out of 141 patients, 24 were excluded and the remaining 117 were classified as follows: ROSC group (n=44) and non-ROSC group (n=73). ROSC group was significantly younger and more likely to have their event witnessed and bystander CPR. ROSC group showed a higher initial TOI than non-ROSC group (60.5%±17.0% vs 37.9%±13.7%: p<0.01). Area under the curve analysis was more accurate with the initial TOI than without it for predicting ROSC (0.88, 95% CI 0.82 to 0.95 vs 0.79, 95% CI 0.70 to 0.87: p<0.01). TOI cut-off value ≥59% appeared to favour survival to hospital discharge whereas TOI ≤24% was associated with non-ROSC.

Conclusion : This study demonstrated an association between higher initial TOI and ROSC. Initial TOI could increase the accuracy of ROSC prognosis and may be a clinical factor in the decision to terminate CPR and select patients who are to proceed to ECPR.

Conclusion (proposition de traduction) : Cette étude a démontré une association entre la spectroscopie proche infrarouge (NIRS) initial plus élevé et le retour à la circulation spontanée (RACS). La spectroscopie proche infrarouge (NIRS) pourrait augmenter la précision du pronostic de la RACS et pourrait être un facteur clinique dans la décision de mettre fin à la réanimation cardio-pulmonaire et de sélectionner les patients qui pourraient bénéficier d'une réanimation cardiorespiratoire extracorporelle (ERCP).

Understanding the management of patients with head injury taking warfarin: who should we scan and when? Lessons from the AHEAD study.
Mason SM, Evans R, Kuczawski M. | Emerg Med J. 2019 Jan;36(1):47-51
DOI: https://doi.org/10.1136/emermed-2018-207621
Keywords: emergency department management; guidelines; imaging, Ct/mri; research, clinical; trauma, head

Reviews

Editorial : Anticoagulated patients represent an important and increasing proportion of the patients with head trauma attending the ED, but there is no international consensus for their appropriate investigation and management. International guidelines vary and are largely based on a small number of studies, which provide poor-quality evidence for the management of patients taking warfarin. This article provides an overview of the clinical research evidence for CT scanning head-injured patients taking warfarin and a discussion of interpretation of risk and acceptable risk. We aim to provide shop floor clinicians with an understanding of the limitations of the evidence in this field and the limitations of applying 'one-size-fits-all' guidelines to individual patients. There is good evidence for a more selective scanning approach to patients with head injuries taking warfarin than is currently recommended by most guidelines. Specifically, patients without any head injury-related symptoms and GCS score 15 have a reduced risk of adverse outcome and may not need to be scanned. We argue that there is evidence to support an individualised approach to decision to CT scan in mild head injuries on warfarin and that clinicians should feel able to discuss risks with patients and sometimes decide not to scan.

Conclusion : Clinicians treating a warfarinised patient with a mild head injury face an emotive dilemma: they must weigh up the risk of missing a potentially devastating intracranial injury with the risk of radi- ation to the patient and the use of time and resources. CDRs based on good-quality evidence are valuable to support the ED clinician in choosing which patients to scan or not but are not currently helpful with warfarinised patients. Recommendations to scan all patients taking warfarin are based on poor-quality evidence. This article summarises how contemporary rele- vant evidence advocates a more considered and individualised approach to decision to CT scan in head injuries. Specifically, consideration of the individual patient context for decisions to CT scan patients taking warfarin who have GCS 15 and no other symptoms is appropriate and of value.

Conclusion (proposition de traduction) : Les cliniciens qui traitent un patient traité par warfarine souffrant d'un traumatisme crânien léger font face à un dilemme émotionnel : ils doivent soupeser le risque de rater une lésion intracrânienne potentiellement grave avec le risque d'irradiation pour le patient et l'utilisation du temps et des ressources. Les règles de décision clinique fondées sur des données probantes de bonne qualité sont utiles pour aider les urgentistes à choisir les patients à scanner ou non, mais ne sont pas actuellement adaptées avec les patients traités par warfarine. Les recommandations visant à examiner tous les patients qui prennent de la warfarine sont fondées sur des données probantes de piètre qualité. Cet article résume comment les données probantes actuelles préconisent une approche plus réfléchie et individualisée de la prise de décision en matière de tomodensitométrie pour les traumatismes crâniens.
Plus précisément, la prise en compte du contexte de chaque patient dans la décision de faire un tomodensitogramme pour les patients qui prennent de la warfarine et qui présentent un Glasgow 15 et aucun autre symptôme est appropriée et utile.

Oseltamivir use for quicker alleviation of symptoms, fewer hospital admissions and lower mortality in adult patients with influenza B..
Bromley C, Reynard C. | Emerg Med J. 2019 Jan;36(1):55-56
DOI: https://doi.org/10.1136/emermed-2018-208381.1
Keywords: emergency care systems

BEST EVIDENCE TOPIC REPORTS

Editorial : A short cut review was carried out to establish whether Oseltamivir leads to faster alleviation of symptoms, fewer hospital admissions and lower mortality in adult patients with confirmed influenza B presenting to the Emergency Department. Two studies were directly relevant to the question using the described search methodology on Ovid Medline and Embase. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated.

Conclusion : There is no good evidence that oseltamivir results in quicker alleviation of symptoms, fewer hospital admissions or lower mortality in adult patients with influenza B.

Conclusion (proposition de traduction) : Rien n’indique que l’oseltamivir ait pour effet de soulager plus rapidement les symptômes, de réduire le nombre d’hospitalisations ou de réduire la mortalité chez les patients adultes atteints du virus de la grippe B.

Eurosurveillance

Interim estimates of 2018/19 vaccine effectiveness against influenza A(H1N1)pdm09, Canada, January 2019.
Skowronski DM, Leir S, Sabaiduc S, Murti M, Dickinson JA, Olsha R, Gubbay JB, Croxen MA, Charest H, Chan T, Bastien N, Li Y, Krajden M, De Serres G. | Euro Surveill. 2019 Jan;24(4)
DOI: https://doi.org/10.2807/1560-7917.ES.2019.24.4.1900055  | Télécharger l'article au format  
Keywords: Canada; ILI; epidemiology; genomics; immunisation; influenza; influenza virus; influenza-like illness; laboratory; vaccine effectiveness; vaccine-preventable diseases; vaccines; viral infections

Rapid communication

Editorial : Using a test-negative design, the Canadian Sentinel Practitioner Surveillance Network assessed interim 2018/19 vaccine effectiveness (VE) against predominant influenza A(H1N1)pdm09 viruses. Adjusted VE was 72% (95% confidence interval: 60 to 81) against medically attended, laboratory-confirmed influenza A(H1N1)pdm09 illness. This substantial vaccine protection was observed in all age groups, notably young children who appeared to be disproportionately affected. Sequence analysis identified heterogeneity in emerging clade 6B.1 viruses but no dominant drift variant.

Conclusion : Interim estimates from Canada for the 2018/19 northern hemisphere indicate substantial VE of ca 70% against influenza A(H1N1)pdm09. Thus far, this epidemic has taken a greater toll on children younger than 9 years even when compared with previous A(H1N1)pdm09-dominant seasons. Given ongoing epidemic activity in some regions, vaccination should be advocated to minimise the A(H1N1)pdm09-associated disease burden. In the context of observed genetic diversity, monitoring for further evolution in circulating 6B.1 variants, and potential impact on vaccine protection, is warranted.

