Bibliographie de Médecine d'Urgence

Mois d'avril 2019

Academic Emergency Medicine

Randomized Clinical Trial Comparing Procedural Amnesia and Respiratory Depression Between Moderate and Deep Sedation With Propofol in the Emergency Department.
Schick A, Driver B, Moore JC, Fagerstrom E, Miner JR. | Acad Emerg Med.  2019 Apr;26(4):364-374
Keywords: Aucun


Introduction : The objective was to determine if there is a difference in procedural amnesia and adverse respiratory events (AREs) between the target sedation levels of moderate (MS) and deep (DS) procedural sedation.

Méthode : This was a prospective, randomized clinical trial of consenting adult patients planning to undergo DS with propofol between March 5, 2015, and May 24, 2017. Patients were randomized to a target sedation level of MS or DS using the American Society of Anesthesiologist's definitions. Drug doses, vital signs, observer's assessment of alertness/sedation (OAAS) score, end-tidal CO2 (ETCO2 ), and the need for supportive airway maneuvers (SAMs; bag-valve mask use, repositioning, and stimulation to induce respirations) were monitored continuously. A standardized image was shown every 30 seconds starting 3 minutes before the procedure continuing until the patient had returned to baseline after the procedure. Recall and recognition of images were assessed 10 minutes after the sedation. Subclinical respiratory depression (RD) was defined as SaO2 ≤ 91%, change in ETCO2 ≥ 10 mm Hg, or absent ETCO2 at any time. The occurrence of RD with a SAM was defined as an ARE. Patient satisfaction, pain, and perceived recollection and physician assessment of procedure difficulty were collected using visual analog scales (VASs). Data were analyzed with descriptive statistics and Wilcoxon rank-sum test.

Résultats : A total of 107 patients were enrolled: 54 randomized to target MS and 53 to DS. Of the patients randomized to target MS, 50% achieved MS and 50% achieved DS. In the target DS group, 77% achieved DS and 23% achieved MS. The median total propofol dose (mg/kg) was lower in the MS group: MS 1.4 (95% confidence interval [CI] = 1.3-1.6, IQR = 1) versus DS 1.8 (95% CI = 1.6-2.0, IQR = 0.9). There were no differences in median OAAS during the procedure (MS 2.4 and DS 2.8), lowest OAAS (MS 2 and DS 2), percentage of images recalled (MS 4.7% vs. DS 3.8%, p = 0.73), or percentage of images recognized (MS 61.1% vs. DS 55%, p = 0.52). In the MS group, 41% patients had any AREs compared to 42% in the DS group (p = 0.77, 95% CI difference = -0.12 to 0.24). The total number of AREs was 23% lower in the MS group (p = 0.01, 95% CI = -0.41 to -0.04). There was no difference in patient-reported pain, satisfaction, or recollection VAS scores. Provider's rating of procedural difficulty and procedural success were similar in both groups.

Conclusion : Targeting MS or DS did not reliably result in the intended sedation level. Targeting MS, however, resulted in a lower rate of total AREs and fewer patients had multiple AREs with no difference in procedural recall. As seen in previous reports, patients who achieved MS had less AREs than those who achieved DS. Our study suggests that a target of MS provides adequate amnesia with less need for supportive airway interventions than a target level of DS, despite the fact that it often does not result in intended sedation level.

Conclusion (proposition de traduction) : Le fait de cibler une sédation procédurale modérée ou profonde n'a pas permis d'obtenir de façon fiable le niveau de sédation prévu. Cependant, le fait de cibler une sédation modérée pendant l'intervention a entraîné un taux plus faible d'événements respiratoires indésirables totaux et moins de patients ont présenté de multiples événements respiratoires indésirables sans qu'il y ait de différence dans la mémorisation de l'intervention. Comme on l'a vu dans les études précédentes, les patients qui ont obtenu une sédation procédurale modérée ont eu moins d'événements respiratoires indésirables que ceux qui ont reçu une sédation procédurale profonde. Notre étude suggère qu'une cible de sédation procédurale modérée procure une amnésie adéquate avec moins besoin d'interventions de soutien des voies respiratoires qu'un niveau cible de sédation procédurale profonde, malgré le fait qu'elle n'entraîne souvent pas le niveau de sédation prévu.

Accuracy and Interobserver Reliability of the Simplified Pulmonary Embolism Severity Index Versus the Hestia Criteria for Patients With Pulmonary Embolism.
Quezada CA, Bikdeli B, Villén T, Barrios D, Mercedes E, León F, Chiluiza D, Barbero E, Yusen RD, Jimenez D. | Acad Emerg Med.  2019 Apr;26(4):394-401
Keywords: Aucun


Introduction : The objective was to assess and compare the accuracy and interobserver reliability of the simplified Pulmonary Embolism Severity Index (sPESI) and the Hestia criteria for predicting short-term mortality in patients with pulmonary embolism (PE).

