Bibliographie de Médecine d'Urgence

Mois de février 2019

Academic Emergency Medicine

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis.
Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Thiruganasambandamoorthy V, Kyeremanteng K, Perry JJ. | Acad Emerg Med. 2019 Feb;26(2):140-151
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Keywords: Aucun


Introduction : The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain.

Méthode : We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined.

Résultats : We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI = 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%), but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%-99.0%) for prediction of MI.

Conclusion : he HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.

Conclusion (proposition de traduction) : Le score HEART présente d'excellentes performances pour prédire les événements cardiaques indésirables majeurs (en particulier la mortalité et l'infarctus du myocarde) chez les patients souffrant de douleurs thoraciques et devrait être le principal instrument de décision clinique utilisé pour la stratification du risque de cette population de patients.

Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study).
Bouida W, Beltaief K, Msolli MA, Azaiez N, Ben Soltane H, Sekma A, Trabelsi I, Boubaker H, Grissa MH, Methemem M, Boukef R, Dridi Z, Belguith A, Nouira S. | Acad Emerg Med. 2019 Feb;26(2):183-191
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Introduction : We aim to determine the benefit of two different doses magnesium sulfate (MgSO4 ) compared to placebo in rate control of rapid atrial fibrillation (AF) managed in the emergency department (ED).

Méthode : We undertook a randomized, controlled, double-blind clinical trial in three university hospital EDs between August 2009 and December 2014. Patients > 18 years with rapid AF (>120 beats/min) were enrolled and randomized to 9 g of intravenous MgSO4 (high-dose group, n = 153), 4.5 g of intravenous MgSO4 (low-dose group, n = 148), or serum saline infusion (placebo group, n = 149), given in addition to atrioventricular (AV) nodal blocking agents. The primary outcome was the reduction of baseline ventricular rate (VR) to 90 beats/min or less or reduction of VR by 20% or greater from baseline (therapeutic response). Secondary outcome included resolution time (defined as the elapsed time from start of treatment to therapeutic response), sinus rhythm conversion rate, and adverse events within the first 24 hours.

Résultats : At 4 hours, therapeutic response rate was higher in low- and high-MgSO4 groups compared to placebo group; the absolute differences were, respectively, 20.5% (risk ratio [RR] = 2.31, 95% confidence interval [CI] = 1.45-3.69) and +15.8% (RR = 1.89, 95% CI = 1.20-2.99). At 24 hours, compared to placebo group, therapeutic response difference was +14.1% (RR = 9.74, 95% CI = 2.87-17.05) with low-dose MgSO4 and +10.3% (RR = 3.22, 95% CI = 1.45-7.17) with high-dose MgSO4 . The lowest resolution time was observed in the low-dose MgSO4 group (5.2 ± 2 hours) compared to 6.1 ± 1.9 hours in the high-dose MgSO4 group and 8.4 ± 2.5 hours in the placebo group. Rhythm control rate at 24 hours was significantly higher in the low-dose MgSO4 group (22.9%) compared to the high-dose MgSO4 group (13.0%, p = 0.03) and the placebo group (10.7%). Adverse effects were minor and significantly more frequent with high-dose MgSO4 .

Conclusion : Intravenous MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control. Similar efficacy was observed with 4.5 and 9 g of MgSO4 but a dose of 9 g was associated with more side effects.

Conclusion (proposition de traduction) : Le MgSO4 intraveineux semble avoir un effet synergique lorsqu'il est associé à d’autres bloqueurs nodaux auriculo-ventriculaires, ce qui permet un meilleur contrôle du débit. Une efficacité similaire a été observée avec 4,5 et 9 g de MgSO4, mais une dose de 9 g était associée à davantage d'effets secondaires.

Commentaire : Nouvelle étude sur l'utilisation du sulfate de magnésium comme anti-arythmique…

Epinephrine for Out-of-hospital Cardiac Arrest.
Kelson K, deSouza IS. | Acad Emerg Med. 2019 Feb;26(2):256-258
Keywords: Aucun


Introduction : The original data supporting the use of epinephrine for cardiac arrest is rooted in a poorly controlled canine study1 from the 1960s. The Advanced Cardiac Life Support (ACLS) recommendation that it “may be reasonable” to use epinephrine in cardiac arrest continues in contemporary practice. Yet, when the ACLS guidelines2 are read carefully, they state that “for both survival to discharge and survival to discharge with good neurological outcome, there was no benefit” to receiving epinephrine. Physiologically, epinephrine is theorized to promote peripheral vasoconstriction, thereby increasing diastolic pressure and coronary perfusion. Epinephrine also increases myocardial work and metabolic demand and may worsen tachydysrhythmia. Despite the purported physiologic benefits, it appears that epinephrine use for out-of-hospital cardiac arrest (OHCA) increases the rate of ROSC but does not increase the chance of survival (Table). Epinephrine may even worsen the neurological outcome in patients who do survive. Epinephrine use for OHCA may therefore extend suffering and increase end-of-life healthcare costs due to intensive care and prolonged hospitalization without clear patient-centered, long-term benefits. Patients who survive to hospital discharge may be more likely to be dependent on others for care. This presents an obvious ethical quandary, as patient and family preferences may differ greatly with regards to life-prolonging therapies.

Méthode : The source meta-analysis3 incorporated 13 observational studies and only one RCT:4 Jacob et al studied 601 patients and showed that epinephrine for OHCA was effective at increasing rate of ROSC (OR 3.4, 95% CI 2.0 to 5.6) and survival to hospital admission (OR 2.3, 95% CI 1.4 to 3.6) but lacked a statistically significant effect on survival to hospital discharge (OR 2.2; 95% CI 0.7 to 6.3). The observational trials included in the meta-analysis3 attempted to control for potential confounders (i.e. time to CPR) by propensity-matching individual study subjects, although bias can never be fully accounted for in any observational study. Similarly, the use of random effects methods cannot fully control for heterogeneity when reporting pooled effects in meta-analyses, and 3/4 of reported outcomes had exceedingly high heterogeneity (I2 = 96%). The source of heterogeneity may be patient characteristics, co-interventions, or trial-level, and random effects methods only attempt to adjust for between-trial variability, which can unintentionally inflate the effect of small studies on the pooled results. Propensity-matched outcomes in individual studies were generally in agreement with the pooled outcomes in this meta-analysis3 with the exception of survival at one month. The pooled results for one month survival may be confounded by the negative effect of smaller studies that were in favor of withholding epinephrine.

Résultats : Specific effect modifiers in the included studies such as the timing and dosing of epinephrine administration may have influenced treatment effects on resuscitation outcomes. Earlier epinephrine administration has been associated with more favorable outcomes. The ‘standard’ one mg of epinephrine given in cardiac arrest is not weight-based and therefore can have a differential physiologic effect depending on the individual patient. The meta-analysis3 included some trials that used ‘high dose’ (0.1 to 0.2 mg/kg) epinephrine, which may have contributed negatively to pooled outcome results. Epinephrine administered at higher doses may be harmful10 and is not recommended by current guidelines. There was no evidence of benefit in the proportion of patients who survived to hospital discharge with a favorable neurologic outcome (OR 1.18, 95% CI 0.86 to 1.61), and the lack of effect persisted at 3 months. This confirms that the use of epinephrine for OHCA is not patient-centered (as defined by patients and the public in preparation for the PARAMEDIC-2 trial) and will cause prolonged suffering in a severely disabled state.

Conclusion : In summary, we chose a color recommendation of “Red” for epinephrine administration in OHCA. There is no patient-centered benefit and probable harm due to increased survival with worse long-term neurological function.

Conclusion (proposition de traduction) : En résumé, nous avons choisi une recommandation de couleur « Rouge » (aucun bénéfice) pour l'administration d'épinéphrine dans l'arrêt cardiaque extrahospitalier. Il n'y a aucun bénéfice et préjudice probable centrés sur le patient en raison d'une survie accrue associée à une détérioration de la fonction neurologique à long terme.

Video Laryngoscopy vs. Direct Laryngoscopy.
Bakhsh A, Ritchie M. | Acad Emerg Med. 2019 Feb;26(2):259-260
Keywords: Aucun


Introduction : Tracheal intubation is a critical step in securing the patient’s airway in a variety of emergent and non-emergent settings. Difficulties and complications may arise with this procedure, and alternative laryngoscopes that use video technology have been designed to improve visibility when airway difficulty is predicted or encountered. These devices may be flexible or rigid in design for the purpose of assisting in intubations, especially expected difficult intubations. Video laryngoscopes have been advertised as being able to reduce difficulty, failure, trauma and other complications compared with direct laryngoscopy. Rigid video laryngoscopy uses a blade to retract the soft tissues and transmits a video image to a screen attached to the end of the handle or to a monitor. This design enables a lighted view of the larynx without direct ‘line of sight’, and is also referred to as indirect laryngoscopy. In the Cochrane review discussed here,1 video laryngoscopy is compared to direct laryngoscopy in the tracheal intubation of adult patients.

Méthode : The Cochrane review included randomized control trials (RCTs) of both parallel and cross- over design. No simulation or manikin studies were included. Participants were aged 16 years and older who required tracheal intubation electively for scheduled surgery, as well as participants requiring emergent intubation in the emergency department or the intensive care unit (ICU). The included trials compared the use of a video laryngoscope (VLS) of any model versus direct laryngoscopy (DL) with a Macintosh blade.

Résultats : The systematic review also demonstrated statistically significant reduction in likelihood of laryngeal/airway traumas (22 trials, OR: 0.68; 95% CI, 0.48-0.96, ARD:3%, NNT:37) and fewer incidences of postoperative hoarseness (6 trials, OR 0.57; 95% CI, 0.36-0.88, ARD:9%; NNT: 11) when a VLS device was used. Additionally, the Cochrane review analyzed intubation difficulty scale (IDS) and airway visualization. IDS scores were recorded in 7 studies with 0 representing no difficulty. VLS increased the likelihood of a reported intubation difficulty scores of 0. Airway visualization was evaluated using Cormack-Lehane views. Achiveing a Cormack-Lehane grade 1 views was also more likely with VLS.

Discussion : The use of video laryngoscopy was not adequately explored in the emergency setting. Out of 64 studies included in the meta-analysis, only 3 studies included participants requiring emergency intubation (one in the intensive care unit, one in the emergency department, and one in an out-of-hospital setting). Therefore, the findings of this systematic review might not be generalizable to emergency settings.
All studies were subject to a high level of bias due to the inability to blind personnel to the type of laryngoscope used with each participant. As a result, the Cochrane authors downgraded the evidence for each outcome by one level for study limitations. Failed intubation, proportion of successful first attempts, and sore throat outcomes were assessed to be moderate quality evidence. Whereas, outcomes of hypoxia, serious respiratory complications, and mortality were downgraded to very low-quality evidence for imprecision. Additionally, a large number of studies with substantial heterogeneity that reported time to tracheal intubation were downgraded to very low quality evidence.
Most studies used an experienced anesthetist to perform laryngoscopies. However, it was not always clear from the papers whether anesthetists had equivalent experience with both devices.

Conclusion : In light of improved patient centered outcome and relative safety, we assign a color recommendation of Green (Benefits > Harms) to this intervention.

Conclusion (proposition de traduction) : À la lumière de l'amélioration du résultat centré sur le patient et de la sécurité relative, nous avons attribué une recommandation de couleur « Vert » (Avantages > Dommages) à cette intervention.

Hot Off the Press: Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study.
Heitz C, Morgenstern J2, Bond C3, Milne WK. | Acad Emerg Med. 2019 Feb 27
Keywords: Aucun

Hot Off The Press

Editorial : Atrial fibrillation is the most common cardiac dysthrymia. Several rate-control strategies have been used, and magnesium sulfate has been investigated as an adjunct. In this review, we look at a trial by Bouida et al in which magnesium sulfate was studied in two different doses for rate control in atrial fibrillation. In addition, we review the social media commentary in response to the Skeptics Guide of Emergency Medicine Hot of the Press podcast.

Introduction : Atrial fibrillation (AF) is the most common cardiac dysrhythmia, increasing in prevalence with age. (1) Options for emergency department (ED) management include rate control with various medications, or rhythm control using either electrical cardioversion or chemical means. (2) Magnesium sulfate (MgS) has been studied as an adjunctive therapy for AF, with varying results. (3-6) The aim of the study was to determine if different doses of MgS would have differing synergistic effects on rate control agents being provided for control of atrial fibrillation.

Méthode : This was a well-done, randomized controlled trial. The patients were recruited consecutively and multiple centers were used. Treating providers and patients were blinded to therapy. Choice of treating agent was left up to the provider, which reduces standardization of patient care. As seen in the results, a large number of patients were treated with digoxin, which differs from most North American practice, reducing external validity of the study. In addition, the outcomes were not patient- oriented such as short-term stroke or cardiac outcomes, but instead were surrogate, objective numeric outcomes such as heart rate and sinus rhythm conversion.

Résultats : They enrolled 450 patients into the trial with 1/3 in each group. The mean age was 67 years and 60% were women. Rate control agents used were digoxin (47%), diltiazem (31%) and beta-blockers (22%).
• Primary Outcome:
o Low dose (4.5g MgS) placebo: absolute difference 20.5%, risk ratio 2.31, 95% CI 1.45-3.69
o High dose (9g MgS) placebo: absolute difference 15.8%, risk ratio 1.89, 95% CI 1.20-2.99
o 5g vs. 9g MgS: absolute difference 4.7%, risk ratio 0.81, 95% CI 0.51-1.30
• Secondary Outcomes: Magnesium groups had faster time to resolution, low dose had a higher sinus rhythm conversion rate and rhythm control at 24 hours. However, adverse events (flushing) were higher in patients treated with magnesium.
o Mean resolution time: 8.4 +5 hours placebo, 6.1 +1.9 hours low dose, 5.2 + 2 hours high dose
o Sinus rhythm conversion at 4 hours 6.7% placebo, 12.1% low dose, 7.8% high dose
o Rhythm control at 24 hours 10.7% placebo, 22.9% low dose, 13.0% high dose
o Adverse events higher with MgS (flushing in 24 patients, transient hypotension in 4 patients – 2 high dose, 1 low dose, one placebo, bradycardia in one patient/group).

Discussion : Magnesium, in either a dose of 4.5g or 9g, appears to be an effective adjunct for rate control, with an increase in minor side effects. However, a large proportion of patients in this study received digoxin, which differs from practice by many North American providers, and the outcomes are not patient-oriented, both of which limit the clinical application of the data.

Conclusion : This study compares two doses of magnesium given concurrently with rate controlling agents (left to the treating provider’s discretion). Patients over 18 years of age with rapid atrial fibrillation (>120 beats per minute), without complicating features such as hypotension, impaired consciousness, renal insufficiency, wide complex tachycardias, acute myocardial infarction or congestive heart failure, were randomized to receive either placebo, 4.5gm, or 9gm of MgS along with initial rate control agent. MgS was given over 30 minutes. The primary outcomes were a ventricular rate within 4 hours of 90 beats/min or less, or a reduction in ventricular rate by 20%. Secondary outcomes included time to therapeutic response, sinus rhythm conversion rate, and adverse events (defined as discontinuation of treatment or death.)