Conclusion (proposition de traduction) : Les estimations provisoires 2018/19 du Canada pour l'hémisphère nord indiquent une efficacité vaccinale substantielle d'environ 70% contre le virus grippal A (H1N1) pdm09. Jusqu'à présent, cette épidémie a eu des conséquences plus graves chez les enfants de moins de 9 ans, même par rapport aux saisons précédentes à dominante A (H1N1) pdm09. Compte-tenu de l'activité épidémique en cours dans certaines régions, la vaccination devrait être préconisée afin de minimiser le les évènements indésirables de la maladie associé à A (H1N1) pdm09. Dans le contexte de la diversité génétique observée, il est nécessaire de surveiller l'évolution des variants 6B.1 en circulation et leur impact potentiel sur la protection du vaccin.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Résultats préliminaires de l’efficacité du vaccin grippe pour la saison 2018-19. A partir de données canadiennes.  . Rédigé par le Dr Jacques Gaillat.

Internal and Emergency Medicine

In situ simulation in the management of anaphylaxis in a pediatric emergency department.
Barni S, Mori F, Giovannini M, de Luca M, Novembre E. | Intern Emerg Med. 2019 Jan;14(1):127-132
DOI: https://doi.org/10.1007/s11739-018-1891-1
Keywords: Anaphylaxis; Children; Epinephrine; In situ simulation; Pediatric emergency department

EM - ORIGINAL

Introduction : Anaphylaxis is a potentially life-threatening, rapid-onset hypersensitive reaction, usually treated in the emergency department (ED). Failure to recognize anaphylaxis leads to under-treatment with epinephrine and even when correctly diagnosed, epinephrine is not always administered. In addition, often patients who are treated in the ED are not referred for allergy work-up. Simulation is a tool that increases exposure to events in a safe environment, allowing trainers to develop skills without harming patients.

Méthode : The main purpose of our study was to determine whether in situ simulation training increases the frequency of epinephrine use. The secondary aim was to observe whether simulation modifies the number of children investigated over the years before and after the setting up of the simulation training.

Résultats : All patients with anaphylaxis referred to the Pediatric Emergency Department (PED) of the Anna Meyer Children's Hospital from 2004 to 2010 [pre-simulation (PRE-s) period], and from 2011 to 2016 [post-simulation (POST-s) period], were retrospectively included in this observational study. Simulation was carried out using a high-fidelity patient simulator mannequin (SimBaby, Laerdal Medical, Inc, Stavanger, NY). The diagnosis of anaphylaxis was based on the EAACI guidelines. The use of epinephrine significantly increased (p < 0.05) between the PRE-s and POST-s time periods: 2.4% versus 10% patients, respectively. During the two time periods, we also observed a significant increase (p = 0.011) in the number of patients who underwent a complete allergy work-up: 36% versus 51% patients, respectively.

Conclusion : According to our results, the in situ simulation program improved the correct management of anaphylaxis in terms of prompt use of epinephrine, and it also led to a higher number of patients being referred to the allergy unit for evaluation.

Conclusion (proposition de traduction) : Selon nos résultats, le programme de simulation in situ a amélioré la gestion correcte de l'anaphylaxie en termes d'utilisation rapide de l'épinéphrine et a également conduit à un nombre plus élevé de patients renvoyés à l'unité des allergies pour évaluation.

Barriers to compliance with emergency department discharge instructions: lessons learned from patients’ perspectives.
Schenhals E, Haidet P, Kass LE. | Intern Emerg Med. 2019 Jan;14(1):133-138
DOI: https://doi.org/10.1007/s11739-018-1943-6
Keywords: Emergency department; Patient compliance; Qualitative study

EM - ORIGINAL

Introduction : The objective of this study is to understand patients' perspectives about system-based barriers that may influence decision-making regarding following discharge instructions.

Méthode : In this qualitative study, subjects were interviewed by phone 1-4 weeks following being discharged to home from the emergency department (ED). We used a semi-structured interview guide to ask a series of open-ended questions about subjects' recent ED visit and subsequent course, including discharge instructions, whether or not they complied with those instructions, and reasoning behind their decisions to follow-up or not. All interviews were recorded and transcribed to identify themes among the transcripts, which were analyzed to identify barriers to compliance. While the majority of those interviewed expressed no specific concerns or challenges, four system-based themes did emerge regarding patient attitudes toward and experiences with discharge instructions.

Résultats : They were: (1) failure to ensure clarity about diagnosis at the time of discharge from the ED, (2) failure to identify patients' feelings of hopelessness regarding the utility of follow-up, (3) difficulty in scheduling follow-up appointments, and (4) the importance of a clear discharge process.

Conclusion : This study finds several system-based barriers might influence compliance. The four identified themes suggest a recurring cycle of visiting the ED, being discharged to primary care or specialists, and ultimately returning to the ED. We propose that systems-based interventions may help to break this cycle.

Conclusion (proposition de traduction) : Cette étude révèle que plusieurs obstacles systémiques pourraient influer sur la conformité. Les quatre thèmes identifiés suggèrent un cycle récurrent de visites à l'urgence, de renvoi aux soins primaires ou à des spécialistes et, en bout de ligne, de retour à l'urgence. Nous proposons que les interventions basées sur les systèmes puissent aider à briser ce cycle.

Non-invasive ventilation in COPD exacerbation: how and why.
Duca A, Rosti V, Brambilla AM, Cosentini R. | Intern Emerg Med. 2019 Jan;14(1):139-142
DOI: https://doi.org/10.1007/s11739-018-1974-z
Keywords: Aucun

CE - Clinical Notes

Editorial : Patients with chronic obstructive pulmonary disease (COPD) often experience “exacerbations,” (AECOPD), defined as episodes of increasing respiratory symptoms, particularly dyspnea, cough and sputum production and increased spu- tum purulence. Many of these patients come to the emer- gency department (ED) in acute respiratory distress, needing prompt assessment and management. Non-invasive ventila- tion (NIV) is of paramount importance in the treatment of these patients.

Conclusion : Patients with experience “exacerbations,” chronic obstructive pulmonary disease experience an impaired lung empty- ing because of increased airway resistance (i.e., the airways oppose to the air outflow). Their expiratory time does not last enough to empty the lung, thus leading to a dynamic lung hyperinflation: the patient is obliged to keep breathing with the lung almost full, not being able to empty it.

Conclusion (proposition de traduction) : Les patients présentant une « exacerbation » de BPCO souffrent d’une insuffisance de vidange des poumons en raison d’une résistance accrue des voies respiratoires (c’est-à-dire que les voies respiratoires s’opposent à la sortie d’air). Leur temps expiratoire ne dure pas assez pour vider le poumon, ce qui conduit à une hyperinflation pulmonaire dynamique : le patient est obligé de continuer à respirer avec le poumon presque plein, ne pouvant pas le vider.

International Journal of Emergency Medicine

Relationship between level of CPR training, self-reported skills, and actual manikin test performance—an observational study.
Lund-Kordahl I, Mathiassen M, Melau J, Olasveengen TM, Sunde K, Fredriksen K. | Int J Emerg Med. 2019 January;12:2
DOI: https://doi.org/10.1186/s12245-018-0220-9  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Bystander; Basic life support; BLS training; Competence; Chest compressions

Educational advances in emergency medicine

Introduction : Quality of bystander cardiopulmonary resuscitation (CPR) skills may influence out of hospital cardiac arrest (OHCA) outcomes. We analyzed how the level of CPR training related to indicators of good CPR quality and also the relationship between self-reported skills and actual CPR performance.

Méthode : Two hundred thirty-seven persons trained in standardized BLS curricula were divided into three groups according to the level of training: group I (40 h basic first aid training), group II, and group III (96 h advanced first aid, group III had also some limited additional life support training courses). We recorded the participants’ real-life CPR experience and self-reported CPR skills, and then assessed selected CPR quality indicators on a manikin. The data were analyzed with multivariate logistic regression. Differences between groups were analyzed with ANOVA/MANOVA.

Résultats : Out of 237 participants, 125 had basic training (group I), 84 reported advanced training (group II), and 28 advanced training plus additional courses (group III). Group II and III had shorter start-up time, better compression depth and hand positioning, higher fraction of effective rescue ventilations, shorter hands-off time, and thus a higher chest compression fraction. Chest compression rate did not differ between groups. The participants in group I assessed their own skills and preparedness significantly lower than groups II and III both before and after the test. In addition, group III reported higher confidence in examining the critically ill patient and preparedness in doing CPR before the manikin test than both groups I and II. However, the observed differences between groups II and III in self-reported skills and preparedness were not statistically significant after the test.