Méthode : This prospective cohort study evaluated consecutive eligible adults with PE diagnosed in the emergency department (ED) at a large, tertiary, academic medical center in the era January 1, 2015, to December 30, 2017. We assessed and compared sPESI and Hestia criteria prognostic accuracy for 30-day all-cause mortality after PE diagnosis and their interobserver reliability for classifying patients as low risk or high risk. Two clinician investigators scored both prediction tools during the ED evaluation. We used the kappa statistic to test for agreement.

Résultats : The 488-patient cohort had a mean (±SD) age of 69.0 (±17.1) years and an approximately even sex distribution. The investigators classified one-quarter of patients as low risk using the sPESI and Hestia criteria (28% vs. 27%, respectively). During the 30-day follow-up, 31 of the 488 (6.4%) patients died. Patients classified as low risk according to the sPESI and the Hestia criteria had a similar 30-day mortality (sPESI 0.7% [1/135], 95% confidence interval [CI] = 0.0%-4.0%; Hestia 2.3% [3/132], 95% CI = 0.5%-6.5%). The two observers had good agreement (κ = 0.80) for the Hestia criteria and very good agreement (κ = 0.97) for the sPESI.

Conclusion : The sPESI and the Hestia criteria had similar risk classification determination and prognostic accuracy for 30-day mortality after PE. However, the succinct and more objective sPESI had higher interobserver reliability than the Hestia criteria.

Conclusion (proposition de traduction) : Les critères sPESI et Hestia permettait une classification similaire des risques et une précision pronostique pour la mortalité à 30 jours après une embolie pulmonaire. Cependant, le sPESI plus court et plus objectif à réaliser présentait une plus grande fiabilité entre observateurs que les critères de Hestia.

Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain.
Chang AK, Bijur PE, Ata A, Campbell C, Pearlman S, White D, Chertoff A, Restivo A, Gallagher EJ. | Acad Emerg Med.  2019 Apr;26(4):402-409
Keywords: Aucun

Original contributions

Introduction : Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain.

Méthode : This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes.

Résultats : Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups.

Conclusion : In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.

Conclusion (proposition de traduction) : Dans cet essai clinique randomisé, l'ajout de paracétamol par voie intraveineuse à l'hydromorphone par voie intraveineuse en tant qu'analgésique adjuvant en cas de douleur aiguë et sévère chez les personnes âgées n'a apporté aucun soulagement de la douleur cliniquement ni statistiquement supérieur à l'hydromorphone seul au cours de la première heure de traitement.

Commentaire : En France, l'hydromorphone est disponible sous la forme de gélule à libération prolongée (Sophidone LP 4, 8, 16 ou 24 mg).
C'est un agoniste opioïde sélectif des récepteurs µ. Les effets pharmacologiques de l'hydromorphone et de la morphine ne diffèrent pas de façon notable.
Le rapport entre la puissance analgésique, par voie orale, de l'hydromorphone par rapport à la morphine est d'environ 7,5. L'hydromorphone et les opioïdes qui lui sont reliés agissent principalement sur le système nerveux central et sur l'intestin. Les effets sont divers et incluent une analgésie, une somnolence, des changements de l'humeur, une dépression respiratoire, une diminution de la motilité gastro-intestinale, des nausées et vomissements, et une modification des systèmes endocrinien et neurovégétatif.
L'hydromorphone est utilisée dans le traitement des douleurs intenses d'origine cancéreuse en cas de résistance ou d'intolérance aux opioïdes forts.

Nebulized Terbutaline and Ipratropium Bromide Versus Terbutaline Alone in Acute Exacerbation of Chronic Obstructive Pulmonary Disease Requiring Noninvasive Ventilation: A Randomized Double-blind Controlled Trial.
Beltaief K, Msolli MA, Zorgati A, Sekma A, Fakhfakh M, Marzouk MB, Boubaker H, Grissa MH, Methamem M, Boukef R, Belguith A, Bouida W, Nouira S. | Acad Emerg Med.  2019 Apr;26(4):434-442
Keywords: Aucun

Original contributions

Introduction : Short-acting β2 -agonists are the mainstay of treatment of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED). It is still unclear whether the addition of short-acting anticholinergics is clinically more effective care compared to treatment with β2 -agonists alone in patients with hypercapnic AECOPD.
OBJECTIVE: The objective was to evaluate whether combining ipratropium bromide (IB) to terbutaline reduces hospital and intensive care unit (ICU) admission rates compared to terbutaline alone in AECOPD hypercapnic patients.