Conclusion (proposition de traduction) : Cette étude compare deux dosages de magnésium administrées en même temps que des médicaments de contrôle du rythme (à la discrétion du fournisseur de traitement). Les patients de plus de 18 ans présentant une fibrillation atriale rapide (>120 battements par minute), sans complications telles qu'une hypotension, une altération de la conscience, une insuffisance rénale, une tachycardie à complexes larges, un infarctus aigu du myocarde ou une insuffisance cardiaque congestive, ont reçu au hasard un placebo, 4,5 g ou 9 g de MgSO4- avec un médicaments de contrôle du rythme initial. MgSO4- a été administré après 30 minutes. Les principaux résultats ont été une fréquence ventriculaire dans les 4 heures de 90 battements/min ou moins, ou une réduction de 20 % de la fréquence ventriculaire. Les résultats secondaires comprenaient le temps avant la réponse thérapeutique, le taux de conversion du rythme sinusal et les effets indésirables (définis comme l'arrêt du traitement ou le décès).
Les groupes de magnésium avaient un temps de réduction du rythme plus rapide, une faible dose, un taux de conversion du rythme sinusal plus élevé et un contrôle du rythme après 24 heures. Cependant, les effets indésirables (bouffées vasomotrices) étaient plus élevés chez les patients traités avec du magnésium.

Annals of Emergency Medicine

Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians.
Heikkilä I, Kuusisto H, Holmberg M, Palomäki A. | Ann Emerg Med. 2019 Feb;73(2):105-112.
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Introduction : Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician-based protocol when no stroke neurologist is available.

Méthode : This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization.

Résultats : A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization.

Conclusion : Implementation of a stroke protocol with emergency physician-directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.

Conclusion (proposition de traduction) : La mise en œuvre d'un protocole d'AVC avec des soins aigus dirigés par un urgentiste a permis de réduire à la fois le temps d'accès et le temps de début du traitement sans augmenter le taux d'hémorragie intracérébrale symptomatique.

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.
Freedman SB, Ali S, Finkelstein Y. | Ann Emerg Med. 2019 Feb;73(2):208-209
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Editorial : April et al conducted an intriguing trial comparing aromatherapy with ondansetron in adult emergency department (ED) patients with nausea. The authors conclude that among ED patients with nausea, aromatherapy provides greater nausea relief than oral ondansetron. It was unexpected to see aromatherapy reported as outperforming a known, potent antiemetic. On close review, we have identified some methodological issues that may have influenced the results and conclusions drawn.

Conclusion : The ondansetron dose used (4 mg) was too low; most studies that have demonstrated effectiveness of oral ondansetron use doses of 8 mg in patients weighing greater than 30 kg. Thus, adults receiving oral ondansetron in the study were administered a subtherapeutic dose and had the benefits quantified at a point when one would not yet expect to observe significant antinausea effects.

Conclusion (proposition de traduction) : La dose d'ondansétron utilisée (4 mg) était trop faible; la plupart des études ayant démontré l'efficacité des doses de 8 mg d'ondansétron par voie orale chez des patients pesant plus de 30 kg. Ainsi, les adultes recevant de l'ondansétron par voie orale au cours de l'étude ont reçu une dose subthérapeutique et les avantages ont été quantifiés à un moment où on ne pouvait pas encore s'attendre à observer d'effets antinauséeux importants.

Commentaire : L'article discuté est :
April MD, Oliver JJ, Davis WT, et al. Aromatherapy versus oral ondansetron for antiemetic therapy among adult emergency department patients: a randomized controlled trial. Ann Emerg Med. 2018;72:184-193  .
Réponse de l'auteur de l'étude :
Nous concédons que notre dose d'ondansétron (4 mg) peut avoir été sous-thérapeutique. Nous avons choisi cette dose comme étant la quantité de médicament couramment administrée dans le cadre de traitement d'urgence pour le traitement des nausées indifférenciées. Des recherches futures pourraient examiner si des doses plus élevées d'ondansétron donneraient des résultats différents.

Epinephrine in Out-of-Hospital Cardiac Arrest: Saving Lives or Prolonging Death?.
Spiegel R, Radecki R. | Ann Emerg Med. 2019 Feb;73(2):206-207
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Annals of Emergency Medicine Journal Club

Conclusion : The P value, first proposed by Fisher in the early 20th century, is defined as the probability, under the assumption of no effect or no difference (the null hypothesis), of obtaining a result equal to or more extreme than what was actually observed if the study were to be conducted a large number of times. The term “significant” was derived from “signify,” or a test that indicates or provides support for rejecting the null hypothesis. Simply put, a P value is the probability that there is no difference between the 2 groups in question.2 In this case, given the observed increase in survival of 0.8%, what is the likelihood that in reality there is no difference between epinephrine and placebo? The authors report a P value of .02, or a 2% probability that these results would be observed if there were in fact no difference between epinephrine and placebo. With the increasing statistical power that comes with increasing sample size, it is inevitable that small statistical differences between groups will be observed because no 2 groups are identical. As such, it is important to differentiate between statistical significance and clinical importance. In the case of epinephrine in out-of-hospital cardiac arrest, we are asked to balance a 0.8% increase in survival to hospital discharge with the harms associated with its use. The harms are significant and clinically important. The resources required to stock epinephrine on ambulances across the country and to employ the staff with the appropriate skill level to administer intra-arrest medications are immense. More important, the use of epinephrine was associated with a significant increase in the risk of survival with neurologic devastation. Although more patients who received epinephrine were transported to the hospital (50.8% versus 30.7%) and survived to ICU admission (14.1% versus 6.8%), 31% of the survivors in the epinephrine group had a modified Rankin Scale score of 4 or 5 (unable to walk or bedridden) compared with 17% in the placebo group, with no increase in the number of patients with neurologically intact survival.

Conclusion (proposition de traduction) : La valeur P, proposée pour la première fois par Fisher au début du XXe siècle, est définie comme la probabilité, sous l'hypothèse d'absence d'effet ou d'absence de différence (l'hypothèse nulle), d'obtenir un résultat égal ou supérieur à ce qui a été observé si l'étude devait être menée un grand nombre de fois. Le terme « significatif » est dérivé de « signify » ou d'un test qui indique ou corrobore le rejet de l'hypothèse nulle. En termes simples, une valeur P est la probabilité qu’il n’y ait aucune différence entre les 2 groupes en question. Dans ce cas, étant donné l’augmentation de survie observée de 0,8 %, quelle est la probabilité qu’il n’y ait aucune différence entre l’épinéphrine et le placebo ? Les auteurs rapportent une valeur de p de 0,02, ou une probabilité de 2 % que ces résultats seraient observés s'il n'y avait en fait aucune différence entre l'épinéphrine et le placebo.
Avec la puissance statistique croissante associée à l’augmentation de la taille de l’échantillon, il est inévitable d’observer de petites différences statistiques entre les groupes car aucun groupe n’est identique. En tant que tel, il est important de faire la distinction entre la signification statistique et l’importance clinique. Dans le cas de l'épinéphrine en cas d'arrêt cardiaque extrahospitalier, il nous est demandé d'équilibrer une augmentation de 0,8 % de la survie à la sortie de l'hôpital avec les dommages associés à son utilisation. Les méfaits sont importants et cliniquement importants. Les ressources nécessaires pour stocker l'épinéphrine dans les ambulances à travers le pays et pour employer le personnel possédant le niveau de compétence approprié pour administrer les médicaments en attente d'arrêt sont immenses. Plus important encore, l'utilisation d'épinéphrine était associée à une augmentation significative du risque de survie associé à des atteintes neurologiques. Bien que davantage de patients ayant reçu de l'épinéphrine aient été transportés à l'hôpital (50,8 % contre 30,7 %) et aient survécu à l'admission en USI (14,1 % contre 6,8 %), 31 % des survivants du groupe épinéphrine présentaient un score modifié sur l'échelle de Rankin de 4 ou 5 (incapable de marcher ou alité) par rapport à 17 % dans le groupe placebo, sans augmentation du nombre de patients avec une survie neurologique intacte.

Commentaire : Commentaires de l'article :
Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379:711-721  .

Trauma-Informed Care for Violently Injured Patients in the Emergency Department.
Fischer KR, Bakes KM, Corbin TJ, Fein JA, Harris EJ, James TL, Melzer-Lange MD. | Ann Emerg Med. 2019 Feb;73(2):193-202
Keywords: Aucun

Injury Prevention

Editorial : Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care.

Conclusion : This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Conclusion (proposition de traduction) : Cette approche repose sur 4 piliers : la connaissance de l’effet du traumatisme, la reconnaissance des signes et symptômes du traumatisme, l’évitement de la traumatologie et l’élaboration de politiques et procédures appropriées.
À l'aide de ce cadre, nous fournissons aux médecins urgentistes des considérations pratiques pour la dispensation des soins sensibles au traumatisme à des patients victimes de blessures violentes.

Is the Liberal Use of Oxygen Associated With Worse Outcomes Among Critically Ill Patients?.
Gottlieb M, Goldstein C, Ward EJ. | Ann Emerg Med. 2019 Feb;73(2):180-182
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Keywords: Aucun

General Medicine

Introduction : The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HealthSTAR, Latin American and Caribbean Health Sciences Literature, PapersFirst, and the World Health Organization International Clinical Trials Registry, without language restrictions, from inception to October 25, 2017, for studies comparing liberal versus conservative oxygen therapy in acutely ill adults. Database searches were supplemented by screening the reference lists of relevant studies and reviews. They also contacted study authors for unpublished data and in all instances with missing or unclear data.

Méthode : Studies were included if they were randomized controlled trials comparing liberal and conservative oxygenation strategies in acutely ill adults (!18 years) and assessed either mortality (inhospital, at 30 days, and at the longest follow-up) or morbidity (ie, disability measured by the modified Rankin Scale score at longest follow-up, risk of hospital-acquired pneumonia, risk of any hospital- acquired infection, and hospital length of stay). Patients were defined as acutely ill if they had any condition requiring nonelective hospital admission and had the potential to be exposed to supplemental oxygen. The treatment group with the higher oxygen target was defined as the liberal arm, whereas the group with the lower oxygen target was defined as the conservative arm. Two reviewers independently screened titles for inclusion, with disagreements resolved by consensus.

Résultats : Two reviewers independently abstracted data, using a standardized data collection form, with disagreements resolved by consensus. For dichotomous outcomes, the authors calculated the relative risk with 95% confidence interval (CI). For continuous outcomes, the mean difference with 95% CI was calculated. For ordinal outcomes, odds ratio and 95% CI were calculated. Heterogeneity between studies was calculated with c2 and the I2 statistic. Publication bias was determined with funnel plots and the Egger’s test. Quality assessment was performed with the Cochrane Risk of Bias tool.

Conclusion : Compared with conservative oxygen therapy, liberal oxygen therapy is associated with increased mortality without improving other patient-relevant outcomes.

Conclusion (proposition de traduction) : Par rapport à l'oxygénothérapie conservatrice, l'oxygénothérapie libérale est associée à une mortalité accrue sans améliorer les autres résultats pertinents pour le patient.

Normal Saline Solution and Lactated Ringer's Solution Have a Similar Effect on Quality of Recovery: A Randomized Controlled Trial.
Friederich A, Martin N, Swanson MB, Faine BA, Mohr NM. | Ann Emerg Med. 2019 Feb;73(2):160-169
DOI:  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Introduction : The purpose of this study is to test the hypothesis that balanced crystalloids improve quality of recovery more than normal saline solution (0.9% sodium chloride) in stable emergency department (ED) patients. Secondary outcomes measured differences in health care use.

Méthode :  single-site, participant- and evaluator-blinded, 2-arm parallel allocation (1:1), comparative effectiveness, randomized controlled trial allocated adults receiving intravenous fluids in the ED before discharge to receive 2 L of lactated Ringer's solution or normal saline solution. The primary outcome was symptom scores measured by the validated Quality of Recovery-40 instrument (scores 40 to 200) 24 hours after enrollment. Secondary outcomes included subsequent health care use and medication compliance.

Résultats : Participants (N=157) were enrolled and follow-up was analyzed for 94 (follow-up rate of 60%) with intention-to-treat methodology. There was no difference in postenrollment Quality of Recovery-40 scores between normal saline solution and lactated Ringer's solution groups (mean difference 2.4; 95% confidence interval [CI] -6.8 to 11.6). Although preenrollment scores were higher in the lactated Ringer's solution group (mean difference 10.5; 95% CI 1.9 to 19.0), adjusting for presurvey imbalances did not change the primary outcome (adjusted difference -3.9; 95% CI -12.9 to 5.2). There were no differences in return to ED (mean difference 7.5%; 95% CI -8.7% to 23.8%), prescriptions filled (mean difference 22.2%; 95% CI -3.3% to 47.6%), or seeking care from another provider (mean difference -2.0%; 95% CI -19.9% to 15.9%) at 7 days.

Conclusion : Normal saline solution and lactated Ringer's solution were associated with similar 24-hour recovery scores and 7-day health care use in stable ED patients. These results supplement those of recent trials by informing fluid choice for stable ED patients.

Conclusion (proposition de traduction) : Une solution saline normale et la solution de Ringer lactate étaient associées à des scores de récupération similaires sur 24 heures et à une utilisation des soins de santé pendant 7 jours chez des patients stables au service des urgences. Ces résultats complètent ceux des essais récents en informant sur le choix des liquides de remplissage pour les patients stables au service des urgences.

Commentaire : Pour compléter la lecture :
- Self WH and al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828  .
- Semler MW and al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018 May 17;378(20):1951  .

British Medical Journal

Give us a break.
Chatfield C, Rimmer A. | BMJ. 2019 Feb 6;364:l481
Keywords: Aucun


Editorial : Have you ever worked a whole shift without a toilet break? Or worked through your morning session into lunchtime and beyond without stopping to eat? Or got into your car at the end of a night shift and wondered how you were going to drive home safely? The chances are that you have. These are not unusual scenarios for doctors working in the NHS or any other overstretched health system. Worryingly, for some staff these scenarios have become the norm. This is not acceptable. Missing essential breaks is bad for doctors and their patients.

Conclusion : Medical organisations, trade unions, and royal colleges have campaigned on this issue in the past and continue to do so. However, the problem persists and may be getting worse. We will bring these organisations together, along with other stakeholders such as employer and patient organisations, in a united effort to change systems, working practices, and culture to ensure that doctors get the breaks they need.

Conclusion (proposition de traduction) : Les organisations médicales, les syndicats et les collèges royaux ont fait campagne sur cette question dans le passé et continuent de le faire. Cependant, le problème persiste et pourrait s'aggraver. Nous réunirons ces organisations, ainsi que d'autres parties prenantes telles que les organisations d'employeurs et de patients, dans un effort commun pour changer les systèmes, les pratiques de travail et la culture afin de garantir aux médecins les pauses dont ils ont besoin.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Urgences : se reposer plus pour travailler mieux  . Rédigé par le Dr Stéphanie Lavaud le 26 février 2019.

Emergency Care Journal

The Acute Abdomen Decision Making course for the initial management of non traumatic acute abdomen: A proposition of the World Society of Emergency Surgeons.
De Simone B, Ansaloni L, Sartelli M, Coccolini F, Paolillo C, Valentino M, Ricci G, Catena F. | Emerg Care J. 2019;15:7767
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Educational Papers

Editorial : The Acute Abdomen Decision Making course® (AADM®) was developed by the World Society of Emergency Surgeons (WSES) members with the purpose to teach a systematic and concise method for approaching acute abdomen patient. It was first introduced in 2016. The course explains step by step the clinical reasoning to follow for immediate managing of the acute abdomen in emergency department with a safe and reliable method. We developed this original decision making model AADM following the Advanced Trauma Life Support (ATLS) philosophy in evaluating non-traumatic abdominal pain patient. The A-B-C-D-E-F management of non-traumatic acute abdominal pain is conceived by WSES to make easy and systematic the evaluation of patients in Emergency Department. AADM course teaches how to assess an acute abdomen patient’s diagnosis and determine the therapeutic approach to reduce unnecessary exams and hospitalizations.