Conclusion : As expected, higher levels of BLS training correlated with better CPR quality. However, this study showed that ventilations and hands-on time were the components of CPR that were most affected by the level of training. Self- assessments of CPR ability correlated well to actual test performance and may have a role in probing CPR skills in students. The results may be important for BLS instructors and program developers.

Conclusion (proposition de traduction) : Comme prévu, des niveaux plus élevés d’entraînement BLS étaient corrélés à une meilleure qualité de la RCP. Cependant, cette étude a montré que la ventilation et le temps de manipulation étaient les composantes de la RCP les plus touchées par le niveau de formation. Les auto-évaluations de la capacité de RCP sont bien corrélées avec les performances réelles des tests et peuvent jouer un rôle dans la vérification des compétences de RCP chez les étudiants. Les résultats peuvent être importants pour les instructeurs BLS et les développeurs de programmes.

JAMA Internal Medicine

Association of Antibiotic Treatment With Outcomes in Patients Hospitalized for an Asthma Exacerbation Treated With Systemic Corticosteroids.
Stefan MS, Shieh MS, Spitzer KA, Pekow PS, Krishnan JA, Au DH, Lindenauer PK. | JAMA Intern Med. 2019 Jan;179(3):333-339
DOI: https://doi.org/10.1001/jamainternmed.2018.5394
Keywords: Aucun

Original Investigation

Introduction : Although professional society guidelines discourage use of empirical antibiotics in the treatment of asthma exacerbation, high antibiotic prescribing rates have been recorded in the United States and elsewhere.
OBJECTIVE: To determine the association of antibiotic treatment with outcomes among patients hospitalized for asthma and treated with corticosteroids.

Méthode : Retrospective cohort study of data of 19 811 adults hospitalized for asthma exacerbation and treated with systemic corticosteroids in 542 US acute care hospitals from January 1, 2015, through December 31, 2016.
EXPOSURES: Early antibiotic treatment, defined as an treatment with an antibiotic initiated during the first 2 days of hospitalization and prescribed for a minimum of 2 days.
MAIN OUTCOMES AND MEASURES: The primary outcome measure was hospital length of stay. Other measures were treatment failure (initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 2, in-hospital mortality, or readmission for asthma) within 30 days of discharge, hospital costs, and antibiotic-related diarrhea. Multivariable adjustment, propensity score matching, propensity weighting, and instrumental variable analysis were used to assess the association of antibiotic treatment with outcomes.

Résultats : Of the 19 811 patients, the median (interquartile range [IQR]) age was 46 (34-59) years, 14 389 (72.6%) were women, 8771 (44.3%) were white, and Medicare was the primary form of health insurance for 5120 (25.8%). Antibiotics were prescribed for 8788 patients (44.4%). Compared with patients not treated with antibiotics, treated patients were older (median [IQR] age, 48 [36-61] vs 45 [32-57] years), more likely to be white (48.6% vs 40.9%) and smokers (6.6% vs 5.3%), and had a higher number of comorbidities (eg, congestive heart failure, 6.2% vs 5.8%). Those treated with antibiotics had a significantly longer hospital stay (median [IQR], 4 [3-5] vs 3 [2-4] days) and a similar rate of treatment failure (5.4% vs 5.8%). In propensity score-matched analysis, receipt of antibiotics was associated with a 29% longer hospital stay (length of stay ratio, 1.29; 95% CI, 1.27-1.31) and higher cost of hospitalization (median [IQR] cost, $4776 [$3219-$7373] vs $3641 [$2346-$5942]) but with no difference in the risk of treatment failure (propensity score-matched OR, 0.95; 95% CI, 0.82-1.11). Multivariable adjustment, propensity score weighting, and instrumental variable analysis as well as several sensitivity analyses yielded similar results.

Conclusion : Antibiotic therapy may be associated with a longer hospital length of stay, higher hospital cost, and similar risk of treatment failure. These results highlight the need to reduce inappropriate antibiotic prescribing among patients hospitalized for asthma.

Conclusion (proposition de traduction) : L'antibiothérapie peut être associée à une durée d'hospitalisation plus longue, à des coûts d'hospitalisation plus élevés et à un risque similaire d'échec du traitement.
Ces résultats soulignent la nécessité de réduire la prescription inappropriée d'antibiotiques chez les patients hospitalisés pour asthme.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Une antibiothérapie améliore-t-elle l’évolution des patients hospitalisés pour crise d’asthme ?  . Rédigé par le Dr Jean-Pierre Bru.
Interprétation/commentaires :
Ce travail portant sur près de 20 000 patients hospitalisés pour crise d’asthme, montre clairement l’absence de bénéfice à une antibiothérapie précoce « systématique ». Il est certes rétrospectif, mais l’utilisation de la base de données a été optimisée pour éviter les biais, avec utilisation de score de propension, modélisation multivariée, analyse en traitement groupés, analyses de sensibilité…
Les précédents travaux portant sur antibiothérapie et crise d’asthme avaient principalement analysé la vitesse de résolution des symptômes et/ou des fonctions respiratoires. Mais aucun n’avait évalué l’évolution sur les paramètres de durée séjour, ventilation mécanique, ré-hospitalisation. Ce travail montre aussi les besoins en politique de bon usage, 44.4 % des malades recevaient une antibiothérapie systématique…

JAMA Surgery

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial.
Birenbaum A, Hajage D, Roche S, Ntouba A, Eurin M, Cuvillon P, Rohn A, Compere V, Benhamou D, Biais M, Menut R, Benachi S, Lenfant F, Riou B; IRIS Investigators Group.. | JAMA Surg. 2019 Jan 1;154(1):9-17
DOI: https://doi.org/10.1001/jamasurg.2018.3577
Keywords: Aucun

Original Investigation

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

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

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

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

Conclusion (proposition de traduction) : Cet essai clinique randomisé de grande envergure réalisé chez des patients sous anesthésie avec induction en séquence rapide n'a pas permis de démontrer la non-infériorité de la procédure factice dans la prévention de l'aspiration pulmonaire.
Des études complémentaires sont nécessaires chez les femmes enceintes et en dehors de la salle d'opération.

Commentaire : Les taux de Cormack et le temps de réalisation de l'intubation étaient plus élevé dans le groupe Sellick

Prehospital and Disaster Medicine

Disaster Health Management: Do Pharmacists Fit in the Team?.
Watson KE, Tippett V, Singleton JA, Nissen LM. | Prehosp Disaster Med. 2019 Jan 3:1-8
DOI: https://doi.org/10.1017/S1049023X18001152
Keywords: CPR cardiopulmonary resuscitation; ED emergency department; FIP International Pharmaceutical Federation; NCD non-communicable disease; PPRR prevention/mitigation preparedness response and recovery; UK United Kingdom; WADEM World Association for Disaster and Emergency Medicine; disaster; disaster medicine; medication therapy management; pharmacists

Original Research

Introduction : In addition to the traditional logistics role, pharmacists are undertaking important new roles in disasters. Despite this, little is known about the level of acceptance of these activities by other providers.ProblemThe aim of this study was to determine the international opinion of disaster and health professionals regarding the emerging roles of pharmacists in disasters.

Méthode : Delegates at the World Association for Disaster and Emergency Medicine's (WADEM; Madison, Wisconsin USA) 20th Congress in Toronto, Canada (April 2017) were invited to complete an anonymous survey posing eight questions regarding attitudes towards pharmacists' roles in disasters. Quantitative data were analyzed using IBM (IBM Corp.; Armonk, New York USA) SPSS statistical software version 23, and qualitative data were manually coded.