Méthode : In this double-blind controlled trial, patients who were admitted to the ED for AECOPD requiring noninvasive ventilation (NIV) were randomized to receive either 5 mg of nebulized terbutaline combined to 0.5 mg of IB (terbutaline/IB group, n = 115) or 5 mg of terbutaline sulfate (terbutaline group, n = 117). Nebulization was repeated every 20 minutes for the first hour and every 4 hours within the first day. Primary outcomes were the rate of hospital admission and need for endotracheal intubation within the first 24 hours of the start of the experimental treatment. Secondary outcomes included changes from baseline of dyspnea, physiologic variables, length of hospital stay, ICU admission rate, and 7-day mortality.

Résultats : The two groups were similar regarding baseline demographic and clinical characteristics. Hospital admission was observed in 70 patients (59.8%) in the terbutaline/IB group and in 75 patients (65.2%) in the terbutaline group (respiratory rate [RR] = 1.09, 95% confidence interval [CI] = 0.93 to 1.27, p = 0.39). ICU admission was required in 37 (32.2%) patients in the terbutaline/IB group and 30 patients (25.6%) in terbutaline group (RR = 1.25, 95% CI = 1.02 to 1.54, p = 0.27). There were no significant differences in dyspnea score, blood gas parameters changes, vital signs improvement, and 7-day death rate between both groups.

Conclusion : In patients admitted to the ED for AECOPD requiring NIV, combination of nebulized IB and terbutaline did not reduce hospital admission and need to ICU care.

Conclusion (proposition de traduction) : Chez les patients admis aux urgences pour exacerbation aiguë d'une maladie pulmonaire obstructive chronique nécessitant une VNI, l'association de bromure d'ipratropium nébulisé et de terbutaline n'a pas réduit le nombre d'hospitalisations et le besoin de soins intensifs.

Coadministration of Probiotics With Prescribed Antibiotics for Preventing Clostridium difficile Diarrhea.
Hamed A, Miller AC. | Acad Emerg Med.  2019 Apr;26(4):454-456
Keywords: Aucun


Editorial : lostridium difficile (C. individuals whose normal gut microbiota has been disrupted. ) colitis is an opportunistic infection that occurs in C. the Harm Endpoints: Abdominal cramping, flatulence, soft stools, nausea, fever, and taste disturbance. Who was in the studies? 9955 adults (> 18 years) and children (0 to 18 years of age) from 39 trials receiving antibiotic therapy for any reason. Narrative: difficile Antibiotics can disturb the normal intestinal microflora, thereby reducing pathogen resistance to gram-positive, anaerobic, spore-forming bacillus. When a person takes antibiotics, good germs that protect against infection are destroyed for several months. During this time, patients can get sick from C. difficile, a gram-positive anaerobic spore-forming bacillus picked up from contaminated surfaces or spread from a health care provider's hands.
This systematic review and meta-analysis assesses the safety and efficacy of probiotics for decreasing the risk of CDAD in adults and children taking antibiotics. Unfortunately, the analysis does not control for type or strain of the probiotics, or for antibiotic class or administration route. In addition to the 39 trials (9955 participants) identified by the Cochrane group, we identified 3 small relevant randomized clinical trials that were published after completion of the Cochrane review. These trials each studied a specific type of probiotic, exclusively in admitted patients, but did not show any significant difference for risk of CDAD between groups. They did not control for baseline risk and likely suffered from Type II error.

Conclusion : Based on this systematic review and meta-analysis of 31 randomized controlled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing CDAD. Although they did not describe how risk was determined, post hoc subgroup analyses indicated that probiotics are effective among trials with a CDAD baseline risk >5% (moderate certainty evidence), but not among trials with a baseline risk ≤5% (low to moderate certainty evidence). No significant harm was reported (low quality evidence). The effect of probiotic type, dose, antibiotic, and antibiotic route remains unclear.

Conclusion (proposition de traduction) : Sur la base de cette revue systématique et de la méta-analyse de 31 essais contrôlés randomisés comprenant 8672 patients, des preuves de certitude modérée suggèrent que les probiotiques sont efficaces pour prévenir une une diarrhée à Clostridium difficile. Bien qu’elles n’aient pas décrit la manière dont le risque avait été déterminé, les analyses post-sous-groupes ont indiqué que les probiotiques étaient efficaces dans les essais avec un risque initial de survenu d'une diarrhée à Clostridium difficile > 5 % (preuves de certitude moyenne), mais pas parmi les essais avec un risque initial ≤ 5 % preuve de certitude).
Aucun préjudice significatif n'a été signalé (preuves de faible qualité). L'effet du type de probiotique, de la dose, de l'antibiotique et de la voie antibiotique reste incertain.