Conclusion : Academic medical education program need to clear action to reach a solid preparation of residents, often alone at night, and ED physicians. The aim of WSES is to revolutionize traditional academic education of physicians. Theory is important in medicine but it can be different from what we can find approaching patients every days. WSES proposes the AADM course as an effective and simple decision making model to approach and systematically manage patients presenting AAP in ED in the shortest possible time, limiting negative and expensive work-out. It was developed by experienced surgeons and emergency physicians based on daily clinical practice and reviewing available literature, considering all the aspects of clinical reasoning.

Conclusion (proposition de traduction) : Le programme d'enseignement médical universitaire doit être clairement défini afin de permettre une solide préparation des résidents, souvent seuls la nuit, et des médecins du service des urgences. L'objectif de la World Society of Emergency Surgeons est de révolutionner la formation académique traditionnelle des médecins. La théorie est importante en médecine, mais elle peut être différente de ce que l'on peut trouver en approche des patients tous les jours.
La World Society of Emergency Surgeons propose le cours Acute Abdomen Decision Making Course® (AADM) comme modèle de prise de décision efficace et simple pour aborder et gérer systématiquement les patients présentant des douleurs abdominales aiguës aux urgences dans les plus brefs délais, limitant ainsi l'entraînement négatif et coûteux. Il a été élaboré par des chirurgiens expérimentés et des urgentistes en fonction de la pratique clinique quotidienne et en examinant la documentation disponible, en tenant compte de tous les aspects du raisonnement clinique.

Emergency Medicine Journal (EMJ)

A simple clinical assessment is superior to systematic triage in prediction of mortality in the emergency department.
Iversen AKS, Kristensen M, Østervig RM, Køber L, Sölétormos G, Lundager Forberg J, Eugen-Olsen J, Rasmussen LS, Schou M, Iversen KK. | Emerg Med J. 2019 Feb;36(2):66-71
Keywords: death/mortality; emergency department; emergency department operations; emergency department utilisation; triage

Original articles

Introduction : To compare the Danish Emergency Process Triage (DEPT) with a quick clinical assessment (Eyeball triage) as predictors of short-term mortality in patients in the emergency department (ED).

Méthode : The investigation was designed as a prospective cohort study conducted at North Zealand University Hospital. All patient visits to the ED from September 2013 to December 2013 except minor injuries were included. DEPT was performed by nurses. Eyeball triage was a quick non-systematic clinical assessment based on patient appearance performed by phlebotomists. Both triage methods categorised patients as green (not urgent), yellow, orange or red (most urgent). Primary analysis assessed the association between triage level and 30-day mortality for each triage method. Secondary analyses investigated the relation between triage level and 48-hour mortality as well as the agreement between DEPT and Eyeball triage.

Résultats : A total of 6383 patient visits were included. DEPT was performed for 6290 (98.5%) and Eyeball triage for 6382 (~100%) of the patient visits. Only patients with both triage assessments were included. The hazard ratio (HR) for 48-hour mortality for patients categorised as yellow was 0.9 (95% CI 0.4 to 1.9) for DEPT compared with 4.2 (95% CI 1.2 to 14.6) for Eyeball triage (green is reference). For orange the HR for DEPT was 2.2 (95% CI 1.1 to 4.4) and 17.1 (95% CI 5.1 to 57.1) for Eyeball triage. For red the HR was 30.9 (95% CI 12.3 to 77.4) for DEPT and 128.7 (95% CI 37.9 to 436.8) for Eyeball triage. For 30-day mortality the HR for patients categorised as yellow was 1.7 (95% CI 1.2 to 2.4) for DEPT and 2.4 (95% CI 1.6 to 3.5) for Eyeball triage. For orange the HR was 2.6 (95% CI 1.8 to 3.6) for DEPT and 7.6 (95% CI 5.1 to 11.2) for Eyeball triage, and for red the HR was 19.1 (95% CI 10.4 to 35.2) for DEPT and 27.1 (95% CI 16.9 to 43.5) for Eyeball triage. Agreement between the two systems was poor (kappa 0.05).

Conclusion : Agreement between formalised triage and clinical assessment is poor. A simple clinical assessment by phlebotomists is superior to a formalised triage system to predict short-term mortality in ED patients.

Conclusion (proposition de traduction) : L'accord entre le triage formalisé et l'évaluation clinique est faible. Une évaluation clinique simple réalisée par des laborantin préleveur (phlébotomistes) est supérieure à un système de triage formalisé pour prédire la mortalité à court terme chez les patients du service des urgences.

Factors influencing variation in investigations after a negative CT brain scan in suspected subarachnoid haemorrhage: a qualitative study.
Chu K, Windsor C, Fox J, Howell T, Keijzers G, Eley R, Kinnear F, Furyk J, Thom O, Brown NJ, Brown AFT. | Emerg Med J. 2019 Feb;36(2):72-77
Keywords: clincial management; neurology, stroke; qualitative research

Original articles

Introduction : Variation in the approach to the patient with a possible subarachnoid haemorrhage (SAH) has been previously documented. The purpose of this study was to identify factors that influence emergency physicians' decisions about diagnostic testing after a normal CT brain scan for ED patients with a headache suspicious of a SAH.

Méthode : We conducted an interview-based qualitative study informed by social constructionist theory. Fifteen emergency physicians from six EDs across Queensland, Australia, underwent individual face-to-face or telephone interviews. Content analysis was performed whereby transcripts were examined and coded independently by two co-investigators, who then jointly agreed on the influencing factors.

Résultats : Six categories of influencing factors were identified. Patient interaction was at the forefront of the identified factors. This shared decision-making process incorporated 'what the patient wants' but may be biased by how the clinician communicates the benefits and harms of the diagnostic options to the patient. Patient risk profile, practice evidence and guidelines were also important. Other influencing factors included experiential factors of the clinician, consultation with colleagues and external influences where practice location and work processes impose constraints on test ordering external to the preferences of the clinician or patient. The six categories were organised within a conceptual framework comprising four components: the context, the evidence, the experience and the decision.

Conclusion : When clinicians are faced with a diagnostic challenge, such as the workup of a patient with suspected SAH, there are a number of influencing factors that can result in a variation in approach. These need to be considered in approaches to improve the appropriateness and consistency of medical care.

Conclusion (proposition de traduction) : Lorsque les cliniciens sont confrontés à un défi diagnostique, comme le bilan d'un patient chez qui l'on suspecte une hémorragie sous-arachnoïdienne, un certain nombre de facteurs influents peuvent entraîner une variation dans l'approche. Il faut en tenir compte dans les approches visant à améliorer la pertinence et l'uniformité des soins médicaux.

Commentaire : Les six catégories de facteurs influençant les investigation cliniques :

Prolonged length of stay in the emergency department and increased risk of hospital mortality in patients with sepsis requiring ICU admission.
Zhang Z, Bokhari F, Guo Y, Goyal H. | Emerg Med J. 2019 Feb;36(2):82-87
Keywords: clinical care; crowding; emergency care systems

Original articles

Introduction : Delayed patient admission to the intensive care unit (ICU) from the ED is common in China. Patients with severe sepsis or septic shock requiring ICU admission are in need of specialised monitoring and tailored treatment. Delayed admission to the ICU might be associated with adverse clinical outcomes for patients with sepsis.

Méthode : Patients with sepsis admitted to the ICU from the ED from January 2010 to April 2018 were retrospectively identified from a clinical data warehouse. The primary endpoint was in-hospital mortality. Length of stay in ED (EDLOS) was compared between survivors and non-survivors. A multivariable regression model was employed to adjust for potential confounding due to patient clinical condition.

Résultats : A total of 1997 patients, including 473 non-survivors and 1524 survivors, were included. The crude mortality rate for patients with EDLOS < 6 hours was 21.4%, which was significantly lower than patients with EDLOS of 12-24 hours (31.9%), and those with EDLOS > 24 hours (31.8%). After adjusting for PaO2/FiO2, serum creatinine, age, Sequential Organ Failure Assessment, body mass index, lactate, comorbidities and infection site, EDLOS continued to be independently associated with increased risk of hospital mortality. Compared with the group with EDLOS < 6 hours, those with EDLOS between 12 and 24 hours (OR 1.82, 95% CI 1.28 to 2.58) and EDLOS > 24 hours (OR 1.79, 95% CI 1.27 to 2.52) showed a significantly increased risk of death.

Conclusion : Our study shows that prolonged EDLOS is independently associated with increased risk of hospital mortality in patients with sepsis requiring ICU admission.

Conclusion (proposition de traduction) : Notre étude montre qu'une durée prolongée de séjour aux urgences est indépendamment associée à un risque accru de mortalité hospitalière chez les patients atteints de sepsis nécessitant une admission en USI.

Emergency medical services oxygen equipment: a fomite for transmission of MRSA?.
Gibson CV | Emerg Med J. 2019 Feb;36(2):89-91
Keywords: bacterial; first responders; infectious diseases; paramedics; prehospital care

Original articles

Introduction : The primary purpose of this study was to determine if methicillin-resistant Staphylococcus aureus (MRSA) was present on the surface of oxygen cylinders and regulators used in the prehospital setting and secondarily to assess other surfaces for MRSA within the ambulance compartment, as a comparison.

Méthode : On 17 March 2018, the surface of oxygen cylinders and regulators located in ambulances at an emergency medical services (EMS) station in North Alabama (n=9) and at an offsite oxygen cylinder storage area (n=70) were swabbed using sterile cotton-tipped applicators saturated in an 0.9% NaCl solution. These cotton-tipped applicators were then streaked across the surface of HardyCHROM MRSA plates, followed by incubation at 36°C for 24 hours. The growth of pink or magenta colonies was considered a positive indication for the presence of MRSA. The motivation for assessing oxygen cylinders at the offsite storage area was to outline the persistence of MRSA on stored oxygen cylinders.

Résultats : Of nine oxygen cylinders tested in the ambulances, nine had MRSA colonisation (100%). MRSA was also present on 67 of 70 oxygen cylinders (96%) tested at the offsite oxygen cylinder storage area.

Conclusion : Oxygen cylinders appear to act as a fomite for MRSA. The development of universal disinfection protocols for oxygen equipment could help reduce the risk of patient infection due to cross-contamination.

Conclusion (proposition de traduction) : Les bouteilles d'oxygène semblent agir comme un facteur de transmission pour le SARM. La mise au point de protocoles universels de désinfection des équipements à oxygène pourrait aider à réduire le risque d'infection du patient en raison d'une contamination croisée.

Approach to syncope in the emergency department.
Reed MJ | Emerg Med J. 2019 Feb;36(2):108-116
Keywords: cardiac care, diagnosis; emergency department


Editorial : Syncope is a common reason for ED attendance and it presents a major management challenge with regard to the appropriate workup and disposition. Nearly 50% of patients are admitted, and for many this is unnecessary; clinical decision rules have not proven to decrease unnecessary admissions. The European Society of Cardiology has recently developed guidance for managing syncope in the ED.

Conclusion : This article highlights the key steps in evaluating syncope in the ED, factors involved in determining risk of a cardiac cause, and considerations for admission, observation or discharge.

Conclusion (proposition de traduction) : Cet article met en évidence les étapes clés de l’évaluation de la syncope aux urgences, les facteurs intervenant dans la détermination du risque cardiaque, ainsi que les facteurs à prendre en compte pour l’admission, l’observation ou la sortie.

Commentaire : Syncope   (Guidelines on Diagnosis and Management of) - ESC Clinical Practice Guidelines

Safety and efficacy of low-dose ketamine versus opioids for acute pain management in the ED.
BinKharfi M, AlSagre A. | Emerg Med J. 2019 Feb;36(2):128-129
Keywords: abdomen


Editorial : A short cut review was carried out to establish whether low-dose ketamine is a safe and effective alternative to opioids in ED patients in acute severe pain. 76 papers were found using the reported searches, of which seven presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated.

Conclusion : It is concluded that low-dose ketamine can be an effective and safe alternative to opioids in acute pain management.

Conclusion (proposition de traduction) : Nous concluons que la kétamine à faible dose peut constituer une alternative efficace et sûre aux opioïdes dans le traitement de la douleur aiguë.

Commentaire : Articles complémentaires sur le sujet :
- Mahshidfar B and al. Acute Pain Management in Emergency Department, Low Dose Ketamine Versus Morphine, A Randomized Clinical Trial. Anesth Pain Med. 2017 Dec 26;7(6):e60561  .
- Beaudoin FL and al. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.Acad Emerg Med. 2014 Nov;21(11):1193-202  .

Emergency Radiology

Use of ultrasonography for differentiation between bullae and pneumothorax.
Karacabey S, Sanri E, Metin B, Erkoc F, Yildirim S, Intepe YS, Yalcinli S. | Emerg Radiol. 2019 Feb;26(1):15-19
Keywords: Bullae; Emergency; Pneumothorax; Ultrasonography

Original Article

Introduction : Modern lung ultrasound (US) is mainly applied not only in critical care, emergency medicine, and trauma surgery, but also in pulmonary and internal medicine. In some cases, pneumothorax (PTX) distinguishes with bullous diseases. In this study, we aimed to discuss the success of US on detecting PTX versus bullae.

Méthode : We performed a prospective blinded study. Patients underwent thorax computed tomography (CT) if bullae or pneumothorax could not be differentiated from the chest radiography. An emergency medicine specialist trained in lung US and unaware of x-ray and CT findings performed US. All patients US performed from anterior and lateral wall.

Résultats : Final study population included 81 patients. The sensitivity of the presence of pleural sliding in the diagnosis of bullae was 97.50% (86.84-99.94%), and specificity was 100.0% (91.4-100.0%).

Conclusion : In conclusion, direct visualisation of ultrasonographic pleural sliding can be a good tool for differentiating bullae and pneumothorax.

Conclusion (proposition de traduction) : En conclusion, la visualisation directe du glissement pleural échographique peut être un bon outil pour différencier les bulles et le pneumothorax.

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.  .

Computed tomography for suspected pulmonary embolism results in a large number of non-significant incidental findings and follow-up investigations.
Anjum O, Bleeker H, Ohle R. | Emerg Radiol. 2019 Feb;26(1):29-35
Keywords: Chest X-ray; Computed tomography; Incidental findings; Pulmonary embolism

Original Article

Introduction : Computed tomographic pulmonary angiograms (CTPAs) are often ordered to evaluate pulmonary embolism (PE) in the emergency department (ED). The increase use of CTPA has led to an increase in incidental findings, often of low clinical significance. Our objectives were to (1) assess the prevalence and clinical significance of incidental findings identified in patients evaluated with CTPAs for PE in the ED, (2) evaluate follow-up investigations for these incidental findings, and (3) assess the utility of routine chest X-rays done prior to CTPA.

Méthode : This is a historical cohort study of adult patients, presenting to two tertiary care EDs from January-December 2015, evaluated with CTPA for possible PE. Two reviewers' extracted data from electronic CT records in a standardized fashion with inter-rater reliability reported using the kappa statistic. We measured the prevalence of PE and stratified non-PE findings according to alternative diagnoses and incidental findings. Data were reported as mean and standard deviation (SD). Univariate analyses were performed with t test for continuous variables.