Résultats : Of the 222 surveys handed out, 126 surveys were completed yielding a 56.8% response rate. Of the respondents, 96.8% (122/126) believed pharmacists had a role in disasters additional to logistics. Out of 11 potential roles pharmacists could perform in a disaster, provided on a 5-point Likert scale, eight roles were given a rating of "Agree" or "Strongly Agree" by 72.4% or more of the participants. Lack of understanding of a pharmacist's roles and capabilities was the highest described barrier to pharmacists' roles in disaster management.

Conclusion : This multi-disciplinary disaster health "community" agreed pharmacists have roles in disasters in addition to the established role in supply chain logistics. Participants accepted that pharmacists could possibly undertake numerous clinical roles in a disaster. Several barriers were identified that may be preventing pharmacists from being further included in disaster health management planning and response.

Conclusion (proposition de traduction) : Cette « communauté » multidisciplinaire en matière de santé en cas de catastrophe a convenu que les pharmaciens avaient des rôles dans les catastrophes, en plus du rôle établi dans la logistique de la chaîne d'approvisionnement. Les participants ont admis que les pharmaciens pourraient éventuellement assumer de nombreux rôles cliniques lors d’une catastrophe. Plusieurs obstacles ont été identifiés qui pourraient empêcher les pharmaciens d'être davantage inclus dans la planification et la gestion de la gestion de la santé en cas de catastrophe.

The American Journal of Emergency Medicine

The gradient between arterial and end-tidal carbon dioxide predicts in-hospital mortality in post-cardiac arrest patient.
Kim YW, Hwang SO, Kang HS, Cha KC. | Am J Emerg Med. 2019 Jan;37(1):1-4
DOI: https://doi.org/10.1016/j.ajem.2018.04.025  | Télécharger l'article au format  
Keywords: Capnography; Carbon dioxide; Cardiopulmonary resuscitation; Heart arrest; Mortality

Original Contribution

Introduction : We investigated the predictive value of the gradient between arterial carbon dioxide (PaCO2) and end-tidal carbon dioxide (ETCO2) (Pa-ETCO2) in post-cardiac arrest patients for in-hospital mortality.

Méthode : This retrospective observational study evaluated cardiac arrest patients admitted to the emergency department of a tertiary university hospital. The PaCO2 and ETCO2 values at 6, 12, and 24 h after return of spontaneous circulation (ROSC) were obtained from medical records and Pa-ETCO2 gap was calculated as the difference between PaCO2 and ETCO2 at each time point. Multivariate logistic regression analysis was performed to verify the relationship between Pa-ETCO2 gap and clinical variables. Receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of Pa-ETCO2 for predicting in-hospital mortality.

Résultats : The final analysis included 58 patients. In univariate analysis, Pa-ETCO2 gaps were significantly lower in survivors than in non-survivors at 12 h [12.2 (6.5-14.8) vs. 13.9 (12.1-19.6) mmHg, p = 0.040] and 24 h [9.1 (6.3-10.5) vs. 17.1 (13.1-23.2) mmHg, p < 0.001)] after ROSC. In multivariate analysis, Pa-ETCO2 gap at 24 h after ROSC was related to in-hospital mortality [odds ratio (95% confidence interval): 1.30 (1.07-1.59), p = 0.0101]. In ROC curve analysis, the optimal cut-off value of Pa-ETCO2 gap at 24 h after ROSC was 10.6 mmHg (area under the curve, 0.843), with 77.8% sensitivity and 85.7% specificity.

Conclusion : The Pa-ETCO2 gap at 24 h after ROSC was associated with in-hospital mortality in post-cardiac arrest patients.

Conclusion (proposition de traduction) : L'écart Pa-EtCO2 24 heures après la RACS était associé à la mortalité intra-hospitalière chez les patients après un arrêt cardiaque.

Comparison of bedside screening methods for frailty assessment in older adult trauma patients in the emergency department.
Shah SP, Penn K, Kaplan SJ, Vrablik M, Jablonowski K, Pham TN, Reed MJ. | Am J Emerg Med. 2019 Jan;37(1):12-18
DOI: https://doi.org/10.1016/j.ajem.2018.04.028  | Télécharger l'article au format  
Keywords: Assessment; Frailty; Geriatrics; Older patient; Trauma; Ultrasound

Original Contribution

Introduction : Frailty is linked to poor outcomes in older patients. We prospectively compared the utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments, and ultrasound muscle measurements against the reference FRAIL scale in older adult trauma patients in the emergency department (ED).

Méthode : We recruited a convenience sample of adults 65 yrs. or older with blunt trauma and injury severity scores <9. We queried subjects (or surrogates) on the FRAIL scale, and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and calculated performance metrics for each comparison using sensitivity, specificity, predictive values, and area under receiver operating characteristic curves (AUROC).

Résultats : Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed by subject/surrogate (AUROC 0.91 [95% CI 0.84-0.98] or physician (AUROC 0.77 [95% CI 0.63-0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9 of 4 or greater. If both physician and subject/surrogate provided scores <4, sensitivity and negative predictive value were 90.0% (54.1-99.5%) and 95.0% (73.1-99.7%). Grip strength and MUAC were not predictors. US measures that combined biceps and quadriceps thickness showed an AUROC of 0.75 compared to the reference standard.

Conclusion : The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent negative predictive value in ruling out frailty. Ultrasound of combined biceps and quadriceps has modest concordance as an alternative in trauma patients who cannot provide a history.

Conclusion (proposition de traduction) : Le service d'urgence a besoin d'outils rapides et validés pour dépister la fragilité. La Clinical Frailty Scale (CFS9) a une excellente valeur prédictive négative pour exclure la fragilité. L'échographie du biceps et du quadriceps combinés a une concordance modeste comme alternative chez les patients traumatisés qui ne peuvent pas fournir d'antécédents.

Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department.
Vukovic AA, Hanson HR, Murphy SL, Mercurio D, Sheedy CA, Arnold DH. | Am J Emerg Med. 2019 Jan;37(1):27-32
DOI: https://doi.org/10.1016/j.ajem.2018.04.039  | Télécharger l'article au format  
Keywords: Apneic oxygenation; Hypoxia; Intubation; Pediatric

Original Contribution

Introduction : Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted.
OBJECTIVE: Determine association between AO and hypoxemia in pediatric patients undergoing ETI.

Méthode : Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011-June 2011) and with (August 2014-March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO2) < 90%. The χ2 and Wilcoxon rank-sum tests examined differences between cohorts. Multivariable regression models examined adjusted associations between covariates and hypoxemia.

Résultats : 149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus <25% in the AO cohort. Median [IQR] lowest SpO2 during ETI was 93 (69, 99) for pre-AO and 100 [95, 100] for the AO cohort (p < 0.001). In a multivariable logistic regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95% confidence interval [CI] 0.1-0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7-1.0), lowest SpO2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8-1.0), and each additional intubation attempt (aOR 4.0, 95% CI 2.2-7.2).

Conclusion : Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia.

Conclusion (proposition de traduction) : L’oxygénation lors de l’apnée est une intervention facile à mettre en oeuvre, associée à une diminution de l’hypoxémie au cours de l’intubation trachéale chez l’enfant. Une hypoxémie a été observée chez près de 50 % des enfants non traités par oxygénation apnéique.

D-dimer levels in VTE patients with distal and proximal clots.
Singer AJ, Zheng H, Francis S, Fermann GJ, Chang AM, Parry BA, Giordano N, Kabrhel C. | Am J Emerg Med. 2019 Jan;37(1):33-37
DOI: https://doi.org/10.1016/j.ajem.2018.04.040  | Télécharger l'article au format  
Keywords: D-dimer; DVT; Distal DVT; Pulmonary embolism; Sub-segmental PE

Original Contribution

Introduction : There is growing evidence that venous thromboembolism (VTE) patients with distal clots (distal calf deep vein thrombosis [DVT] and sub-segmental pulmonary embolism [PE]) may not routinely benefit from anticoagulation. We compared the D-dimer levels in VTE patients with distal and proximal clots.