Tranexamic Acid for the Treatment of Epistaxis.
Gottlieb M, Koyfman A, Long B. | Acad Emerg Med.  2019 Apr 1
Keywords: Aucun

The Brass Tacks: Concise Reviews of Published Evidence

Introduction : Epistaxis is a common reason for patients to present to the Emergency Department (ED), reflecting 1 out of every 200 ED visits in the United States. While many cases of epistaxis are self-limiting, those requiring medical treatment can be associated with significant time and healthcare costs. Additionally, nasal packing and hemostatic matrices can be painful and require the patient to return for at least one follow-up visit. Therefore, identifying an effective and inexpensive treatment is of particular importance. Tranexamic acid is an anti-fibrinolytic agent that has been proposed as one potential modality for this.

Méthode : The Cochrane Review discussed here included randomized controlled trials comparing tranexamic acid (TXA) in any formulation (eg, delivered orally, intravenously, or topically) with usual care versus usual care with placebo, usual care with any other hemostatic agent, or usual care alone.3 The primary outcome was the proportion of patients with rebleeding within 10 days and significant adverse events (ie, seizures, thromboembolic events).

Résultats : Among the six trials (n=692 patients), two studies used oral TXA while the remaining four used topical TXA. For the primary outcome (n=225 patients), TXA was associated with lower rates of rebleeding at 10 days (47% vs 67%; relative risk [RR]: 0.71, 95% CI, 0.56 to 0.90; Absolute risk difference [ARD]: 20%; number needed to treat [NNT]: 5; moderate quality evidence) compared to placebo. There were no significant differences between groups for adverse events, although only five of the trials reported adverse events. The included trials did not report outcomes requiring further intervention (e.g. repacking, surgery, embolization).
Another recent systematic review of topical TXA in epistaxis identified faster discharge rates, reduced rebleeding at 24 hours, and greater patient satisfaction with TXA, but no difference in rebleeding at 30 minutes. While the studies utilized different search strategies, both were informed by similar studies in their reviews. The current review further supports the potential value of this intervention.

Conclusion : The existing evidence supports the efficacy of TXA to reduce the risk of rebleeding at 10 days among adult patients. Despite inconsistent reporting of adverse events, the occurrence of such events appears to be unlikely, particularly with topical use. Therefore, we have assigned a color recommendation of Green (Benefit > Harm) to the use of TXA for epistaxis.

Conclusion (proposition de traduction) : Les données existantes confirment l’efficacité de l'acide tranexamique pour réduire le risque de récidive à 10 jours chez les patients adultes. Malgré le manque d'uniformité dans la déclaration des effets indésirables, il semble peu probable que de tels effets se produisent, en particulier dans le cas d'un usage topique. Par conséquent, nous avons attribué une recommandation de couleur de vert (avantage > dommage) à l'utilisation d'acide tranexamique pour l'épistaxis.

AEM Education and Training

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.
Pettit KE, Rattray NA, Wang H, Stuckey S, Mark Courtney D, Messman AM, Kline JA. | AEM Educ Train.  2019 April 28;3(2):136-144
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers.

Méthode : We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants.

Résultats : Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle."

Conclusion : Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

Conclusion (proposition de traduction) : Les participants aux groupes de discussion ont mis l'accent sur les thèmes et les comportements concrets pour améliorer l'empathie dans les soins d'urgence. Celles-ci ont été intégrées à Empathy Circle, un nouveau schéma conceptuel pouvant servir de cadre pour enseigner l'empathie aux dispensateurs de soins d'urgence.

Coaching for Chaos: A Qualitative Study of Instructional Methods for Multipatient Management in the Emergency Department.
Chan TM, Van Dewark K, Sherbino J, Lineberry M. | AEM Educ Train.  2019 Avril;3(2):145-155
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : Busy environments, like the emergency department (ED), require teachers to develop instructional strategies for coaching trainees to function within these same environments. Few studies have documented the strategies used by emergency physician (EP)-teachers within these busy, chaotic environments, instead emphasizing teaching in more predictable environments such as the outpatient clinic, hospital wards, or operating room. The authors sought to discover what strategies EP-teachers were using and what trainees recalled experiencing when learning to handle these unpredictable, overcrowded, complex, multipatient environments.