Résultats : A total of 1708 studies were included (mean 62 years (SD 16.7), 56.9% female). PE was found in 233 (13.6%) patients. A total of 223 (13.1%) patients had an incidental finding, the majority of which included pulmonary nodules (n = 83, 37.2%) and adenopathy (n = 26, 11.6%). Of the incidental findings, 197 (88.3%) were non-significant and led to no definitive diagnosis of cancer. In patients who underwent both CTPA and chest X-ray, X-ray reports revealed the same diagnosis in 77% of PE-negative patients without missing a clinically significant incidental finding.

Conclusion : Incidental findings are as common as a diagnosis of PE in patients undergoing CTPA. They are rarely clinically significant. Chest radiograph remains a reasonable initial investigation as it can aid in identifying alternative diagnoses especially in the setting of a low pre-test probability for PE.

Conclusion (proposition de traduction) : Les découvertes fortuites sont aussi fréquentes qu'un diagnostic d'embolie pulmonaire chez les patients qui subissent un angiogramme pulmonaire par tomodensitométrie. Ils sont rarement cliniquement significatifs. La radiographie pulmonaire demeure un examen initial raisonnable, car elle peut aider à identifier d'autres diagnostics, surtout si la probabilité d'une embolie pulmonaire est faible avant le test.

Abdominopelvic bleed rate on admission CT correlates with mortality and transfusion needs in the setting of blunt pelvic fractures: a single institution pilot study.
Borror W, Gaski GE, Steenburg S. | Emerg Radiol. 2019 Feb;26(1):37-44
Keywords: Active bleeding; Active extravasation; Blunt trauma; Emergency radiology; Hematoma; Pelvic fractures; Pelvis

Original Article

Introduction : The objectives of this study were to calculate the total volumetric rate of abdominopelvic bleeding in patients with acute pelvic fractures and examine the relationships between the bleeding rate, patient outcomes, and required patient interventions.

Méthode : This was a retrospective cohort study which included 29 patients from a 4-year period (May 2013 to May 2017). Patients with acute pelvic fractures and active bleeding detected on CT with two phases of imaging were included. Software was used to measure the volume of active bleeding on arterial and parenchymal phases. The active bleeding rate was calculated by dividing the change in active bleeding volume by the time between the two phases. The total volumetric bleed rate from all sites was then computed. Clinical variables were compared between survivors and non-survivors.

Résultats : Overall mortality in this cohort was 21% (n = 6). The mean abdominopelvic volumetric bleed rate in non-survivors was much greater than survivors (40.7 cc/min vs. 5.7 cc/min; p < 0.01). Ninety-six percent of survivors had an abdominopelvic bleed rate < 20 cc/min compared to 33% of non-survivors. An abdominopelvic bleed rate > 20 cc/min was associated with a mortality rate of 80% while a rate of < 20 cc/min was associated with a 92% survival rate. The mean pelvic hematoma volume was greater in non-survivors compared to survivors (1854 cc vs. 746 cc; p < 0.01). There was a positive association between hematoma volume and units of blood transfused (rs = 0.4, n = 29, p = 0.04).

Conclusion : An abdominopelvic bleeding rate > 20 cc/min was associated with a high risk of mortality.

Conclusion (proposition de traduction) : Un taux de saignement abdominopelvien > 20 cc/min a été associé à un risque élevé de mortalité.

European Journal of Emergency Medicine

High flow nasal cannula oxygen versus noninvasive ventilation in adult acute respiratory failure: a systematic review of randomized-controlled trials.
Beng Leong L, Wei Ming N, Wei Feng L. | Eur J Emerg Med. 2019 Feb;26(1):9-18
Keywords: Aucun


Editorial : We reviewed the use of noninvasive ventilation (NIV) versus high flow nasal cannula (HFNC) oxygen in adult acute respiratory failure (ARF). We searched major databases and included randomized trials comparing at least NIV with HFNC or NIV+HFNC with NIV in ARF. Primary outcomes included intubation/re-intubation rates. Secondary outcomes were ICU mortality and morbidities. Five trials were included; three compared HFNC with NIV, one compared HFNC, NIV and oxygen whereas one compared HFNC+NIV with NIV. Patients had hypoxaemic ARF (PaO2/FiO2≤300 mmHg). Heterogeneity prevented result pooling. Three and two studies had superiority and noninferiority design, respectively. Patients were postcardiothoracic surgery, mixed medical/surgical patients and those with pneumonia. Two trials were conducted after extubation, two before intubation and one during intubation. Three trials reported intubation/re-intubation rates as the primary outcomes. The other two trials reported the lowest peripheral capillary oxygen saturation readings during bronchoscopy or intubation. In the former three trials, the odds ratio for intubation/re-intubation rates between HFNC versus the NIV group ranged from 0.80 (95% confidence interval: 0.54-1.19) to 1.65 (95% confidence interval: 0.96-2.84). In the latter two trials, only one reported a difference in the lowest peripheral capillary oxygen saturation between NIV+HFNC versus the NIV group during intubation [100% (interquartile range: 95-100) vs. 96% (interquartile range: 92-99); P=0.029]. The secondary outcomes included differences in ICU mortality and patient tolerability, favouring HFNC. Results were conflicting, but highlighted future research directions. These include patients with hypercapneic ARF, more severe hypoxaemia (PaO2/FiO2≤200 mmHg), a superiority design, an oxygen arm and patient-centred outcomes.

Conclusion : There are conflicting results from RCTs investigating the effects of HFNC or HFNC + NIV versus NIV in acute hypoxaemic RF across diverse ICU patient populations. These conflicting results arise because of differences in patient populations, primary outcomes, trial design (superiority vs. noninferiority) as well as comparison arms. Despite these differences, HFNC is a viable option in patients with less severe hypoxaemic RF from pneu- monia and ARDS as well as patients at risk of post- extubation RF. The limitations of these studies also help to direct and fine-tune future research efforts involving HFNC to improve on the existing evidence base.

Conclusion (proposition de traduction) : Les résultats d'essais contrôlés randomisés portant sur les effets de l'oxygénothérapie à haut débit ou de l'oxygénothérapie à haut débit et de la ventilation non invasive par rapport à la ventilation non invasive en cas d'insuffisance respiratoire hypoxémique aiguë chez diverses populations de patients en USI sont contradictoires. Ces résultats contradictoires résultent de différences dans les populations de patients, les résultats principaux, la conception de l’essai (supériorité par rapport à la non infériorité) et les bras de comparaison. Malgré ces différences, une oxygénothérapie à haut débit est une option viable chez les patients présentant une insuffisance respiratoire hypoxémique moins grave due à une pneumonie et un syndrome de détresse respiratoire aiguë, ainsi que les patients présentant un risque d'insuffisance respiratoire post-extubation. Les limites de ces études permettent également d'orienter et d'affiner les efforts de recherche futurs impliquant une oxygénothérapie à haut débit afin d'améliorer la base de données existante.

The frequency, characteristics and aetiology of stroke mimic presentations: a narrative review.
McClelland G, Rodgers H, Flynn D, Price CI. | Eur J Emerg Med. 2019 Feb;26(1):2-8
Keywords: Aucun

Review articles

Editorial : A significant proportion of patients with acute stroke symptoms have an alternative 'mimic' diagnosis. A narrative review was carried out to explore the frequency, characteristics and aetiology of stroke mimics. Prehospital and thrombolysis-treated patients were described separately. Overall, 9972 studies were identified from the initial search and 79 studies were included with a median stroke mimic rate of 19% (range: 1-64%). The prehospital median was 27% (range: 4-43%) and the thrombolysis median 10% (range: 1-25%). Seizures, migraines and psychiatric disorders are the most frequently reported causes of stroke mimics. Several characteristics are consistently associated with stroke mimics; however, they do not fully exclude the possibility of stroke. Nineteen per cent of suspected stroke patients had a mimic condition. Stroke mimics were more common with younger age and female sex. The range of mimic diagnoses, a lack of clear differentiating characteristics and the short treatment window for ischaemic stroke create challenges for early identification.

Conclusion : Twenty-two per cent of all suspected stroke patients had an SM condition. SM patients included a higher pro- portion of females and tended to be younger than stroke patients. Many conditions present as SM, but seizures and migraines are the most frequent aetiologies. It is challenging to identify clinically useful characteristics that differentiate SM from stroke; however. a combina- tion of stroke and SM assessment tools during the acute phase of emergency stroke care might reduce the number of false positive identifications created by commonly used symptom checklists.

Conclusion (proposition de traduction) : Vingt-deux pour cent de tous les patients soupçonnés d'avoir fait un AVC avaient un tableau mimant un AVC. Les patients présentant un tableau mimant un AVC incluaient une proportion plus élevée de femmes et avaient tendance à être plus jeunes que les patients ayant fait un AVC. De nombreuses affections présentent les mêmes effets que les accidents vasculaires cérébraux, mais les étiologies les plus fréquentes sont les convulsions et les migraines. Il est difficile d'identifier des caractéristiques utiles sur le plan clinique qui différencient les effets d'imitation de l'AVC de ceux de l'AVC. Toutefois, une combinaison d'outils d'évaluation et d'accidents vasculaires cérébraux simulant les accidents vasculaires cérébraux au cours de la phase aiguë des soins d'urgence, pourrait réduire le nombre d'identifications faussement positives créées par les listes de vérification des symptômes couramment utilisées.


Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial.
Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J; The ANDROMEDA SHOCK Investigators and the Latin America Intensive Care Network (LIVEN), Hernández G, Ospina-Tascón G, Petri Damiani L, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M and al.. | JAMA. 2019 Feb 19;321(7):654-664
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction :  IMPORTANCE : Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established.
OBJECTIVE : To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality.

Méthode : DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018.
INTERVENTIONS : Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period.
MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay.

Résultats : Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed.

Conclusion : Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality.

Conclusion (proposition de traduction) : Chez les patients en choc septique, une stratégie de réanimation visant à normaliser le temps de remplissage capillaire, comparée à une stratégie visant les taux de lactate sérique, n'a pas permis de réduire la mortalité toutes causes confondues à 28 jours.

Commentaire : Voir l'analyse de l'article sur le site de la Société de Réanimation de Langue Française (SRLF) : Intérêt de l’évaluation clinique lors de la réanimation initiale des patients en choc septique  . Rédigé par le Dr G. Hariri et le Pr H. Ait-Oufella le 16/10/2019.

Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review.
Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, Pinto R, Simel DL, Wijeysundera DN, Scales DC. | JAMA. 2019 Feb 5;321(5):493-503
Keywords: Aucun

Introduction : Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.
OBJECTIVE : To identify risk factors and physical findings that predict difficult intubation.

Méthode : The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.
STUDY SELECTION: Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.
DATA EXTRACTION AND SYNTHESIS: Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.

Résultats : Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).

Conclusion : Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.

Conclusion (proposition de traduction) : Bien que plusieurs résultats cliniques simples soient utiles pour prédire une probabilité plus élevée d'intubation endotrachéale difficile, aucun résultat clinique n'exclut de manière fiable une intubation difficile.
Un test anormal de morsure de la lèvre supérieure, qui est facilement évalué par les cliniciens, augmente la probabilité d'une intubation difficile de 10 % à plus de 60 % pour le patient à risque moyen.

Commentaire : 
Score de Mallampati modifié : classe 1 : la luette et les loges amygdaliennes sont visibles ; classe 2 : la luette est partiellement visible ; classe 3 : le palais membraneux est visible ; classe 4 : seul le palais osseux est visible.

La valeur seuil de 2 (> 2) prédit une laryngoscopie difficile avec le score de Wilson (étendu du score de 0 à 10).

JAMA Internal Medicine

Association of Corticosteroid Treatment With Outcomes in Adult Patients With Sepsis: A Systematic Review and Meta-analysis.
Fang F, Zhang Y, Tang J, Lunsford LD, Li T, Tang R, He 1, Xu P, Faramand A, Xu J, You C. | JAMA Intern Med. 2019 Feb 1;179(2):213-223
Keywords: Aucun

Original Investigation

Introduction : Although corticosteroids are widely used for adults with sepsis, both the overall benefit and potential risks remain unclear.
OBJECTIVE: To conduct a systematic review and meta-analysis of the efficacy and safety of corticosteroids in patients with sepsis.

Méthode : MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until March 20, 2018, and updated on August 10, 2018. The terms corticosteroids, sepsis, septic shock, hydrocortisone, controlled trials, and randomized controlled trial were searched alone or in combination. Randomized clinical trials (RCTs) were included that compared administration of corticosteroids with placebo or standard supportive care in adults with sepsis.
DATA EXTRACTION AND SYNTHESIS: Meta-analyses were conducted using a random-effects model to calculate risk ratios (RRs) and mean differences (MDs) with corresponding 95% CIs. Two independent reviewers completed citation screening, data abstraction, and risk assessment.
MAIN OUTCOMES AND MEASURES: Twenty-eight-day mortality.

Résultats : This meta-analysis included 37 RCTs (N = 9564 patients). Eleven trials were rated as low risk of bias. Corticosteroid use was associated with reduced 28-day mortality (RR, 0.90; 95% CI, 0.82-0.98; I2 = 27%) and intensive care unit (ICU) mortality (RR, 0.85; 95% CI, 0.77-0.94; I2 = 0%) and in-hospital mortality (RR, 0.88; 95% CI, 0.79-0.99; I2 = 38%). Corticosteroids were significantly associated with increased shock reversal at day 7 (MD, 1.95; 95% CI, 0.80-3.11) and vasopressor-free days (MD, 1.95; 95% CI, 0.80-3.11) and with ICU length of stay (MD, -1.16; 95% CI, -2.12 to -0.20), the sequential organ failure assessment score at day 7 (MD, -1.38; 95% CI, -1.87 to -0.89), and time to resolution of shock (MD, -1.35; 95% CI, -1.78 to -0.91). However, corticosteroid use was associated with increased risk of hyperglycemia (RR, 1.19; 95% CI, 1.08-1.30) and hypernatremia (RR, 1.57; 95% CI, 1.24-1.99).

Conclusion : The findings suggest that administration of corticosteroids is associated with reduced 28-day mortality compared with placebo use or standard supportive care. More research is needed to associate personalized medicine with the corticosteroid treatment to select suitable patients who are more likely to show a benefit.

Conclusion (proposition de traduction) : Les conclusions suggèrent que l'administration de corticoïdes est associée à une réduction de la mortalité à 28 jours comparée à l'utilisation de placebo ou des soins standards. Des recherches supplémentaires sont nécessaires pour associer la médecine personnalisée au traitement par corticoïdes afin de sélectionner les patients les plus susceptibles de présenter un bénéfice.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : L’utilisation des corticoïdes au cours du sepsis apparaît incontournable  . Rédigé par le Dr Olivier Leroy.

JAMA Pediatrics

Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial.
Frey TM, Florin TA, Caruso M, Zhang N, Zhang Y, Mittiga MR. | JAMA Pediatr. 2019 Feb 1;173(2):140-146
Keywords: Aucun

Original Investigation

Introduction : Timely analgesia is critical for children with injuries presenting to the emergency department, yet pain control efforts are often inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Opioids are historically used for significant pain from traumatic injuries but have concerning adverse effects. Intranasal ketamine may provide an effective alternative.
OBJECTIVE: To determine whether intranasal ketamine is noninferior to intranasal fentanyl for pain reduction in children presenting with acute extremity injuries.