Méthode : We conducted a multinational, prospective observational study of low-to-intermediate risk adult patients presenting to the emergency department (ED) with suspected VTE. Patients were classified as distal (calf DVT or sub-segmental PE) or proximal (proximal DVT or non-sub-segmental PE) clot groups and compared with univariate and multivariate analyses.

Résultats : Of 1752 patients with suspected DVT, 1561 (89.1%) had no DVT, 78 (4.4%) had a distal calf DVT, and 113 (6.4%) had a proximal DVT. DVT patients with proximal clots had higher D-dimer levels (3760 vs. 1670 mg/dL) than with distal clots. Sensitivity and negative predictive value (NPV) for proximal DVT at an optimal D-dimer cutoff of 5770 mg/dL were 40.7% and 52.1% respectively. Of 1834 patients with suspected PE, 1726 (94.1%) had no PE, 7 (0.4%) had isolated sub-segmental PE, and 101 (5.5%) had non-sub-segmental PE. PE patients with proximal clots had higher D-dimer levels (4170 vs. 2520 mg/dL) than those with distal clots. Sensitivity and NPV for proximal PE at an optimal D-dimer cutoff of 3499 mg/dL were 57.4% and 10.4% respectively.

Conclusion : VTE patients with proximal clots had higher D-dimer levels than patients with distal clots. However, D-dimer levels cannot be used alone to discriminate between VTE patients with distal or proximal clots.

Conclusion (proposition de traduction) : Les patients atteints de thrombophlébite avec des caillots proximaux avaient des taux de D-dimères plus élevés que ceux des patients avec des caillots distaux. Cependant, les taux de D-dimères ne peuvent pas être utilisés seuls pour discriminer les patients atteints de thrombophlébite présentant des caillots distaux ou proximaux.

Alternatives to opioids for pain management in the emergency department decreases opioid usage and maintains patient satisfaction.
Duncan RW, Smith KL, Maguire M, Stader DE 3rd. | Am J Emerg Med. 2019 Jan;37(1):38-44
DOI: https://doi.org/10.1016/j.ajem.2018.04.043  | Télécharger l'article au format  
Keywords: Emergency department; Opioid; Pain; Patient satisfaction

Original Contribution

Introduction : The objective of this study was to assess opioid use in an emergency department following the development and implementation of an alternative to opioids (ALTO)-first approach to pain management. The study also assessed how implementation affected patient satisfaction scores.

Méthode : This study compared data collected from October to December of 2015 (prior to implementation) to data collected between October and December of 2016 (after the intervention had been implemented). Emergency department visits during the study timeframe were included. Opioid reduction was measured in morphine equivalents (ME) administered per visit. Secondary outcomes on patient satisfaction were gathered using the Press Ganey survey.

Résultats : Intravenous (IV) opioid administration during the study period decreased by >20%. The predicted mean ME use in 2016 was 0.25 ME less when compared to 2015 (95% CI -0.27 to -0.23). Estimated use for patients in the pre-implementation period was 1.45 ME mgs (SD 0.88), and 1.13 ME mg (SD 0.69) for patients in the post-implementation period. Patient satisfaction scores using the Press Ganey Scale also were assessed. There was no significant difference in the scores between 2015 and 2016 when patients were asked "How well was you pain controlled?" (-0.94, 95% CI -5.29 to 3.4) and "How likely are you to recommend this emergency department?" (-1.55, 95% CI -5.26 to 2.14).

Conclusion : In conclusion, by using an ALTO-first, multimodal treatment approach to pain management, participating clinicians were able to significantly decrease the use of IV opioids in the emergency department. Patient satisfaction scores remained unchanged following implementation.

Conclusion (proposition de traduction) : En conclusion, en utilisant une alternative au traitement multimodal des opioïdes : le traitement multimodal de la douleur, les cliniciens participants ont été en mesure de réduire considérablement l'utilisation des opioïdes par voie intraveineuse au service des urgences. Les scores de satisfaction des patients sont restés inchangés après la mise en œuvre.

Commentaire : Matériel supplémentaire  

Identification of risk factors for failure in patients with skin and soft tissue infections.
Cieri B, Conway EL, Sellick JA, Mergenhagen KA. | Am J Emerg Med. 2019 Jan;37(1):48-52
DOI: https://doi.org/10.1016/j.ajem.2018.04.046  | Télécharger l'article au format  
Keywords: Abscess; Antibiotics; Failure; Skin infection

Original Contribution

Introduction : The purpose was to determine significant predictors of treatment failure of skin and soft tissue infections (SSTI) in the inpatient and outpatient setting.

Méthode : A retrospective chart review of patients treated between January 1, 2005 to July 1, 2016 with ICD-9 or ICD-10 code of cellulitis or abscess. The primary outcome was failure defined as an additional prescription or subsequent hospital admission within 30 days of treatment. Risk factors for failure were identified through multivariate logistic regression.

Résultats : A total of 541 patients were included. Seventeen percent failed treatment. In the outpatient group, 24% failed treatment compared to 9% for inpatients. Overweight/obesity (body mass index (BMI) > 25 kg/m2) was identified in 80%, with 15% having a BMI >40 kg/m2. BMI, heart failure, and outpatient treatment were determined to be significant predictors of failure. The unit odds ratio for failure with BMI was 1.04 (95% [Cl] = 1.01 to 1.1, p = 0.0042). Heart failure increased odds by 2.48 (95% [Cl] = 1.3 to 4.7, p = 0.0056). Outpatients were more likely to fail with an odds ratio of 3.36.

Conclusion : Patients with an elevated BMI and heart failure were found to have increased odds of failure with treatment for SSTIs. However, inpatients had considerably less risk of failure than outpatients. These risk factors are important to note when making the decision whether to admit a patient who presents with SSTI in the emergency department. Thoughtful strategies are needed with this at-risk population to prevent subsequent admission.

Conclusion (proposition de traduction) : Les patients présentant un IMC élevé et une insuffisance cardiaque ont montré une probabilité accrue d'échec du traitement pour les infections des tissus mous. Cependant, les patients hospitalisés présentaient un risque d'échec considérablement moindre que les patients ambulatoires. Il est important de noter ces facteurs de risque lors de la décision d’admettre un patient présentant une infection des tissus mous au service des urgences.
Des stratégies réfléchies sont nécessaires avec cette population à risque pour éviter une admission ultérieure.

Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospital invasive ventilation.
Jouffroy R, Saade A, Saint Martin LC, Philippe P, Carli P, Vivien B. | Am J Emerg Med. 2019 Jan;37(1):56-60
DOI: https://doi.org/10.1016/j.ajem.2018.04.050  | Télécharger l'article au format  
Keywords: Aucun

Original Contribution

Introduction : Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre-hospital mechanical ventilation.

Méthode : We performed a monocentric retrospective observational study on 77 patients. PaO2 was measured at ICU admission. The primary outcome was mortality at day 28 (D28).

Résultats : Forty-nine (64%) patients were included. The mean PaO2 at ICU admission was 153 ± 77 and 202 ± 82 mm Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO2 < 100, 25% for 100 < PaO2 < 150 and 57% for a PaO2 > 150 mm Hg. PaO2 was significantly associated with mortality at D28 (p = 0.04). Using propensity score analysis including SOFA score, pre-hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO2 > 150 mm Hg (p = 0.02, OR [CI95] = 1.59 [1.20-2.10]).

Conclusion : In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The early adjustment of the PaO2 should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre-hospital invasive ventilation.