Méthode : An interpretive description study was conducted at multiple teaching hospitals affiliated with McMaster University from July 2014 to May 2015. Participants (10 EP-teachers and 10 junior residents) were asked to recall teaching strategies related to handling ED patient flow. Participants were asked to describe techniques that they used, observed, or experienced as trainees. Two independent coders read through interview transcripts, analyzing these documents inductively and iteratively.

Résultats : Two main types of strategies to teach ED management were discovered: 1) workplace-based methods, including both observation and in situ instruction; and 2) principle-based advice. The most often described techniques were workplace-based methods, which included a variety of in situ techniques ranging from conversations to managerial coaching (e.g., collaborative problem-solving of real-life administrative dilemmas).

Conclusion : A mix of strategies are used to teach and coach trainees to handle multipatient environments. Further research is required to determine how to optimize the use of these techniques and innovate new strategies to support the learning of these crucial skills.

Conclusion (proposition de traduction) : Une combinaison de stratégies est utilisée pour enseigner et former les stagiaires à la gestion d’environnements à patients multiples. Des recherches supplémentaires sont nécessaires pour déterminer comment optimiser l'utilisation de ces techniques et innover de nouvelles stratégies pour soutenir l'apprentissage de ces compétences cruciales.

The Impact of Video Laryngoscopy on the Clinical Learning Environment of Emergency Medicine Residents: A Report of 14,313 Intubations..
Monette DL, Brown CA, Benoit JL, McMullan JT, Carleton SC, Steuerwald MT, Eyre A, Pallin DJ; NEAR III Investigators. | AEM Educ Train.  2019 April;3(2):156-162
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : The introduction of video laryngoscopy (VL) may impact emergency medicine (EM) residents' intubation practices.

Méthode : We analyzed 14,313 intubations from 11 EM training sites, July 1, 2002, to December 31, 2012, assessing the likelihood of first-attempt success and likelihood of having a second attempt, by rank and device. We determined whether direct laryngoscopy (DL) first-attempt success decreased as VL became more prevalent using a logistic regression model with proportion of encounters initiated with VL at that center in the prior 90 and 365 days as predictors of DL first-attempt success.

Résultats : First-attempt success by PGY-1s was 71% (95% confidence interval [CI] = 63% to 78%); PGY-2s, 82% (95% CI = 78% to 86%); and PGY-3+, 89% (95% CI = 85% to 92%). Residents' first-attempt success rate was higher with the C-MAC video laryngoscope (C-MAC) versus DL, 92% versus 84% (risk difference [RD] = 8%, 95% CI = 4% to 11%), but there was no statistical difference between the GlideScope video laryngoscope (GVL) and DL, 80% versus 84% (RD = -4%, 95% CI = -10% to 1%). PGY-1s were more likely to have a second intubation attempt after first-attempt failure with VL versus DL: 32% versus 18% (RD = 14%, 95% CI = 5% to 23%). DL first-attempt success rates did not decrease as VL became more prevalent.

Conclusion : First-attempt success increases with training. Interns are more likely to have a second attempt when using VL. The C-MAC may be associated with increased first-attempt success for EM residents compared with DL or GVL. The increasing prevalence of VL is not accompanied by a decrease in DL success.

Conclusion (proposition de traduction) : Le succès de la première tentative augmente avec l'entraînement. Les internes sont plus susceptibles de devoir réaliser une deuxième tentative avec l’utilisation d'un vidéo-laryngoscope.
Le vidéo-laryngoscope C-MAC peut être associé à une première tentative réussie pou les interne de médecine d'urgence par rapport à la laryngoscopie directe ou au vidéo-laryngoscope GlideScope.
La prévalence croissante de la vidéo laryngoscopie ne s'accompagne pas d'une diminution du succès de la laryngoscopie directe.

Direct Observation Assessment of Ultrasound Competency Using a Mobile Standardized Direct Observation Tool Application With Comparison to Asynchronous Quality Assurance Evaluation.
Boniface KS, Ogle K, Aalam A, LeSaux M, Pyle M, Mandoorah S, Shokoohi H. | AEM Educ Train.  2019 Avril;3(2):172-178
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original contributions

Introduction : Competency assessment is a key component of point-of-care ultrasound (POCUS) training. The purpose of this study was to design a smartphone-based standardized direct observation tool (SDOT) and to compare a faculty-observed competency assessment at the bedside with a blinded reference standard assessment in the quality assurance (QA) review of ultrasound images.