Méthode : The Pain Reduction With Intranasal Medications for Extremity Injuries (PRIME) trial was a double-blind, randomized, active-control, noninferiority trial in a pediatric, tertiary, level 1 trauma center. Participants were children aged 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries between March 2016 and February 2017. Analyses were intention to treat and began in May 2017.
INTERVENTIONS: Intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 µg/kg)..
MAIN OUTCOMES AND MEASURES: The primary outcome was reduction in visual analog scale pain score 30 minutes after intervention. The noninferiority margin for this outcome was 10.

Résultats : Of 90 children enrolled, 45 (50%) were allocated to ketamine (mean [SD] age, 11.8 [2.6] years; 26 boys [59%]) and 45 (50%) to fentanyl (mean [SD] age, 12.2 [2.3] years; 31 boys [74%]). Thirty minutes after medication, the mean visual analog scale reduction was 30.6 mm (95% CI, 25.4-35.8) for ketamine and 31.9 mm (95% CI, 26.6-37.2) for fentanyl. Ketamine was noninferior to fentanyl for pain reduction based on a 1-sided test of group difference less than the noninferiority margin, as the CIs crossed 0 but did not cross the prespecified noninferiority margin (difference in mean pain reduction between groups, 1.3; 90% CI, -6.2 to 8.7). The risk of adverse events was higher in the ketamine group (relative risk, 2.5; 95% CI, 1.5-4.0), but all events were minor and transient. Rescue analgesia was similar between groups (relative risk, 0.89; 95% CI, 0.5-1.6).

Conclusion : Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk.

Conclusion (proposition de traduction) : La kétamine fournit une analgésie efficace qui n'est pas inférieure au fentanyl, bien que les participants qui ont reçu de la kétamine aient présenté une augmentation d'événements indésirables mineurs et transitoires. La kétamine par voie intranasale peut constituer une alternative appropriée au fentanyl par voie intranasale pour le traitement de la douleur associée à des lésions aiguës des extrémités. La kétamine devrait être envisagée pour la gestion de la douleur chez les enfants en situation d'urgence, en particulier lorsque les opioïdes sont associés à un risque accru.

La Revue Sage-Femme

Hamdaoui N, Cardinale C, Agostini A. | Rev Sage-femme. 2019 February;18(1):52-59
Keywords: Emergency contraception; Unprotected intercourse; Post-coital copper intrauterine device; Ulipristal acetate; Levonorgestrel

Recommandations pour la pratique clinique

Introduction : Éditer, par le Collège national des gynécologues et obstétriciens français (CNGOF), des recommandations fondées sur les preuves disponibles dans la littérature pour l’utilisation en termes d’efficacité, de sécurité et d’effets secondaires de la contraception d’urgence (CU).

Méthode : Une revue de la littérature a été effectuée en consultant les données Medline, Cochrane Library et les recommandations internationales en langue française et anglaise du 1er janvier 1979 jusqu’au 1er mai 2018.

Résultats : Il est recommandé d’informer les patientes que la CU n’est pas efficace à 100 %. Un test de grossesse est recommandé en cas de retard de règles après prise d’une CU. Il est recommandé d’utiliser la CU le plus tôt possible après le rapport à risque. En l’absence de contraception au long cours, dans les 72 premières heures après le rapport sans protection, l’ulipristal acétate (UPA) ou le lévonorgestrel (LNG) peuvent être proposés avec une supériorité de l’UPA entre 0 et 72 h. Au-delà de 72 h, les données suggèrent une meilleure efficacité de l’UPA. Cependant, en prenant en compte des éléments pratiques (accès à la CU, coût, répercussions sur la prise d’une contraception hormonale après UPA), il est difficile de recommander l’UPA en priorité entre 0 et 72 h. Les menstruations sont plus susceptibles d’arriver précocement avec le LNG. Le DIU au cuivre est une méthode efficace et peut être utilisé en CU jusqu’à 120 h après un rapport sexuel non protégé ou en cas de risque d’échec d’une méthode contraceptive.

Conclusion (proposition de traduction) : La contraception d’urgence n’est pas efficace à 100 %. Plus la prise de la CU est proche du rapport à risque, plus elle est efficace en termes de taux de grossesse.

Commentaire : Pour consulter la Recommandations pour la pratique clinique - Contraception   - 2018.

Le Praticien en Anesthésie Réanimation

Léopolda V, Gayat E. | Prat Anesth Reanim. 2019 February;23(1):19-24
DOI:  | Télécharger l'article au format  
Keywords: Cardiogenic shock; Inotropes; Vasopressors

Mise au point

Editorial : Le choc cardiogénique est un état d’hypoperfusion associée à un débit cardiaque altéré dont le traitement pharmacologique repose sur l’association de vasopresseurs et d’inotropes. Malgré les effets bénéfiques sur la contractilité, les inotropes ont des effets indésirables. De nouvelles molécules (Levosimendan, Milrinone, Enomixone, Ivabradine) prometteuses par leur mode d’action semblent pallier certains de ces défauts. Par ailleurs, les molécules historiques (Dobutamine, Noradrénaline, Adrénaline) font et feront l’objet de nouvelles études dans le choc cardiogénique, et leur utilisation est amenée à changer.

Conclusion (proposition de traduction) : De manière générale, l’association d’un vasopresseur et d’un inotrope est préférable à l’utilisation d’un vasopresseur seul, en particulier si le volume d’éjection systolique, le débit cardiaque. D’autre part, les agents à effet pur (noradrénaline, dobutamine) devraient être privilégiés par rapport aux agents à effet combiné (adrénaline, dopamine) pour une meilleure titration des effets hémodynamiques et inotropes attendus. Une méta-analyse récente de la Cochrane Library a comparé les différents inotropes en termes de mortalité à court terme dans le choc cardiogénique. Les études randomisées contrôlées de bonne qualité portant sur des patients en choc cardiogénique sont rares, mais il semble que le levosimendan et la dobutamine aient des effets similaires dans cette indication, avec une possible superiorité du levosimendan sur la mortalité à court terme dans le choc cardiogénique (niveau de preuve bas). Une autre méta-analyse portant exclusivement sur les patients de chirurgie cardiaque retrouvait le même résultat. Concernant les vasopresseurs, la noradrénaline doit être préférée à l’adrénaline. L’adrénaline et la dopamine devraient être abandonnées dans le choc cardiogénique car ces molécules ont un effet délétère en terme de mortalité. Les recommandations de l’European Society of Cardiology (ESC) 2016 sur la prise en charge du choc cardiogénique vont dans ce sens : la noradrénaline doit être utilisée en priorité, après restauration d’une euvolémie. Si l’utilisation d’un inotrope est nécessaire, la dobutamine fait référence. Les inhibiteurs de phosphodiestérase III et le levosimendan ont une place marginale : il est recommandé de les utiliser chez les patients dont l’hypotension est en partie imputable à un traitement bêtabloquant, pour qui les catécholamines seraient inefficaces sur l’inotropisme. Enfin, ces recommandations ne retiennent pas d’indication à la dopamine ni à l’adrénaline. Un support circulatoire mécanique temporaire est recommandé en seconde intention, en cas de choc réfractaire au traitement médical, selon les comorbidités du patient. Le Ballon de contre pulsion intra-aortique (CPIA) n’est pas recommandé, devant l’absence d’efficacité démontré dans un essai randomisant 600 patients en choc cardiogénique post-infarctus (CPIA versus soins courants).

Pediatric Emergency Care

Intranasal Analgesia and Sedation in Pediatric Emergency Care-A Prospective Observational Study on the Implementation of an Institutional Protocol in a Tertiary Children's Hospital.
Nemeth M, Jacobsen N, Bantel C, Fieler M, Sümpelmann R, Eich C. | Pediatr Emerg Care. 2019 Feb;35(2):89-95
Keywords: Aucun

Original Articles

Introduction : Children presenting with acute traumatic pain or in need of therapeutic or diagnostic procedures require rapid and effective analgesia and/or sedation. Intranasal administration (INA) promises to be a reliable, minimally invasive delivery route. However, INA is still underused in Germany. We hence developed a protocol for acute pain therapy (APT) and urgent analgesia and/or sedation (UAS). Our aim was to evaluate the effectiveness and safety of our protocol.

Méthode : We performed a prospective observational study in a tertiary children's hospital in Germany. Pediatric patients aged 0 to 17 years requiring APT or UAS were included. Fentanyl, s-ketamine, midazolam, or combinations were delivered according to protocol. Primary outcome variables included quality of analgesia and/or sedation as measured on age-appropriate scales and time to onset of drug action. Secondary outcomes were adverse events and serious adverse events.

Résultats : One hundred pediatric patients aged 0.3 to 16 years were enrolled, 34 for APT and 66 for UAS. The median time onset of drug action was 5 minutes (ranging from 2 to 15 minutes). Fentanyl was most frequently used for APT (n = 19). Pain scores decreased by a median of 4 points (range, 0-10; P < 0.0001). For UAS, s-ketamine/midazolam was most frequently used (n = 25). Sedation score indicated minimal sedation in most cases. Overall success rate after the first attempt was 82%. Adverse events consisted of nasal burning (n = 2) and vomiting (n = 2). No serious adverse events were recorded.

Conclusion : A fentanyl-, s-ketamine-, and midazolam-based INA protocol was effective and safe for APT and UAS. It should then be considered where intravenous access is impossible or inappropriate.

Conclusion (proposition de traduction) : Un protocole d'administration intranasale à base de fentanyl, de s-kétamine et de midazolam s'est révélé efficace et sûr pour le traitement de la douleur aiguë et l'analgésie et/ou la sédation urgentes. Il faut alors l'envisager lorsque l'accès par voie intraveineuse est impossible ou inapproprié.

Provider Prediction of Disposition for Children With an Acute Exacerbation of Asthma Presenting to the Pediatric Emergency Department.
Caperell K, Pettigrew J, Gerughty A, Stevenson M. | Pediatr Emerg Care. 2019 Feb;35(2):108-111
Keywords: Aucun

Original articles

Introduction : The aim of this study was to evaluate the accuracy of the initial impression of emergency department providers on the disposition of children with asthma exacerbation.

Méthode : We conducted a prospective survey of physicians and other providers in the emergency department of a children's hospital and parents of children presenting with asthma exacerbation. The treating provider completed a survey after finishing the examination and immediately upon exiting the patient's room. Providers predicted the disposition of the child. Additionally, the providers indicated the likelihood of admission using several 10-cm visual analog scales (VASs). Physician accuracy was calculated, and logistic regression models and receiver operator characteristic curves were generated.

Résultats : Complete data were available for 177 subjects. Medical doctors/nurse practitioners made correct predictions in 129 (79.6%; 95% confidence interval [CI], 73.4-85.8) of 162 encounters. Respiratory therapists were correct in 69 (67.6%; 95% CI, 58.6%-76.7%) of 102 encounters, and parents were correct in 116 (67.4%; 95% CI, 60.4%-74.4%) of 172 encounters. Logistic regression with disposition as the dependent variable revealed that provider VAS for likelihood of admission (odds ratio, 23.717; 95% CI, 9.298-60.495) was associated with admission. A receiver operator characteristic curve generated for actual disposition versus "likelihood of admission" VAS had an area under the curve of 0.856 (95% CI, 0.793-0.919). For admission, a VAS of greater than 7 was 89.9% specific, greater than 7.6 was 92.9% specific, and greater than 8.6 was 96% specific.

Conclusion : Emergency department providers correctly predicted disposition 80% of the time. Providers were particularly likely to correctly predict admission. A VAS score of 7 or greater is nearly 90% specific for admission, with specificity increasing at higher values.

Conclusion (proposition de traduction) : Dans 80 % des cas, les professionnels de santé des services d'urgence ont correctement prédit les caractéristiques de la crise. Les prestataires étaient particulièrement susceptibles de prédire correctement l'admission. Un score d'échelle analogique visuelle de 7 ou plus est spécifique à près de 90 % pour l'admission, la spécificité augmentant à des valeurs plus élevées.

A Reexamination of the Accuracy of the Broselow Tape as an Instrument for Weight Estimation.
Waseem M, Chen J, Leber M, Giambrone AE, Gerber LM. | Pediatr Emerg Care. 2019 Feb;35(2):112-116
Keywords: Aucun

Original articles

Introduction : Accurate weight estimation is important for calculating appropriate medication dosages, determining rates of fluid replacement, and selecting correct equipment sizes in critically ill children requiring resuscitation. The actual measurement of the weight of a critically ill or injured child is often not possible. The Broselow Pediatric Emergency Tape (BT) is an important tool for predicting a child's weight based on his/her height. Although BT has previously been validated, given the increasing prevalence of obesity in today's society, it behooves clinicians relying on this resuscitation aid to revisit the issue.
OBJECTIVE: The aim of this study was to evaluate the accuracy of the color-coded BT in weight estimation and the influence of obesity on its accuracy.

Méthode : This is a retrospective study conducted in a pediatric clinic of urban hospital. This study reviewed the medical records of children up to 96 months of age, who presented during 2008-2010. We recorded the child's age (in months), actual (measured) weight (in kilograms), and height (in centimeters). Based on the height, weight estimation was obtained using the color-coded BT. The actual weight was compared with the predicted weight obtained by the height-based BT. Patients presenting with any medical condition that would substantially affect growth of the child were excluded. A univariate logistic regression model was utilized to predict any underestimation based on age, sex, and body mass index (BMI) percentile.

Résultats : he medical records of 538 children were reviewed. There was a discrepancy in 226 children (42%). Broselow Pediatric Emergency Tape underestimated weight (measured weight was higher than predicted weight) in 158 children (29.4%) and overestimated (measured weight was lower than predicted weight) in 68 children (12.6%). Of the 158 underestimated children, 138 were off by 1 color zone, 16 by 2 color zones, and 4 by more than 2 color zones. When characterized by BMI, 46 children (13.6%) had normal BMI, 27 (45.8%) were overweight, and 84 (80.8%) were obese, whereas one child (2.8%) was underweight.

Conclusion : In our population, BT was inaccurate in predicting weight in 42% of children (underestimation in 158 children [29.4%] and overestimation weight in 68 children [12.6%]). However, the majority of discrepancies involved only 1 BT color zone. Emergency physicians should be aware of this discrepancy until more accurate methods become available.

Conclusion (proposition de traduction) : Dans notre population, l’échelle de Broselow n'a pas prédit avec précision le poids chez 42 % des enfants (sous-estimation chez 158 enfants[29,4 %] et surestimation du poids chez 6 enfants[12,6 %]). Toutefois, la majorité des divergences ne concernaient qu'une seule zone de couleur de la « Broselow Pediatric Emergency Tape ». Les urgentistes devraient être au courant de cet écart jusqu'à ce que des méthodes plus précises soient disponibles.