Conclusion (proposition de traduction) : Dans cette étude, nous rapportons une association significative entre l'hyperoxie à l'admission en USI et la mortalité chez les patients présentant un choc septique bénéficiant d'une ventilation mécanique invasive préhospitalière. Un ajustement précoce de la PaO2 doit être envisagé chez ces patients pour éviter les effets toxiques de l'hyperoxie. Cependant, l'analyse des gaz sanguins est difficile à obtenir dans un contexte préhospitalier. Par conséquent, des mesures alternatives et réalisables sont nécessaires, telles que l'oxymétrie de pouls, pour améliorer la gestion de la ventilation invasive préhospitalière.

Arterial pH selectively predicts critical care needs in emergency department obese patients with acute dyspnea: A prospective comparative study.
Gourhant V, Vuillot O, Claret PG, Lefebvre S, Schaub R, Flacher A, Dumont R, Sebbane M. | Am J Emerg Med. 2019 Jan;37(1):67-72
DOI: https://doi.org/10.1016/j.ajem.2018.04.059  | Télécharger l'article au format  
Keywords: Blood gas analysis; Dyspnea; Emergency department; Intensive care unit; Obesity; Prognosis; pH

Original Contribution

Introduction : Obese patients with acute dyspnea may be prone to misorientation from the emergency department (ED), due to impaired gas exchange evaluation and altered basal respiratory profiles. This study aims to evaluate the prognostic value of arterial blood pH in obese ED patients with acute dyspnea in comparison to non-obese counterparts.

Méthode : Single-center observational study of a cohort of 400 consecutive ED patients with acute dyspnea. The primary endpoint was a composite of Intensive Care Unit admission (with critical care needs) or in ED mortality. Predictors of the primary endpoint were assessed using multivariable logistic regression and ROC curve analysis, in obese (BMI ≥ 30 kg·m-2) and non-obese patients.

Résultats : 252 patients who had arterial blood gas testing were analyzed including 76 (30%) obese comparable to non-obese in terms of clinical history. 51 patients were admitted to ICU and 2 deceased before admission (20 obese (26%) vs 33 non-obese (19%); p = 0.17). Factors associated with ICU admission were arterial blood pH (pH < 7.36 vs pH ≥ 7.36) and gender. In multivariate models adjusted for risk factors, pH remained the sole independent predictor in obese patients, with no predictive value in non-obese patients (ROC AUC: 0.74, 95% CI [0.60; 0.87], optimal threshold for pH: 7.36, odds ratio: 10.5 [95% CI 3.18; 34.68]).

Conclusion : Arterial blood pH may selectively predict critical care needs in ED obese patients with acute dyspnea, in comparison to non-obese. A falsely reassuring pH < 7.36 should be regarded as a marker of severity when assessing acute dyspnea in obese ED patients.

Conclusion (proposition de traduction) : Le pH du sang artériel peut prédire de manière sélective les besoins en soins critiques des patients obèses présentants une dyspnée aiguë au service des urgences, par rapport aux patients non obèses. Un pH faussement rassurant < à 7,36 doit être considéré comme un marqueur de sévérité lors de l’évaluation de la dyspnée aiguë chez les patients obèses aux services des urgences.

Commentaire : Matériel supplémentaire  

Metoprolol vs. diltiazem in the acute management of atrial fibrillation in patients with heart failure with reduced ejection fraction.
Hirschy R, Ackerbauer KA, Peksa GD, O'Donnell EP, DeMott JM. | Am J Emerg Med. 2019 Jan;37(1):80-84
DOI: https://doi.org/10.1016/j.ajem.2018.04.062  | Télécharger l'article au format  
Keywords: Arrhythmia; Atrial fibrillation; Diltiazem; Heart failure; Metoprolol

Original Contribution

Introduction : The objective of this study was to examine the effects of metoprolol versus diltiazem in the acute management of atrial fibrillation (AF) with rapid ventricular response (RVR) in patients with heart failure with reduced ejection fraction (HFrEF).

Méthode : This retrospective cohort study of patients with HFrEF in AF with RVR receiving either intravenous push (IVP) doses of metoprolol or diltiazem was conducted between January 2012 and September 2016. The primary outcome was successful rate control within 30 min of medication administration, defined as a heart rate (HR) < 100 beats per minute or a HR reduction ≥ 20%. Secondary outcomes included rate control at 60 min, maximum median change in HR, and incidence of hypotension, bradycardia, or conversion to normal sinus rhythm within 30 min. Signs of worsening heart failure were also evaluated.

Résultats : Of the 48 patients included, 14 received metoprolol and 34 received diltiazem. The primary outcome, successful rate control within 30 min, occurred in 62% of the metoprolol group and 50% of the diltiazem group (p = 0.49). There was no difference in HR control at predefined time points or incidence of hypotension, bradycardia, or conversion. Although baseline HR varied between groups, maximum median change in HR did not differ. Signs of worsening heart failure were similar between groups.

Conclusion : For the acute management of AF with RVR in patients with HFrEF, IVP diltiazem achieved similar rate control with no increase in adverse events when compared to IVP metoprolol.

Conclusion (proposition de traduction) : Pour le traitement aigu de la fibrillation atriale avec réponse ventriculaire rapide chez les patients insuffisants cardiaques avec fraction d’éjection altérée, le diltiazem par administration intraveineuse a permis un contrôle du rythme cardiaque similaire sans augmentation des effets indésirables par rapport au métoprolol par administration intraveineuse.

Adverse events and satisfaction with use of intranasal midazolam for emergency department procedures in children.
Malia L, Laurich VM, Sturm JJ. | Am J Emerg Med. 2019 Jan;37(1):85-88
DOI: https://doi.org/10.1016/j.ajem.2018.04.063  | Télécharger l'article au format  
Keywords: Anxiolysis; Intranasal midazolam; Satisfaction

Original Contribution

Introduction : Procedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED.
OBJECTIVE: To evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores.

Méthode : A prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction.

Résultats : 112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale.

Conclusion : Our data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM.

Conclusion (proposition de traduction) : Nos données suggèrent que l'utilisation du midazolam intranasal est sans danger pour les patients quasiment à jeun pour les solides et les liquides. De plus, les scores de satisfaction des parents et des prestataires étaient élevés avec l'utilisation du midazolam intranasal.

Commentaire : Pour aller plus loin :
- Tsze DS and al. Optimal Volume of Administration of Intranasal Midazolam in Children: A Randomized Clinical Trial. Ann Emerg Med. 2017 May;69(5):600-609  .
- Neville DN and al. Double-blind Randomized Controlled Trial of Intranasal Dexmedetomidine Versus Intranasal Midazolam as Anxiolysis Prior to Pediatric Laceration Repair in the Emergency Department.Acad Emerg Med. 2016 Aug;23(8):910-7  .

What biomechanical factors are more important in compression depth for children lifesavers? A randomized crossover study.
Otero-Agra M, Rodríguez-Núñez A, Rey E, Abelairas-Gómez C, Besada-Saavedra I, Antón-Ogando AP, López-García S, Martín-Conty JL, Barcala-Furelos R. | Am J Emerg Med. 2019 Jan;37(1):100-108
DOI: https://doi.org/10.1016/j.ajem.2018.05.003  | Télécharger l'article au format  
Keywords: Children; Cardiopulmonary Resuscitation; Depth; Biomechanical analysis; Anthropometric; Elevation; Step

Original contribution

Introduction : To evaluate the biomechanical aspects involved in Cardiopulmonary Resuscitation's compression depth by children.

Méthode : A randomized crossover study with 196 children between 9 and 14 years-old was conducted. The chil- dren performed four CPR hands-only tests of 1 min in four different heights (floor, 5 cm, 10 cm, and 15 cm). An- thropometric, angulation and quality of CPR variables were registered during the tests.

Résultats : CPR quality was sub-optimal in all tests. Tests with the simulated victim placed on the floor had the best compression quality. Children that made deeper compressions had significantly higher values in all anthropo- metric variables. Analysis gives more discriminatory power to the anthropometric variables than angulation var- iables on compression depth.