Méthode : In this prospective, observational study, an SDOT was created using SurveyMonkey containing specific scoring and evaluation items based on the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound: Consensus Document for the Emergency Ultrasound Milestone Project. Ultrasound faculty used the mobile phone-based data collection tool as an SDOT at the bedside when students, residents, and fellows were performing one of eight core POCUS examinations. Data recorded included demographic data, examination-specific data, and overall quality measures (on a scale of 1-5, with 3 and above being defined as adequate for clinical decision making), as well as interpretation and clinical knowledge. The POCUS examination itself was recorded and uploaded to QPath, a HIPAA-compliant ultrasound archive. Each examination was later reviewed by another faculty blinded to the result of the bedside evaluation. The agreement of examinations scored adequate (3 and above) in the two evaluation methods was the primary outcome.

Résultats : A total of 163 direct observation evaluations were collected from 23 EM residents (93 SDOTs [57%]), 14 students (51 SDOTs [31%]), and four fellows (19 SDOTs [12%]). The trainees were evaluated on completing cardiac (54 [33%]), focused assessment with sonography for trauma (34 [21%]), biliary (25 [15%]), aorta (18 [11%]), renal (12 [7%]), pelvis (eight [5%]), deep vein thrombosis (seven [4%]), and lung scan (5 [3%]). Overall, the number of observed agreements between bedside and QA assessments was 81 (87.1% of the observations) for evaluating the quality of images (scores 1 and 2 vs. scores 3, 4, and 5). The strength of agreement is considered to be "fair" (κ = 0.251 and 95% confidence interval [CI] = 0.02-0.48). Further agreement assessment demonstrated a fair agreement for images taken by residents and students and a "perfect" agreement in images taken by fellows. Overall, a "moderate" inter-rater agreement was found in 79.1% for the accuracy of interpretation of POCUS scan (e.g., true positive, false negative) during QA and bedside evaluation (κ = 0.48, 95% CI = 0.34-0.63). Faculty at the bedside and QA assessment reached a moderate agreement on interpretations noted by residents and students and a "good" agreement on fellows' scans.

Conclusion : Using a bedside SDOT through a mobile SurveyMonkey platform facilitates assessment of competency in emergency ultrasound learners and correlates well with traditional competency evaluation by asynchronous weekly image review QA.

Conclusion (proposition de traduction) : L'utilisation d'un outil d'observation directe normalisé basé sur un smartphone au chevet du patient via une plate-forme mobile SurveyMonkey facilite l'évaluation des compétences des apprenants en échographie d'urgence et est en corrélation avec l'évaluation traditionnelle des compétences par un contrôle qualité hebdomadaire asynchrone des images.

Annales Françaises de Médecine d'Urgence

Lemoine L, Legrand M, Potel G, Rossignol P, Montassier E. | Ann Fr Med Urgence.  2019 Avril;9(2):102-111
Keywords: Severe hyperkalemia; Arrhythmias; Cardiac; Emergency treatment; Renal insufficiency; Adrenergic beta-agonists; Insulin

Mise Au Point / Update

Editorial : L’hyperkaliémie est l’un des désordres hydroélectrolytiques les plus fréquemment rencontrés aux urgences. Les étiologies principales sont l’insuffisance rénale aiguë ou chronique, le diabète et l’insuffisance cardiaque. L’hyperkaliémie aiguë peut être une urgence vitale, car elle est potentiellement létale du fait du risque d’arythmie cardiaque. Sa prise en charge aux urgences manque actuellement de recommandations claires en ce qui concerne le seuil d’intervention et les thérapeutiques à utiliser. Les thérapeutiques couramment appliquées sont fondées sur un faible niveau de preuve, et leurs effets secondaires sont mal connus. Des études supplémentaires sont nécessaires pour évaluer l’utilisation de ces traitements et celle de nouveaux traitements potentiellement prometteurs.

Conclusion : In this article, we focus on known data in terms of epidemiology, clinical and electrographic manifestations, and the different medications that can be proposed in the management of hyperkalemia in the emergency department.

Conclusion (proposition de traduction) : Nous faisons ici une mise au point sur les données connues en termes d’épidémiologie, de manifestations cliniques et électrocardiographiques, et des différentes thérapeutiques qui peuvent être proposées dans la prise en charge de l’hyperkaliémie aux urgences.

Marçais C, Chetioui A, Yordanov Y, Reuter PG, Raynal1 PA, Pateron D, Thiebaud PC. | Ann Fr Med Urgence.  2019 Avril;9(2):102-111
Keywords: Drugs; Emergency; Prehospital; Smur

Article Original / Original Article

Introduction : La dotation médicamenteuse nécessaire lors d’une intervention médicale préhospitalière n’est pas référencée, ce qui laisse chaque structure libre de constituer sa propre pharmacie. L’objectif principal de notre étude était de faire un état des lieux des dotations médicamenteuses des services mobiles d’urgence et de réanimation (Smur).