Commentaire : L’échelle de Broselow (échelle visuelle de couleur) est utilisée dans l’élaboration des tableaux d’administration de médicaments.
Dans l'étude, elle sous-estime le poids de nombreux enfants en surpoids ou obèses, ce qui pourrait entraîner une sous-estimation des doses de médicaments de réanimation dans les situations d'urgence.
Les auteurs attirent l'attention des prescripteurs sur la nécessité d'envisager des ajustements lors de l'utilisation de cet outil de réanimation pédiatrique, en particulier chez les enfants obèses.
Consulter la méta-analyse de Wells M and al. The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide - A systematic review and meta-analysis. Resuscitation. 2017 Dec;121:9-33  
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Characterizing the Toxicity and Dose-Effect Profile of Tramadol Ingestions in Children.
Stassinos GL, Gonzales L, Klein-Schwartz W. | Pediatr Emerg Care. 2019 Feb;35(2):117-120
Keywords: Aucun

Original articles

Introduction : Tramadol can cause life-threatening toxicity in overdose; however, data on its toxicity in children are lacking. This study investigates toxicity associated with tramadol ingestions in children. The hypothesis is that children will experience dose-related central nervous system and respiratory depression and seizures.

Méthode : A retrospective evaluation of cases from the National Poison Center Data System between January 1, 2000, and December 31, 2013, was performed. Inclusion criteria were age below 6 years and single-substance acute tramadol ingestion. For dose-effect analysis, cases with sufficient dose quantity information were included.

Résultats : There were 7334 cases that met inclusion criteria. Outcomes were 84.8% no effect, 12.6% minor, 2.2% moderate, and 0.4% major effect. There was 1 fatality. Most of the children (36.4%) were treated/released from the emergency department; other management sites were home (36.4%), admission (5.9%), and others (3.2%). In the 1115 children with symptoms, drowsiness (N = 611) and vomiting (N = 178) occurred most frequently. More serious clinical effects included respiratory depression in 36 and seizures in 24 children. Of 2772 children with milligram dose recorded, there were 10 cases of respiratory depression and 6 of seizure. Median doses for respiratory depression and seizure were 225 (range, 50-600 mg) and 525 mg (range, 50-1050 mg), respectively. The minimum weight-based dose for respiratory depression/arrest was 7.9 mg/kg and for seizures, 4.8 mg/kg.

Conclusion : Seizure and respiratory depression are uncommon in pediatric tramadol ingestions. Given the small number of patients with dose data and lack of laboratory confirmation of dose, more studies are needed to determine the minimum dose at which medical management is recommended.

Conclusion (proposition de traduction) : Des convulsions et une dépression respiratoire sont rares chez les enfants qui ingèrent du tramadol. Étant donné le petit nombre de patients pour lesquels on dispose de données sur les doses et l'absence de confirmation de la dose en laboratoire, d'autres études sont nécessaires pour déterminer la dose minimale à laquelle la prise en charge médicale est recommandée.

Pain Assessment in Children Younger Than 8 Years in Out-of-Hospital Emergency Medicine: Reliability and Validity of EVENDOL Score.
Beltramini A, Galinski M, Chabernaud JL, Ruiz Almenar R, Tsapis M, Goddet NS, Kessous K, Falissard B, Fournier-Charrière E. | Pediatr Emerg Care. 2019 Feb;35(2):125-131
Keywords: Aucun

Original articles

Introduction : Pain in children is underestimated and undertreated in out-of-hospital emergency medicine. In this setting, caregivers need a reliable pain scale, but none has been validated. A single observational pain scale for all children younger than 8 years, EVENDOL, has been validated in emergency pediatric units. We study the feasibility of EVENDOL score in an out-of-hospital emergency setting.

Méthode : This prospective multicenter study included all conscious children younger than 8 years transported by a mobile intensive care unit between October 2008 and May 2010. The emergency physician and nurse independently assessed the child's pain using first a numeric rating scale (score 0-10), then the 5-item EVENDOL scale (verbal/vocal expression, facial expression, movements, postures, and relationship with entourage) (score 0-3/item) at 3 time points (at rest, during examination, and after analgesia). We studied the scale's internal validity, interrater reliability, discriminant ability (influence of fever and anxiety), and face validity.

Résultats : Of the 422 included children, 82 and 62 (29%-39%) were in pain according to the emergency physician and nurses (numeric rating scale >3/10). All EVENDOL scale attributes were satisfied at all 3 time points, for all population subsets. Values for the first assessment (entire study population) were as follows: internal validity (0.78-0.89), interrater reliability (r = 0.63-0.76, weighted κ = 0.49-0.65), construct validity, and discriminant ability (r = 0.6-0.7). Fever did not impact on EVENDOL score. Anxiety level and pain were correlated. Completion time was fast (mean, 2.3-3.4 minutes). Face validity was good.

Conclusion : EVENDOL is a quick, easy-to-use, discriminant instrument to assess pain in young children in out-of-hospital emergency settings.

Conclusion (proposition de traduction) : EVENDOL est un instrument rapide, facile à utiliser et discriminant pour évaluer la douleur chez les jeunes enfants dans les situations d'urgence extra-hospitalière.

Shock Index as a Predictor of Morbidity and Mortality in Pediatric Trauma Patients.
Strutt J, Flood A, Kharbanda AB. | Pediatr Emerg Care. 2019 Feb;35(2):132-137
Keywords: Aucun

Original articles

Introduction : Compared with unadjusted shock index (SI) (heart rate/systolic blood pressure), age-adjusted SI improves identification of negative outcomes after injury in pediatric patients. We aimed to further evaluate the utility of age-adjusted SI to predict negative outcomes in pediatric trauma.

Méthode : We performed an analysis of patients younger than 15 years using the National Trauma Data Bank. Elevated SI was defined as high normal heart rate divided by low-normal blood pressure for age. Our primary outcome measure was mortality. Secondary outcomes included need for a blood transfusion, ventilation, any operating room/interventional radiology procedures, and intensive care unit stay. Multiple logistic regressions were performed.

Résultats : Twenty-eight thousand seven hundred forty-one cases met the study criteria. The overall mortality rate was 0.7%, and 1.7% had an elevated SI. Patients with an elevated SI were more likely (P < 0.001) to require blood transfusion, ventilation, an operating room/interventional radiology procedure, or an intensive care unit stay. An elevated SI was the strongest predictor for mortality (odds ratio [OR] 22.0) in pediatric trauma patients compared with hypotension (OR, 12.6) and tachycardia (OR, 2.6).

Conclusion : Elevated SI is an accurate and specific predictor of morbidity and mortality in pediatric trauma patients and is superior to tachycardia or hypotension alone for predicting mortality.

Conclusion (proposition de traduction) : Un indice de choc élevé est un prédicteur précis et spécifique de la morbidité et de la mortalité chez les enfants traumatisés et est supérieur à la tachycardie ou à l'hypotension pour prédire la mortalité.

Commentaire : - Shock Index (SI) = Heart Rate/ Systolic Blood Pressure.
Une valeur > 0,8-0,9 est associée à une évolution péjorative.
Chez les patients adultes traumatisés, un SI > 0,9 fait prévoir une mortalité accrue à 24 heures.
- Consulter le Shock Index, Pediatric Age-Adjusted (SIPA) sur MDCalc  

Pulmonary Embolism in Children.
Navanandan N, Stein J, Mistry RD. | Pediatr Emerg Care. 2019 Feb;35(2):143-151
Keywords: Aucun

CME Review Article

Editorial : Pulmonary embolism is an uncommon but potentially life-threatening event in children. There has been increasing awareness of pulmonary embolism in children with improved survival in children with systemic disease and advancements in diagnostic modalities. However, literature regarding pulmonary embolism in children is sparse, and thus current guidelines for management of pulmonary embolism in children are extrapolated from adult literature and remain controversial. This article reviews the background and pathophysiology of venous thromboembolism, as well as current diagnostic approach and recommended management of pulmonary embolism in children.

Conclusion : There is greater awareness of PE in the pediatric population with improved survival in children with systemic disease and in- creasing use of central venous lines and oral contraceptives. The evaluation and management of PE in the pediatric population are challenging as available literature is sparse and current prac- tices are based on adult literature. While a validated pediatric- specific clinical prediction rule does not exist, a thorough risk assessment for PE should be performed in appropriate clinical settings to aid in the prompt diagnosis of PE in children. Clini- cians should also be aware of the risks and benefits of the different modalities that exist for evaluation of PE in children. While guidelines exist for the treatment of venous thromboem- bolism in children, providers should be aware that these guide- lines are based on data from adult literature. Thus, treatment should be based on the hemodynamic status and underlying dis- ease processes of the patient. Additional pediatric-specific litera- ture is necessary in the evaluation and management of PE in children in order to improve the care provided to this population.

Conclusion (proposition de traduction) : Il y a une plus grande prise de conscience de l'EP dans la population pédiatrique avec une amélioration de la survie chez les enfants atteints d'une maladie systémique et une augmentation de l'utilisation des cathéters veineux centraux et des contraceptifs oraux. L'évaluation et la prise en charge de l'EP dans la population pédiatrique représentent un défi, car la littérature disponible est rare et les pratiques actuelles sont fondées sur la littérature adulte. Bien qu'il n'existe pas de règle de prédiction clinique validée spécifique à l'enfant, une évaluation approfondie des risques d'EP devrait être effectuée dans un cadre clinique approprié pour faciliter le diagnostic rapide de l'EP chez les enfants. Les cliniciens devraient également être conscients des risques et des avantages des différentes modalités qui existent pour l'évaluation de l'EP chez les enfants.
Bien qu'il existe des lignes directrices pour le traitement de la thrombophlébite veineuse chez les enfants, les praticiens doivent savoir que ces lignes directrices sont fondées sur des données tirées de la littérature adulte. Ainsi, le traitement devrait être basé sur l'état hémodynamique et les processus de maladie sous-jacents du patient.
Une littérature supplémentaire spécifique à la pédiatrie est nécessaire dans l'évaluation et la gestion de l'EP chez les enfants afin d'améliorer les soins fournis à cette population.

The American Journal of Emergency Medicine

Gender-based outcome differences for emergency department presentation ofnon-STEMI acute coronary syndrome.
Langabeer JR 2nd, Champagne-Langabeer T, Fowler R, Henry T. | Am J Emerg Med. 2019 Feb;37(2):179-182
Keywords: Mortality; Myocardial infarction; NSTEMI; Outcomes; Sex

Original Contribution

Introduction : It is known that women generally have worse mortality outcomes than men with regards to ST-segment elevation myocardial infarction. However, less is known about contemporary gender differences in non-STEMI acute coronary syndrome, particularly those presenting to emergency departments within a regionalized system of care with standardized protocols.

Méthode : Retrospective registry data from 2010 to 2016 were examined from the North Texas Mission: Lifeline system of care, representing 33 hospitals around the Dallas Texas metropolitan area. We explored gender-based differences using multivariate logistic regression model, controlling for patient's age, baseline condition, and hospital factors.

Résultats : There were 16,861 patients who presented directly to emergency departments with NSTEMI, and 6513 (38.6%) were women. At baseline, women were older (68.04 vs. 63.7 years, p < 0.001) and presented with history of prior cardiovascular disease more often than men. Women had higher unadjusted in-hospital mortality rates than men (4.8% vs. 3.9%, p < 0.001), which persisted after controlling for patient age, comorbidities, and hospital factors. Women also had 23 min longer ED lengths of stay (p < 0.001) and were much less likely to receive an early invasive strategy (diagnostic coronary angiography within 24 h of arrival) than men (47.0% vs 54.4%, p < 0.001).

Conclusion : Emergency department NSTEMI protocols should consider potential gender disparities that exist for women. Overall, women had worse outcomes, which persist even in an urban system of care with standardized protocols.

Conclusion (proposition de traduction) : Les protocoles NSTEMI des services d'urgence devraient tenir compte des disparités potentielles entre les sexes qui existent pour les femmes. Dans l'ensemble, les résultats des femmes ont été pires, ce qui persiste même dans un système de soins en milieu urbain avec des protocoles normalisés.

Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department.
Scott NL, Klein LR, Cales E, Driver BE. | Am J Emerg Med. 2019 Feb;37(2):209-213
Keywords: Emergency department; Glucose; Hyperkalemia; Hypoglycemia; Insulin; Shifting

Original Contribution

Introduction : Complications associated with the emergency department (ED) management of hyperkalemia are not well characterized. The goals of this study were to describe the frequency of hypoglycemia following the use of insulin to shift potassium intracellularly and to examine the association of key variables with this complication.

Méthode : Adult ED patients (≥18 years old) with hyperkalemia (>5.3 mmol/L) were identified in the electronic medical record over a 5-year period at the study site. Patient characteristics, laboratory results, and treatments in the ED were captured. A generalized estimating equation (GEE) model was utilized to determine independent associations with the development of hypoglycemia.

Résultats : 1307 encounters were identified where hyperkalemia was present. Hypoglycemia (defined as a glucose <70 mg/dL) occurred in 68/409 (17%) of patients given insulin, compared to 4% of patients who did not receive insulin. Lower glucose prior to insulin (adjusted odds ratio [aOR] 0.90; 95% confidence interval [95% CI] 0.85 to 0.96), higher doses of insulin (aOR 1.07; 95% CI 1.01 to 1.15) and lower doses of D50 (aOR 0.98; 95% CI 0.97 to 0.99) were independently associated with hypoglycemia in the multivariate analysis. Age, history of diabetes, and history renal failure were not independently associated.

Conclusion : Hypoglycemia is a frequent complication of treatment with IV insulin in the ED. Interventions such as standardized protocols to assist with the ED management of hyperkalemia should be developed; their efficacy and safety should be compared.

Conclusion (proposition de traduction) : L’hypoglycémie est une complication fréquente du traitement par insuline IV aux urgences. Des interventions telles que des protocoles standardisés pour aider à la gestion de l'hyperkaliémie par les urgences devraient être développées ; leur efficacité et leur innocuité doivent être comparées.

Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial.
Motov S1, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. | Am J Emerg Med. 2019 Feb;37(2):220-227
Keywords: Analgesia; Emergency Department; Infusion; Ketamine

Original contribution

Introduction : We compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine (SDK) versus morphine in geriatric Emergency Department (ED) patients.

Méthode : This was a prospective, randomized, double-blind trial evaluating ED patients aged 65 and older experiencing moderate to severe acute abdominal, flank, musculoskeletal, or malignant pain. Patients were randomized to receive SDK at 0.3 mg/kg or morphine at 0.1 mg/kg by short intravenous infusion over 15 min. Evaluations occurred at 15, 30, 60, 90, and 120 min. Primary outcome was reduction in pain at 30 min. Secondary outcomes included overall rates of adverse effects and incidence of rescue analgesia.

Résultats : Thirty patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 9.0 versus 8.4 at baseline (mean difference 0.6; 95% CI -0.30 to 1.43) and 4.2 versus 4.4 at 30 min (mean difference -0.2; 95% CI -1.93 to1.46). Patients in the SDK group reported higher rates of psychoperceptual adverse effects at 15, 30, and 60 min post drug administration. Two patients in the ketamine group and one in the morphine group experienced brief desaturation episodes. There were no statistically significant differences with respect to changes in vital signs and need for rescue medication.

Conclusion : SDK administered at 0.3 mg/kg over 15 min provides analgesic efficacy comparable to morphine for short-term treatment of acute pain in the geriatric ED patients but results in higher rates of psychoperceptual adverse effects.

Conclusion (proposition de traduction) : La kétamine à dose sub-dissociative administré à la posologie de 0,3 mg/kg sur 15 minutes procure une efficacité analgésique comparable à celle de la morphine pour le traitement à court terme de la douleur aiguë chez les patients gériatriques des urgences, mais entraîne des taux plus élevés d'effets indésirables psycho-dysleptiques.