Conclusion : Chest compression depth obtained by children depends more on their anthropometric characteristics than on their body position. The approximate age to perform compressions with an acceptable quality is 12 years-old. The use of steps increased arm angle, getting it closer to 90° but did not increase quality CPR when compared with performance on the floor.

Conclusion (proposition de traduction) : La profondeur de compression thoracique obtenue par les enfants dépend plus de leurs caractéristiques anthropométriques que de la position de leur corps. L'âge approximatif pour effectuer des compressions avec une qualité acceptable est de 12 ans. L'utilisation de marches augmentait l'angle du bras, le rapprochant de 90° mais n'augmentait pas la qualité de la RCP par rapport à la performance au sol.

Identifying infant hydrocephalus in the emergency department with transfontanellar POCUS.
Subramaniam S1, Chen AE, Khwaja A, Rempell R. | Am J Emerg Med. 2019 Jan;37(1):127-132
DOI: https://doi.org/10.1016/j.ajem.2018.10.012  | Télécharger l'article au format  
Keywords: Emergency ultrasound; Hydrocephalus; POCUS; Transfontanellar POCUS; Transfontanellar ultrasound

Diagnostics

Editorial : Hydrocephalus carries significant morbidity in the infant population. Although clinical symptoms are often non- specific, hydrocephalus is easily identified using transfontanellar sonography. In this review, we provide the emergency physician with a succinct overview of infant hydrocephalus and the point-of-care ultrasound (POCUS) technique for identification of this pathology.

Conclusion : Transfontanellar sonography is an established method of imaging the infant brain and has long been used by radiologists to identify hy- drocephalus. Emergency physicians are beginning to use this applica- tion, and are likely to find it most useful when assessing an infant with a differential diagnosis that includes hydrocephalus. In this con- text, transfontanellar POCUS has the ability to provide the emergency physician with a binary answer to the condition of the infant ventricular system. More research on this specific POCUS application within the field of emergency medicine is needed to determine its full potential.

Conclusion (proposition de traduction) : L'échographie transfontanelle est une méthode bien établie d'imagerie du cerveau du nourrisson. Elle est utilisée depuis longtemps par les radiologues pour identifier une hypocéphalie. Les urgentistes commencent à utiliser cette méthode et la trouveront probablement plus utile lors de l'évaluation d'un nourrisson avec un diagnostic différentiel incluant une hydrocéphalie. Dans ce contexte, l'échographie transfontanelle au point d'intervention a la capacité de fournir au médecin urgentiste une réponse binaire à l'état du système ventriculaire du nourrisson. Des recherches supplémentaires sur cette méthode spécifique d'échographie au point d'intervention dans le domaine de la médecine d'urgence sont nécessaires pour déterminer son plein potentiel.

Commentaire : Matériel supplémentaire  

Serum cardiac troponins as prognostic markers in patients with traumatic and non-traumatic brain injuries: A meta-analysis.
El-Menyar A, Sathian B, Wahlen BM, Al-Thani H. | Am J Emerg Med. 2019 Jan;37(1):133-142
DOI: https://doi.org/10.1016/j.ajem.2018.10.002  | Télécharger l'article au format  
Keywords: Non-traumatic brain injury mortality; Traumatic brain injury; Troponin

Reviews

Introduction : The association between brain injury and elevated serum cardiac troponin (cTn) remains poorly understood. We conducted a systematic review and meta-analysis to evaluate whether elevated cTn increases the risk of mortality in patients with traumatic (TBI) or non-traumatic brain injury (NT-BI).

Méthode : Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google scholar databases, and clinicaltrials.gov were searched for a retrospective, prospective and randomized clinical trials (RCT) or quasi-RCT studies that assessed the effect of elevated cTn (conventional or high sensitive assay) on the outcomes of brain injury patients. The main outcome of interest was mortality. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for analysis, whenever appropriate. The total number of patients pooled was 2435, of which 916 had elevated cTn and 1519 were in control group.

Résultats : Out of 691 references identified through the search, 8 analytical studies met inclusion criteria. Among both types of brain injuries, an elevated cTn was associated with a higher mortality with an overall pooled odd ratio (OR) of 3.37 (95% CI 2.13-5.36). The pooled OR for mortality was 3.31 (95% CI 1.99-5.53) among patients with TBI and 3.36 (95% CI 1.32-8.6) among patients with NT-BI.

Conclusion : Pooled analysis indicates that elevated cTn is significantly associated with a high mortality in patients with TBI and NT-BI. Prospective clinical trials are needed to support these findings and to inform a biomarker risk stratification regardless of the mechanism of injury.

Conclusion (proposition de traduction) : L'analyse groupée indique qu'une élévation de la troponine cardiaque sérique est significativement associée à une mortalité élevée chez les patients présentant une lésion cérébrale traumatique (TBI) ou non traumatique (NT-BI). Des essais cliniques prospectifs sont nécessaires pour appuyer ces résultats et informer sur une stratification du risque des biomarqueurs, quel que soit le mécanisme de la blessure.

The Journal of Emergency Medicine

Repeat Intravenous Ketamine Dosing in Children Undergoing Emergency Department Procedural Sedation.
Forrester KR, Thomas SM, Gupta NK, Karumuri M, Gerard JM. | J Emerg Med. 2019 Jan;56(1):1-6
DOI: https://doi.org/10.1016/j.jemermed.2018.09.047  | Télécharger l'article au format  
Keywords: ketamine; pediatrics; procedural sedation

Original contributions

Introduction : Patients undergoing procedural sedation with intravenous ketamine often receive repeat doses to maintain dissociation; however, data between doses are lacking.
OBJECTIVES: The purpose of this study was to characterize the frequency, time interval, and dosages of ketamine received by children undergoing procedural sedation and to explore the effects of age and body mass index on these parameters.

Méthode : This was a retrospective study of patients 1 to 18 years of age undergoing procedural sedation with intravenous ketamine in a pediatric emergency department between October 2016 and June 2017. Total repeat ketamine dosages were standardized to a 1-h sedation.

Résultats : Four hundred nineteen patients were included in the analysis. The median sedation time was 33.0 minutes (interquartile range [IQR] 25.0-45.0). Three hundred sixty-three patients (86.6%) received at least 1 repeat ketamine dose. The median time between doses was 7.0 minutes (IQR 5.0-12.0). Children <6 years of age, compared with older children, received higher hourly doses of ketamine in mg/kg/h (2.8 [IQR 1.8-3.9] vs. 1.8 [IQR 1.2-2.6], pc < 0.01). Children <3 years of age, compared with older children, received the highest hourly dose of ketamine in mg/kg/h (3.7 [IQR 2.3-5.0] vs. 1.9 [IQR 1.4-2.8], pc < 0.01). Ketamine repeat and hourly dosing does not appear to be significantly different in children of differing body mass index classes.

Conclusion : Patients undergoing ketamine sedation often receive repeat doses to maintain dissociation. Patients <3 years of age received the highest total repeat ketamine dosages.

Conclusion (proposition de traduction) : Les patients subissant une sédation par la kétamine reçoivent souvent des doses répétées afin de maintenir la dissociation. Les patients âgés de moins de 3 ans ont reçu les doses de kétamine totales les plus élevées.

Evaluation of Central Venous Access with Accelerated Seldinger Technique Versus Modified Seldinger Technique.
Thaut L, Weymouth W, Hunsaker B, Reschke D. | J Emerg Med. 2019 Jan;56(1):23-28
DOI: https://doi.org/10.1016/j.jemermed.2018.10.021
Keywords: Seldinger technique; accelerated Seldinger technique; central venous catheter; central venous lines; fluid resuscitation; modified Seldinger technique; resuscitation; vascular access

Brief Reports

Introduction : Central vein catheter (CVC) placement using the modified Seldinger technique is a common procedure in the emergency department, but can be time consuming due to the multiple pieces of equipment included in central line kits and the number of steps in the procedure. Preassembled devices combine a needle, guidewire, dilator, and sheath into one unit and potentially simplify the process and reduce time required for CVC placement using the accelerated Seldinger technique.
OBJECTIVE: Our aim was to evaluate whether the use of combination central line devices and the accelerated Seldinger technique will reduce the time required to place a CVC and increase the ease of the procedure.