Méthode : Il s’agit d’une étude observationnelle déclarative, réalisée entre novembre 2017 et avril 2018 auprès de l’ensemble des Smur adultes de France.

Résultats : Sur 402 services sollicités, 191 (48 %) ont répondu et 177 (44 %) inclus. Un Smur disposait en moyenne de 74 ± 9 médicaments. Au total, 231 molécules ont été répertoriées. Parmi elles, 73 (32%) étaient disponibles dans plus de 50%des structures et 94 (41%) dans moins de 5%. Il existait des disparités des dotations médicamenteuses dans l’ensemble des spécialités, plus ou moins importantes selon la classe thérapeutique.

Conclusion : The majority of the prehospital emergency medical services have the necessary drugs to take care of the most serious emergencies. However, some recommendations do not seem to be followed. Based on our results and existing recommendations, we have proposed a possible list of necessary drugs for prehospital emergency units.

Conclusion (proposition de traduction) : La majorité des services dispose des médicaments nécessaires à la prise en charge des urgences les plus graves. Cependant, quelques recommandations ne sont pas toujours respectées. À la vue de nos résultats et des recommandations en vigueur, nous proposons une liste de molécules qui nous semblent être indispensables dans l’arsenal thérapeutique des Smur.

Bérard LM | Ann Fr Med Urgence.  2019 Avril;9(2):81-88
Keywords: Antibiotics; Urinary infections; Emergency department

Article original / Original article

Introduction : De nombreux traitements anti-infectieux sont débutés dans les services d’urgences (SU). Nous avons étudié la qualité de la prescription d’antibiotiques dans le traitement probabiliste des infections urinaires (IU) au SU d’un centre hospitalier général français.

Méthode : Nous avons conduit une étude rétrospective monocentrique du 1er janvier au 30 juin 2017. Tous les patients pour lesquels une IU a été diagnostiquée au SU ont été inclus. Les traitements hospitaliers et ambulatoires des IU ont été analysés au regard des recommandations de 2015 de la Société d’infectiologie française. Le critère principal d’évaluation a été le classement des antibiothérapies probabilistes en deux catégories : « conforme » ou « non conforme » à ce référentiel. Le critère secondaire d’évaluation a été l’adéquation du traitement antibiotique initial à la sensibilité des souches bactériennes identifiées.

Résultats : Cent quatre-vingt-onze patients ont été inclus : 99 pyélonéphrites (52 %), 18 prostatites (9 %), 48 cystites (25 %) et 26 infections urinaires de siège non précisé (14 %). L’âge moyen a été de 52 ans avec 26 % d’hommes et 74 % de femmes. Au total, 114 antibiothérapies (60 %) ont été considérées conformes aux recommandations. Des antibiotiques ont été prescrits par excès dans 35 cas. La souche identifiée n’était pas sensible au traitement instauré au SU dans neuf situations.

Conclusion : This study underlines the difficulties in the practical application of antibiotic recommendations in the ED for 40 % cases. A reminder and a continuous assessment of good practice for antibiotic prescription in the ED are required.

Conclusion (proposition de traduction) : Cette étude met en exergue les difficultés pour la mise en application des recommandations en thérapeutique anti-infectieuse au SU dans 40 % des situations. Un rappel et une évaluation continue des bonnes pratiques de prescription des antibiotiques au SU sont nécessaires.

Marx T, Kepka S, Desmettre T. | Ann Fr Med Urgence.  2019 Avril;9(2):112-116
Keywords: Pneumothorax; Aspiration; Emergency

Geste en médecine d’urgence

Editorial : Les pneumothorax rencontrés aux urgences peuvent être d’origine spontanée ou traumatique. L’exsufflation est une méthode thérapeutique simple du pneumothorax spontané primitif. Cette technique consiste à réaliser une aspiration par l’intermédiaire d’un cathéter, sans que le matériel soit laissé en place. Elle permet une prise en charge ambulatoire du patient et répond à des enjeux de qualité des soins (efficacité, simplicité, sécurité) et d’économie de la santé (diminution de la durée et du taux d’hospitalisation). L’exsufflation peut être réalisée via différents dispositifs tout simples d’utilisation, par voie antérieure ou axillaire. L’exsufflation à l’aiguille avec des cathéters de perfusion intraveineux est peu recommandée devant le risque d’échec lié à une longueur de cathéter inadaptée à la morphologie du patient. Les usages de drains de faible calibre avec la méthode de Seldinger ou de kits dédiés de thoracentèse sont à privilégier. Les complications sont moindres comparées à la pose d’un drain thoracique. Il s’agit le plus souvent d’obstruction ou de déplacement du cathéter. L’exsufflation est également un geste de sauvetage à réaliser en urgence en cas de pneumothorax suffocant. La bonne maîtrise de l’une de ces techniques est donc indispensable dans le cadre de la formation et de la pratique en médecine d’urgence.