Safety and effectiveness of intranasal midazolam and fentanyl used in combination in the pediatric emergency department.
Ryan PM, Kienstra AJ, Cosgrove P, Vezzetti R, Wilkinson M. | Am J Emerg Med. 2019 Feb;37(2):237-240
Keywords: Aucun

Original contribution

Introduction : To examine the safety and effectiveness of intranasal midazolam and fentanyl used in combination for laceration repair in the pediatric emergency department.

Méthode : We performed a retrospective chart review of a random sample of 546 children less than 18 years of age who received both intranasal midazolam and fentanyl for laceration repair in the pediatric emergency department at a large, urban children's hospital. Records were reviewed from April 1, 2012 to June 31, 2015. The primary outcome measures were adverse events and failed laceration repair.

Résultats : Of the 546 subjects analyzed, 5.1% had multiple lacerations. Facial lacerations were the most common site representing 70.3%, followed by lacerations to the hand (9.9%) and leg (7.0%). The median length of lacerations was 1.5 cm [1.0-2.5]. The median dose of fentanyl was 2.0 μg/kg [1.9-2.0] and midazolam was 0.2 mg/kg [0.19-0.20]. There were no serious adverse events reported. The rate of minor side effects was 0.7% (95% CI 0.2% to 1.9%); 0.5% (95% CI 0.1% to 1.6%) experienced anxiety and 0.2% (95% CI 0.0% to 1.0%) vomited. No patients developed hypotension or hypoxia. Of the 546 patients, 2.4% (95% CI 1.3% to 4.0%) experienced a treatment failure. 2.0% (95% CI 1.3% to 4.0%) required IV sedation and 0.4% (95% CI 0.0% to 1.3%) were repaired in the operating room.

Conclusion : Our results suggest that the combination of INM and INF may be a safe and effective strategy for procedural sedation in young children undergoing simple laceration repair.

Conclusion (proposition de traduction) : Nos résultats suggèrent que la combinaison de midazolam et de fentanyl par voie intranasale pourrait constituer une stratégie sûre et efficace de sédation procédurale chez les jeunes enfants pour le traitement d'une plaie simple.

Association of the time to first epinephrine administration and outcomes in out-of-hospital cardiac arrest: SOS-KANTO 2012 study.
Homma Y, Shiga T, Funakoshi H, Miyazaki D, Sakurai A, Tahara Y, Nagao K, Yonemoto N, Yaguchi A, Morimura N; SOS-KANTO 2012 Study Group. | Am J Emerg Med. 2019 Feb;37(2):241-248
Keywords: Advanced cardiac life support; Cardiopulmonary resuscitation; Emergency medical services; Epinephrine; Heart arrest; Out-of-hospital cardiac arrest

Original contribution

Introduction : This study assessed the association between the timing of first epinephrine administration (EA) and the neurological outcomes following out-of-hospital cardiac arrests (OHCAs) with both initial shockable and non-shockable rhythms.

Méthode : This was a post-hoc analysis of a multicenter prospective cohort study (SOS-KANTO 2012), which registered OHCA patients in the Kanto region of Japan from January 2012 to March 2013. We included consecutive adult OHCA patients who received epinephrine. The primary result included 1-month favorable neurological outcomes defined as cerebral performance category (CPC) 1 or 2. Secondary results included 1-month survival and return of spontaneous circulation (ROSC) after arrival at the hospital. Multivariable logistic regression analysis determined the association between delay per minute of the time from call to first EA in both pre- or in-hospital settings and outcomes.

Résultats : Of the 16,452 patients, 9344 were eligible for our analyses. In univariable analysis, the delay in EA was associated with decreased favorable neurological outcomes only when the initial rhythm was a non-shockable rhythm. In multivariable analyses, delay in EA was associated with decreased ROSC (adjusted odds ratio [OR] for one minute delay, 0.97; 95% confidence interval [CI], 0.96-0.98) and 1-month survival (adjusted OR, 0.95; 95% CI, 0.92-0.97) when the initial rhythm was a non-shockable rhythm, whereas during a shockable rhythm, delay in EA was not associated with decreased ROSC and 1-month survival.

Conclusion : While assessing the effectiveness of epinephrine for OHCA, we should consider the time-limited effects of epinephrine. Additionally, consideration of early EA based on the pathophysiology is needed.

Conclusion (proposition de traduction) : Lors de l'évaluation de l'efficacité de l'épinéphrine en cas d'arrêt cardiaque extra-hospitalier, nous devrions tenir compte des effets limités dans le temps de l'épinéphrine. De plus, il faut envisager l'administration précoce d'épinéphrine en fonction de la pathophysiologie.

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study.
Siriwardena AN, Siriwardena AN, Asghar Z, Lord B, Pocock H, Phung VH, Foster T, Williams J, Snooks H. | Am J Emerg Med. 2019 Feb;37(2):266-271
Keywords: Analgesia, pain, paramedic, ambulance; Emergency medical services; Prehospital

Original contribution

Introduction : We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation.

Méthode : We used a cross-sectional design with a 7-day retrospective sample of adults aged 18 years or over requiring primary emergency transport to hospital, excluding patients with Glasgow Coma Scale below 13, in two UK ambulance services. Multivariate multilevel regression using Stata 14 analysed factors independently associated with analgesic administration and a clinically meaningful reduction in pain (≥2 points on 0-10 numerical verbal pain score [NVPS]).

Résultats : We included data on 9574 patients. At least two pain scores were recorded in 4773 (49.9%) patients. For all models fitted there was no significant relationship between analgesic administration or pain reduction and sex of the patient or ambulance staff. Reduction in pain (NVPS ≥2) was associated with ambulance crews including at least one paramedic (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14 to 2.04, p < 0.01), with any recorded pain score and suspected cardiac pain (OR 2.2, 95% CI 1.02 to 4.75). Intravenous morphine administration was also more likely where crews included a paramedic (OR 2.82, 95% CI 1.93 to 4.13, P < 0.01), attending patients aged 51 to 64 years (OR 2.04, 95% CI 1.21 to 3.45, p = 0.01), in moderate to severe (NVPS 4-10) compared with lower levels of pain for any clinical condition group compared with the reference condition.

Conclusion : There was no association between patient sex or ambulance staff sex or grade and analgesic administration or pain reduction.

Conclusion (proposition de traduction) : Il n'y avait pas d'association entre le sexe du patient ou le sexe ou le grade du personnel ambulancier et l'administration d'analgésique ou la réduction de la douleur.

Procalcitonin as a diagnostic marker for sepsis/septic shock in the emergency department; a study based on Sepsis-3 definition.
Kim SJ, Hwang SO, Kim YW, Lee JH, Cha KC. | Am J Emerg Med. 2019 Feb;37(2):272-276
Keywords: Biomarkers; Emergency department; Sepsis

Original contribution

Introduction : The recent definition of sepsis was modified based on a scoring system focused on organ failure (Sepsis-3). It would be a time-consuming process to detect the sepsis patient using Sepsis-3. Procalcitonin (PCT) is a well-known biomarker for diagnosing sepsis/septic shock and monitoring the efficacy of treatment. We conducted a study to verify the predictability of PCT for diagnosing sepsis based on Sepsis-3 definition.

Méthode : This is a retrospective cohort study. The patients whose PCT was measured on the emergency department (ED) arrival and had final diagnosis related infection were enrolled. The patients were categorized by infection, sepsis, or septic shock followed by Sepsis-3 definition. "Pre-septic shock" was defined when a patient was initially diagnosed with sepsis, following which his/her mean arterial blood pressure decreased to under 65 mmHg refractory to fluid resuscitation and there was need for vasopressor use during ED admission. Receiver operating characteristics (ROC) curve and area under the curve (AUC) analysis were performed to verify sensitivity and specificity of PCT.

Résultats : 866 patients were enrolled in the final analysis. There are 287 cases of infection, 470 cases of sepsis, and 109 cases of septic shock. An optimal cutoff value for diagnosing sepsis was 0.41 ng/dL (sensitivity: 74.8% and specificity: 63.8%; AUC: 0745), septic shock was 4.7 ng/dL (sensitivity: 66.1% and specificity: 79.0%; AUC: 0.784), and "pre-septic shock" was 2.48 ng/dL (sensitivity: 72.8%, specificity: 72.8%, AUC: 0.781), respectively.

Conclusion : PCT is a reliable biomarker to predict sepsis or septic shock according to the Sepsis-3 definitions.

Conclusion (proposition de traduction) : La procalcitonine est un biomarqueur fiable permettant de prédire le sepsie ou le choc septique selon les définitions Sepsis-3.

Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage.
Jeong N, Kim KS, Jung YS, Kim T, Shin SM. | Am J Emerg Med. 2019 Feb;37(2):277-280
Keywords: Endoscopy; Gastrointestinal hemorrhage; Mortality

Original contribution

Introduction : To determine the association between delayed (>24 h) endoscopy and hospital mortality in patients with upper gastrointestinal hemorrhage (UGIH).

Méthode : We retrospectively analyzed all adult patients with UGIH who underwent endoscopy in a single emergency room for 2 years. The primary exposure was defined as >24 h from the ED visit to the first endoscopy. The primary outcome was defined as all cause hospital mortality. Secondary outcomes were intensive care unit admission rate, ED length of stay, and hospital length of stay.

Résultats : Among 1101 patients enrolled, 898 received endoscopy within 24 h (early group) and 203 received endoscopy after 24 h (delayed group). The hospital mortality of early and delayed group was 2.8% and 6.4%, respectively (unadjusted relative risk [RR] 2.30: 95% CI, 1.20-4.42, p = 0.012). This was significant after adjusting covariates including AIMS65 and Glasgow-Blatchford score (adjusted RR 2.23: 95% CI, 1.18-4.20, p = 0.013). Intensive care unit admission rate was not different between two groups. ED and hospital length of stay were significantly longer in delayed group.

Conclusion : Endoscopy performed after 24 h was associated with increased hospital mortality in UGIH. Patients in the delayed group stayed longer in the ED and in the hospital.

Conclusion (proposition de traduction) : L'endoscopie effectuée après 24 h a été associée à une augmentation de la mortalité hospitalière dans l'hémorragie gastro-intestinale haute. Les patients du groupe retardé sont restés plus longtemps aux urgences et à l'hôpital.

Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath.
Buhumaid RE, St-Cyr Bourque J, Shokoohi H, Ma IWY, Longacre M, Liteplo AS. | Am J Emerg Med. 2019 Feb;37(2):298-303
Keywords: Aucun

Brief reports

Introduction : The differential diagnoses of patients presenting with chest pain (CP) and shortness of breath (SOB) are broad and non-specific. We aimed to 1) determine how use of point-of-care ultrasound (POCUS) impacted emergency physicians' differential diagnosis, and 2) evaluate the accuracy of POCUS when compared to chest radiograph (CXR) and composite final diagnosis.

Méthode : We conducted a prospective observational study in a convenience sample of patients presenting with CP and SOB to the Emergency Department (ED). Treating physicians selected possible diagnoses from a pre-indexed list of possible diagnoses of causes of CP and SOB. The final composite diagnosis from a chart review was determined as the reference standard for the diagnosis. The primary analysis involved calculations of sensitivity and specificity for POCUS identifiable diagnoses in detecting cause of CP and SOB. Additional comparative accuracy analysis with CXRs were conducted.

Résultats : 128 patients with a mean age of 64 ± 17 years were included in the study. Using a reference standard of composite final diagnoses, POCUS had equal or higher specificity to CXR for all indications for which it was used, except for pneumonia. POCUS correctly identified all patients with pneumothorax, pleural effusion and pericardial effusion. In patients with a normal thoracic ultrasound, CXR never provided any actionable clinical information. Adding POCUS to the initial evaluation causes a significant narrowing of the differential diagnoses in which the median differential diagnosis from 5 (IQR 3-6) to 3 (IQR 2-4) p < 0.001.

Conclusion : In evaluation of patients with CP and SOB, POCUS is a highly feasible diagnostic test which can assist in narrowing down the differential diagnoses. In patients with a normal thoracic ultrasound, the added value of a CXR may be minimal.

Conclusion (proposition de traduction) : Dans l'évaluation des patients souffrant de douleurs thoraciques et de dyspnée, l'échographie au point d'intervention est un test diagnostique hautement faisable qui peut aider à réduire le nombre de diagnostics différentiels. Chez les patients ayant une échographie thoracique normale, la valeur ajoutée d'une radiographie pulmonaire peut être minime.

Central venous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients.
Pare JR, Pollock SE, Liu JH, Leo MM, Nelson KP. | Am J Emerg Med. 2019 Feb;37(2):317-320
Keywords: Central venous catheter; Difficult vascular access; Intravenous access failure; Ultrasound guided intravenous catheter

brief reports

Introduction : Ultrasound guided peripheral intravenous catheters (USPIV) are frequently utilized in the Emergency Department (ED) and lead to reduced central venous catheter (CVC) placements. USPIVs, however, are reported to have high failure rates. Our primary objective was to determine the proportion of patients that required CVC after USPIV. Our secondary objective was to determine if classic risk factors for difficult vascular access were predictive of future CVC placement.

Méthode : We performed a retrospective review for patients treated at a large academic hospital. Patients were identified by electronic health record and were restricted to age older than 21 years, had received USPIV, and admittance. Exclusion criteria included an existing CVC. Descriptive statistics, t-tests, chi-square proportions, and logistic regression were performed to test associations.

Résultats : Of 363 eligible patients, 20 were excluded allowing for 343 for analysis. Of 343, 45 (13.1% 95% CI 9.9-17.1%) required CVC after USPIV. For secondary outcomes, no expected characteristics (diabetes, end-stage renal disease, IV drug abuse, peripheral vascular disease, or sickle cell disease) were predictive of CVC placement. The only predictive variables were admission to ICU/stepdown and length of stay. Each additional day of hospitalization had an OR 1.11 (95% CI 1.06-1.16%) of having a CVC placed.

Conclusion : Of those admitted after USPIV placement, approximately 7 out of every 8 patients did not require a subsequent CVC. Of the nearly 1 in 8 patients that required a CVC, factors associated with CVC placement were admission to a higher level of care and length of stay.

Conclusion (proposition de traduction) : Parmi les patients admis après la pose de cathéters intraveineux périphériques guidés par échographie, environ 7 patients sur 8 n'ont pas eu besoin d'un cathéter veineux central ultérieur. Sur près d'un patient sur huit ayant eu besoin d'un cathéter veineux central, les facteurs associés au placement du cathéter veineux central étaient l'admission à un niveau de soins plus élevé et la durée du séjour.

Acute liver failure: A review for emergency physicians.
Montrief T, Koyfman A, Long B. | Am J Emerg Med. 2019 Feb;37(2):329-337
Keywords: Acute liver failure; Liver function; Transplantation


Introduction : Acute liver failure (ALF) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization.

Méthode : This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of ALF.

Résultats : While ALF remains a rare clinical presentation, surveillance data suggest an overall incidence between 1 and 6 cases per million people every year, accounting for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the U.S. The definition of ALF includes neurologic dysfunction, an international normalized ratio ≥ 1.5, no prior evidence of liver disease, and a disease course of ≤26 weeks, and can be further divided into hyperacute, acute, and subacute presentations. There are many underlying etiologies, including acetaminophen toxicity, drug induced liver injury, and hepatitis. Emergency physicians will be faced with several complications, including encephalopathy, coagulopathy, infectious processes, renal injury, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the transplant team for appropriate patients improves patient outcomes. This review provides several guiding principles for management of acute complications. Using a pathophysiological-guided approach to the management of ALF associated complications is essential to optimizing patient care.