Méthode : This two-arm randomized crossover study comparing the accelerated Seldinger technique to the modified Seldinger technique was performed in a simulation setting. Subjects were selected from among emergency physicians, emergency medicine residents, interns, physician assistants, and medical students. Subjects were timed using the modified and accelerated Seldinger techniques. Ease of use and satisfaction data were collected after both procedures.

Résultats : The use of the accelerated Seldinger technique with a combination CVC device was significantly faster compared to the modified Seldinger technique with a standard CVC kit. Procedure time was reduced by 35% (p = 0.001), and ease of use was increased by 7% (p = 0.046), without any increase in errors.

Conclusion : In the simulated setting, the accelerated Seldinger technique using combination CVC devices is a faster and easier method for CVC placement compared to the modified Seldinger technique.

Conclusion (proposition de traduction) : En simulation, la technique de Seldinger accélérée utilisant une combinaison de dispositifs de cathéter de veine central est une méthode plus rapide et plus simple pour la mise en place de cathéter de veine central par rapport à la technique de Seldinger modifiée.

Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis.
Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R. | J Emerg Med. 2019 Jan;56(1):53-69
DOI: https://doi.org/10.1016/j.jemermed.2018.09.009  | Télécharger l'article au format  
Keywords: acute heart failure; asthma; chronic pulmonary obstructive disease; diagnostic accuracy; lung ultrasound; pneumonia

Ultrasound in Emergency Medicine

Introduction : Lung ultrasound can accelerate the diagnosis of life-threatening diseases in adults with respiratory symptoms.
OBJECTIVE: Systematically review the accuracy of lung ultrasonography (LUS) for emergency diagnosis of pneumonia, acute heart failure, and exacerbation of chronic obstructive pulmonary disease (COPD)/asthma in adults.

Méthode : PubMed, Embase, Scopus, Web of Science, and LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde; until 2016) were searched for prospective diagnostic accuracy studies. Rutter-Gatsonis hierarchical summary receiver operating characteristic method was used to measure the overall accuracy of LUS and Reitsma bivariate model to measure the accuracy of the different sonographic signs. This review was previously registered in PROSPERO (Centre for Reviews and Dissemination, University of York, York, UK; CRD42016048085).

Résultats : Twenty-five studies were included: 14 assessing pneumonia, 14 assessing acute heart failure, and four assessing exacerbations of COPD/asthma. The area under the summary receiver operating characteristic curve of LUS was 0.948 for pneumonia, 0.914 for acute heart failure, and 0.906 for exacerbations of COPD/asthma. In patients suspected to have pneumonia, consolidation had sensitivity of 0.82 (95% confidence interval [CI] 0.74-0.88) and specificity of 0.94 (95% CI 0.85-0.98) for this disease. In acutely dyspneic patients, modified diffuse interstitial syndrome had sensitivity of 0.90 (95% CI 0.87-0.93) and specificity of 0.93 (95% CI 0.91-0.95) for acute heart failure, whereas B-profile had sensitivity of 0.93 (95% CI 0.72-0.98) and specificity of 0.92 (95% CI 0.79-0.97) for this disease in patients with respiratory failure. In patients with acute dyspnea or respiratory failure, the A-profile without PLAPS (posterior-lateral alveolar pleural syndrome) had sensitivity of 0.78 (95% CI 0.67-0.86) and specificity of 0.94 (95% CI 0.89-0.97) for exacerbations of COPD/asthma.

Conclusion : Lung ultrasound is an accurate tool for the emergency diagnosis of pneumonia, acute heart failure, and exacerbations of COPD/asthma.

Conclusion (proposition de traduction) : L'échographie pulmonaire est un outil précis pour le diagnostic d'urgence de la pneumonie, de l'insuffisance cardiaque aiguë et des exacerbations de la BPCO/asthme.

Commentaire : Retrouver les articles de Lichtenstein détaillant la technique de l'échographie pulmonaire et le « Blue Code » :
- Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014 Jan 9;4(1):1  .
- Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest. 2015 Jun;147(6):1659-1670  .
- Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25.  .
 

The Lancet Respiratory Medicine

Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.
Alam N1, Alam N, Oskam E, Stassen PM, Exter PV, van de Ven PM, Haak HR, Holleman F, Zanten AV, Leeuwen-Nguyen HV, Bon V, Duineveld BAM, Nannan Panday RS, Kramer MHH, Nanayakkara PWB; PHANTASi Trial Investigators and the ORCA (Onderzoeks Consortium Acute Geneeskunde) Research Consortium the Netherlands. | Lancet Respir Med. 2018 Jan;6(1):40-50
DOI: https://doi.org/10.1016/S2213-2600(17)30469-1
Keywords: Aucun

ARTICLES

Introduction : Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care.

Méthode : After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428.

Résultats : 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone.

Conclusion : In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity.

Conclusion (proposition de traduction) : Chez les patients présentant un sepsis de gravité variable, la formation du personnel des services médicaux d'urgence a amélioré la reconnaissance précoce et les soins dans l'ensemble de la chaîne de soins de courte durée.
Cependant, l'administration d'antibiotiques dans l'ambulance n'a pas amélioré la survie, quelle que soit la gravité de la maladie.

Commentaire : Voir l'analyse de l'article sur le site de la SRLF : L’antibiothérapie en préhospitalier n’améliore pas la survie dans le sepsis  . Commenté par Emmanuel Montassie, publié le 27/03/2019.

World Journal of Emergency Medicine

Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers.
Wahlen BM, El-Menyar A, Asim M, Al-Thani H. | World J Emerg Med. 2019 Jan;10(1):19-26
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2019.01.003  | Télécharger l'article au format  
Keywords: Anaesthetists; Drugs; Emergency physicians; Rapid-sequence induction; Trauma

Original Articles

Introduction : We aimed to describe the current practice of emergency physicians and anaesthesiologists in the selection of drugs for rapid-sequence induction (RSI) among trauma patients.

Méthode : A prospective survey audit was conducted based on a self-administered questionnaire among two intubating specialties. The preferred type and dose of hypnotics, opioids, and muscle relaxants used for RSI in trauma patients were sought in the questionnaire. Data were compared for the use of induction agent, opioid use and muscle relaxant among stable and unstable trauma patients by the intubating specialties.

Résultats : A total of 102 participants were included; 47 were anaesthetists and 55 were emergency physicians. Propofol (74.5%) and Etomidate (50.0%) were the most frequently used induction agents. Significantly higher proportion of anesthesiologist used Propofol whereas, Etomidate was commonly used by emergency physicians in stable patients (P=0.001). Emergency physicians preferred Etomidate (63.6%) and Ketamine (20.0%) in unstable patients. The two groups were comparable for opioid use for stable patients. In unstable patients, use of opioid differed significantly by intubating specialties. The relation between rocuronium and suxamethonium use did change among the anaesthetists. Emergency physicians used more suxamethonium (55.6% vs. 27.7%, P=0.01) in stable as well as unstable (43.4 % vs. 27.7%, P=0.08) patients.

Conclusion : There is variability in the use of drugs for RSI in trauma patients amongst emergency physicians and anaesthesiologists. There is a need to develop an RSI protocol using standardized types and dose of these agents to deliver an effective airway management for trauma patients.

Conclusion (proposition de traduction) : Chez les urgentologues et les anesthésistes, l’utilisation des médicaments pour l'ISR chez les patients traumatisés est variable. Il est nécessaire de développer un protocole ISR utilisant des types et des doses standardisés de ces agents afin de permettre une gestion efficace des voies respiratoires chez les patients traumatisés.


Mois de janvier 2019