Conclusion : ALF remains a rare clinical presentation, but has significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with a transplantation center is imperative, as is identifying the underlying etiology and initiating symptomatic care.

Conclusion (proposition de traduction) : L'insuffisance hépatique aiguë demeure une manifestation clinique rare, mais sa morbidité et sa mortalité sont importantes. Les médecins doivent diagnostiquer rapidement ces patients tout en évaluant d'autres maladies et complications. Une consultation précoce avec un centre de transplantation est impérative, de même que l'identification de l'étiologie sous-jacente et l'initiation des soins symptomatiques.

The British Medical Journal

Give us a break.
Chatfield C, Rimmer A. | BMJ. 2019 Feb 6;364:l481
Keywords: Aucun


Editorial : Have you ever worked a whole shift without a toilet break? Or worked through your morning session into lunchtime and beyond without stopping to eat? Or got into your car at the end of a night shift and wondered how you were going to drive home safely? The chances are that you have. These are not unusual scenarios for doctors working in the NHS or any other overstretched health system. Worryingly, for some staff these scenarios have become the norm. This is not acceptable. Missing essential breaks is bad for doctors and their patients.

Conclusion : Lack of facilities is not the only problem. A recent investigation by the Health Service Journal found that since August 2016, 63 309 exception reports—which allow junior doctors to report concerns about their working hours—have been made by nearly 36 000 doctors. Although these figures don’t tell the whole story, they show that junior members of the team are often not able to take the breaks that they need or to finish work when they should. Similar concerns have been raised in primary care, where workload pressures prevent GPs from taking the breaks that they need. Although workload and a lack of designated spaces make it hard for doctors to take breaks, doctors must also shoulder some of the responsibility. In its report on what could make a difference to the mental health of UK doctors, the Society of Occupational Medicine called on employers to consider the need for doctors to take regular breaks. However, it also stressed that doctors were responsible for prioritising self care.

Conclusion (proposition de traduction) : Bien que la charge de travail et le manque d’espaces réservés empêchent les médecins de prendre des pauses, ils doivent également assumer une partie de la responsabilité. Dans son rapport sur ce qui pourrait améliorer la santé mentale des médecins britanniques, la Society of Occupational Medicine a appelé les employeurs à envisager la nécessité pour les médecins de prendre des pauses régulières. Cependant, il a également souligné que les médecins étaient responsables en priorité des soins à eux-mêmes.

The Journal of Emergency Medicine

Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study).
Kramer A, Urban N, Döll S, Hartwig T, Yahiaoui-Doktor M, Burkhardt R, Petros S, Gries A, Bernhard M. | J Emerg Med. 2019 Feb;56(2):135-144
Keywords: emergency department; lactate; lactate-clearance; lactate-dynamics; mortality; non-traumatic critically ill patients; resuscitation room

Original Contributions

Introduction : Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes.
OBJECTIVE: As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients.

Méthode : In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (LacTW) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission.

Résultats : The admission lactate, LacTW, and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and LacTW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and LacTW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ.

Conclusion : In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and LacTW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design.

Conclusion (proposition de traduction) : Chez les patients gravement malades au service des urgences nécessitant initialement un traitement en salle de réanimation, la dynamique du lactate à 6 h et la moyenne du lactate pondérée dans le temps peuvent prédire leur survie au-delà de 30 jours. Ces résultats doivent être confirmés dans une étude prospective.

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging.
VandenBerg J, Cullison K, Fowler SA, Parsons MS, McAndrew CM, Carpenter CR. | J Emerg Med. 2019 Feb;56(2):153-165
Keywords: blunt trauma; computed tomography; diagnostic imaging; radiography; spine trauma

Clinical Reviews in Emergency Medicine

Introduction : Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging.
OBJECTIVE: Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients.

Méthode : A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios.

Résultats : In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I2 = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I2 = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I2 = 23%; p = 0.26).

Conclusion : CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.

Conclusion (proposition de traduction) : Le scanner est plus précis que les clichés standard pour détecter les fractures du rachis dorso-lombaire.
Le mécanisme de lésion, l'examen clinique et les lésions associées ne permettent pas à eux seuls d'exclure ou de confirmer une fracture du rachis dorso-lombaire.

The Potential Role of Ultrasound in the Work-up of Appendicitis in the Emergency Department.
Tyler PD, Carey J, Stashko E, Levenson RB, Shapiro NI, Rosen CL. | J Emerg Med. 2019 Feb;56(2):191-196
Keywords: acute appendicitis; emergency department; ultrasound

Ultrasound in Emergency Medicine

Introduction : Acute appendicitis is common in the adult emergency department (ED). Computed tomography (CT) scan is frequently used to diagnose this condition, but ultrasound (US)-commonly used in pediatric diagnosis-may also have a role.
OBJECTIVES: Review the clinical utility and define the frequency and diagnostic accuracy of US to diagnose appendicitis in an adult population in the ED setting.

Méthode : Retrospective cohort study of patients who underwent appendiceal US in an academic, tertiary ED from July 2013-October 2015.

Résultats : There were 174 patients included, of which 39 (22%) had pathology-confirmed appendicitis. There were 25 patients who had an US scan that was positive for appendicitis, 146 (84%) were indeterminate, and 3 (1.7%) were negative. Among patients with a positive US, 25/25 (100%, 95% confidence interval [CI] 84-100%) had appendicitis, 32/146 (22%, 95% CI 16-29%) with an indeterminate US had appendicitis, and 0/3 (0%, 95% CI 0-6.2%) with a negative US had appendicitis. In the 28 definitive cases, US had a sensitivity of 64%, specificity of 2%, positive predictive value of 100%, and negative predictive value of 100%. The likelihood ratio positive and negative were 173 and 0, respectively.

Conclusion : Our initial data suggest that an US that shows appendicitis seems to be reliable; however, a high prevalence of indeterminate studies limits the diagnostic utility as a universal approach in adult patients in the ED setting. Larger studies are needed to identify which patient populations would benefit from US as the initial imaging modality, what factors contribute to the large numbers of indeterminate results, and if any interventions may reduce the number of indeterminate results.

Conclusion (proposition de traduction) : Nos données initiales suggèrent qu'une échographie montrant une appendicite semble être fiable; cependant, une prévalence élevée d'études indéterminées limite l'utilité diagnostique en tant qu'approche universelle chez les patients adultes dans le service des urgences.
Des études plus importantes sont nécessaires pour identifier les populations de patients qui bénéficieraient de l'échographie en tant que modalité d'imagerie initiale, quels facteurs contribuent au grand nombre de résultats indéterminés et, le cas échéant, des interventions permettant de réduire le nombre de résultats indéterminés.

The Elbow Technique: A Novel Reduction Technique for Anterior Shoulder Dislocations.
Lo H, Shen PY, Shen PC, Chou PH, Lu CC. | J Emerg Med. 2019 Feb;56(2):201-204
Keywords: humerus; orthopaedic; shoulder dislocations; shoulder injury

Techniques and Procedures

Introduction : Anterior dislocation of the glenohumeral joint is a common upper extremity injury in orthopedic and emergency medicine. The aim of this study was to introduce a novel reduction technique, "elbow technique," for anterior shoulder dislocations.

Discussion : This study included 26 patients with anterior shoulder dislocation who were treated using the elbow technique in our hospital's emergency department between October 2014 and December 2015. One orthopedic physician performed the reduction maneuver and the vast majority of the patients were sedated. Patients who presented with posterior shoulder dislocation, remained dislocated for more than 7 days, who had Neer three or four parts proximal humerus fractures, and who had received previous shoulder surgery were excluded from this study. Twenty-one dislocations (80% of the patients) were primary. Six patients (23% of the dislocations) had associated fractures of the greater tuberosity. All of the patients were successfully reduced with the elbow technique. Mean time for reduction was 5 s (range 3-69 s). No iatrogenic fractures or neurovascular injuries were noted after the reductions.

Conclusion : The elbow technique involves traction, leverage, pulsion, and can be performed by a single operator. The elbow technique is a safe, elegant, simple, effective, fast, and gentle reduction procedure for anterior shoulder dislocations in the emergency department.

Conclusion (proposition de traduction) : La technique du coude implique traction, effet de levier, pulsion et peut être réalisée par un seul opérateur. La technique du coude est une procédure de réduction sûre, élégante, simple, efficace, rapide et douce des luxations antérieures de l'épaule aux urgences.

Commentaire : La technique « Elbow »
La technique « Elbow ». (A, B) L'opérateur tient le poignet du patient avec sa main extérieure et applique une force de traction douce pour maintenir le coude en extension (flèche droite). Une force de rotation peut être obtenue en tournant le poignet du patient, ce qui entraîne une rotation de l'avant-bras et de l'épaule (flèche courbe). (C, D) Avec la surface latérale du coude de l'opérateur, une force s'exerce sur la diaphyse de l'humérus du patient (flèche droite). En allongeant le bras de levier (D), le moment de force est augmenté, ce qui permet à la tête humérale de glisser plus facilement dans la glène humérale. (E) La force de réduction peut pousser la tête humérale vers l'arrière, vers le haut et latéralement dans la glène humérale.

The Journal of the American Medical Association

Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review.
Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, Pinto R, Simel DL, Wijeysundera DN, Scales DC. | JAMA. 2019 Feb 5;321(5):493-503
Keywords: Aucun

The Rational Clinical Examination

Introduction : Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.
OBJECTIVE: To identify risk factors and physical findings that predict difficult intubation.

Méthode : The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.
STUDY SELECTION: Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.
DATA EXTRACTION AND SYNTHESIS: Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.

Résultats : Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).

Conclusion : Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.

Conclusion (proposition de traduction) : Bien que plusieurs résultats cliniques simples soient utiles pour prédire une probabilité plus élevée d'intubation endotrachéale difficile, aucun résultat clinique n'exclut de manière fiable une intubation difficile. Un test anormal d'occlusion de la lèvre supérieure, facile à évaluer par les cliniciens, augmente la probabilité d'une intubation difficile de 10 % à plus de 60 % chez le patient à risque moyen.

Commentaire : Le test de morsure de la lèvre supérieure consiste à demander aux patients de se mordre la lèvre supérieure avec les incisives inférieures. Les résultats sont classés comme suit :
classe 1, les incisives inférieures s'étendent au-delà du bord vermillon de la lèvre supérieure ;
classe 2, les incisives inférieures mordent la lèvre mais ne peuvent pas dépasser la limite vermillon ;
classe 3, les incisives inférieures ne peuvent pas mordre la lèvre supérieure.

The Lancet

Plaster Cast Versus Functional Brace for Non-Surgical Treatment of Achilles Tendon Rupture (UKSTAR): A Multicentre Randomised Controlled Trial and Economic Evaluation.
Costa ML, Achten J, Marian IR, Dutton SJ, Lamb SE, Ollivere B, Maredza M, Petrou S, Kearney RS; UKSTAR trial collaborators. | Lancet. 2020 Feb 8;395(10222):441-448
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Patients with Achilles tendon rupture who have non-operative treatment have traditionally been treated with immobilisation of the tendon in plaster casts for several weeks. Functional bracing is an alternative non-operative treatment that allows earlier mobilisation, but evidence on its effectiveness and safety is scarce. The aim of the UKSTAR trial was to compare functional and quality-of-life outcomes and resource use in patients treated non-operatively with plaster cast versus functional brace.

Méthode : UKSTAR was a pragmatic, superiority, multicentre, randomised controlled trial done at 39 hospitals in the UK. Patients (aged ≥16 years) who were being treated non-operatively for a primary Achilles tendon rupture at the participating centres were potentially eligible. The exclusion criteria were presenting more than 14 days after injury, previous rupture of the same Achilles tendon, or being unable to complete the questionnaires. Eligible participants were randomly assigned (1:1) to receive a plaster cast or functional brace using a centralised web-based system. Because the interventions were clearly visible, neither patients nor clinicians could be masked. Participants wore the intervention for 8 weeks. The primary outcome was patient-reported Achilles tendon rupture score (ATRS) at 9 months, analysed in the modified intention-to-treat population (all patients in the groups to which they were allocated, excluding participants who withdrew or died before providing any outcome data). The main safety outcome was the incidence of tendon re-rupture. Resource use was recorded from a health and personal social care perspective.

Résultats : Between Aug 15, 2016, and May 31, 2018, 1451 patients were screened, of whom 540 participants (mean age 48·7 years, 79% male) were randomly allocated to receive plaster cast (n=266) or functional brace (n=274). 527 (98%) of 540 were included in the modified intention-to-treat population, and 13 (2%) were excluded because they withdrew or died before providing any outcome data. There was no difference in ATRS at 9 months post injury (cast group n=244, mean ATRS 74∙4 [SD 19∙8]; functional brace group n=259, ATRS 72∙8 [20∙4]; adjusted mean difference -1∙38 [95% CI -4∙9 to 2∙1], p=0·44). There was no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group, p=0·40). The mean total health and personal social care cost was £1181 for the plaster cast group and £1078 for the functional bract group (mean between-group difference -£103 [95% CI -289 to 84]).

Conclusion : Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by ATRS, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting.

Conclusion (proposition de traduction) : La pose d'un plâtre traditionnel ne s'est pas révélé supérieur à la mise en charge précoce d'une attelle fonctionnelle, mesurée par le score de rupture du tendon d'Achille, dans la prise en charge des patients traités non chirurgicalement pour une rupture du tendon d'Achille. Les cliniciens peuvent considérer l'utilisation d'une mise en charge précoce dans une attelle fonctionnelle comme une alternative sûre et rentable à pose d'un plâtre.

The New England Journal of Medicine

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults.
Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, Brown RM, Zouk AN, Gulati S, Heideman BE, Lester MG, Toporek AH, Bentov I, Self WH, Rice TW, Semler MW; PreVent Investigators and the Pragmatic Critical Care Research Group.. | N Engl J Med. 2019 Feb 28;380(9):811-821
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial.

Méthode : In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%.

Résultats : Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P = 0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P = 0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P = 0.73).

Conclusion : Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation.

Conclusion (proposition de traduction) : Chez l'adulte en réanimation qui nécessitaient une intubation trachéale, les patients qui bénéficiaient d'une ventilation avec un ballon autoremplisseur à valve unidirectionnelle (BAVU) (ndlr : pour préoxygénation) présentaient une saturation en oxygène plus élevée et une incidence d'hypoxémie grave plus faible que ceux qui ne recevaient aucune ventilation.

Commentaire : • Voir l'analyse de l'article sur le site de la Société Française d’Anesthésie et de Réanimation (SFAR) : BAVU or not BAVU ? Est-ce réellement une question pour l’intubation trachéale des patients de réanimation ?  . Article commenté par les Dr Thomas GODET et Emmanuel FUTIER (CHU Clermont-Ferrand) pour le comité scientifique de la SFAR.
• Voir aussi l'analyse de l'article sur le site de la Société de Réanimation de Langue Française (SRLF) : Ventilation au ballon d’oxygène pendant l’apnée durant la procédure d’intubation trachéale : un dogme qui s’évanouit ?  . Rédigé par le Dr Jean-Pierre Frat, Service de Réanimation médicale, CHU de Poitiers.
• Article sur le site RENAU - RÉseau Nord Alpin des Urgences : Ventiler au masque pendant l’intubation trachéale : c’est possible et peut-être même bien&hellip ?  . Rédigé par les Dr Patrick Lesage et Dr Vincent Peigne.

Mois de février 2019