Conclusion (proposition de traduction) : L’exsufflation est un geste technique simple qui fait partie de la formation et de la pratique en médecine d’urgence. Elle permet une prise en charge simplifiée, moins invasive en cas de pneumothorax spontanés primitifs. Il s’agit également du geste de sauvetage à réaliser en extrême urgence dans le cadre de pneumothorax suffocant. Cette technique a pour avantage d’être plus simple à réaliser par rapport au drainage thoracique conventionnel, avec un taux de complications moindres, tout en permettant une mise en sécurité du patient. L’exsufflation peut être réalisée via différents dispositifs, tout simples d’utilisation et avec des techniques (méthode de Seldinger) déjà maîtrisées par les médecins urgentistes. La bonne maîtrise de l’une de ces techniques, ainsi que son usage fréquent, est importante dans le maintien des compétences.

Annals of Emergency Medicine

Development and Evaluation of a Machine Learning Model for the Early Identification of Patients at Risk for Sepsis.
Delahanty RJ, Alvarez J, Flynn LM, Sherwin RL, Jones SS. | Ann Emerg Med.  2019 Apr;73(4):334-344
Keywords: Aucun

Infectious Disease

Introduction : The Third International Consensus Definitions (Sepsis-3) Task Force recommended the use of the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score to screen patients for sepsis outside of the ICU. However, subsequent studies raise concerns about the sensitivity of qSOFA as a screening tool. We aim to use machine learning to develop a new sepsis screening tool, the Risk of Sepsis (RoS) score, and compare it with a slate of benchmark sepsis-screening tools, including the Systemic Inflammatory Response Syndrome, Sequential Organ Failure Assessment (SOFA), qSOFA, Modified Early Warning Score, and National Early Warning Score.

Méthode : We used retrospective electronic health record data from adult patients who presented to 49 urban community hospital emergency departments during a 22-month period (N=2,759,529). We used the Rhee clinical surveillance criteria as our standard definition of sepsis and as the primary target for developing our model. The data were randomly split into training and test cohorts to derive and then evaluate the model. A feature selection process was carried out in 3 stages: first, we reviewed existing models for sepsis screening; second, we consulted with local subject matter experts; and third, we used a supervised machine learning called gradient boosting. Key metrics of performance included alert rate, area under the receiver operating characteristic curve, sensitivity, specificity, and precision. Performance was assessed at 1, 3, 6, 12, and 24 hours after an index time.

Résultats : The RoS score was the most discriminant screening tool at all time thresholds (area under the receiver operating characteristic curve 0.93 to 0.97). Compared with the next most discriminant benchmark (Sequential Organ Failure Assessment), RoS was significantly more sensitive (67.7% versus 49.2% at 1 hour and 84.6% versus 80.4% at 24 hours) and precise (27.6% versus 12.2% at 1 hour and 28.8% versus 11.4% at 24 hours). The sensitivity of qSOFA was relatively low (3.7% at 1 hour and 23.5% at 24 hours).

Conclusion : In this retrospective study, RoS was more timely and discriminant than benchmark screening tools, including those recommend by the Sepsis-3 Task Force. Further study is needed to validate the RoS score at independent sites.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, le RoS (apprentissage machine) était plus rapide et discriminant que les outils de dépistage de référence, y compris ceux recommandés par le Groupe de travail Sepsis-3. D'autres études sont nécessaires pour valider le score RoS dans des services indépendants.

Commentaire : Voir l'analyse de l'article : Actualités en médecine d’urgence. Ann. Fr. Med. Urgence. 2019 Avril;9(3):200-206  . Rédigé par le Dr M. Oberlin.

Emergency Department Crowding Is Associated With Delayed Antibiotics for Sepsis.
Peltan ID, Bledsoe JR, Oniki TA, Sorensen J, Jephson AR, Allen TL, Samore MH, Hough CL, Brown SM. | Ann Emerg Med.  2019 Apr;73(4):345-355
Keywords: Aucun

Infectious Disease

Introduction : Barriers to early antibiotic administration for sepsis remain poorly understood. We investigated the association between emergency department (ED) crowding and door-to-antibiotic time in ED sepsis.

Méthode : We conducted a retrospective cohort study of ED sepsis patients presenting to 2 community hospitals, a regional referral hospital, and a tertiary teaching hospital. The primary exposure was ED occupancy rate, defined as the ratio of registered ED patients to licensed ED beds. We defined ED overcrowding as an ED occupancy rate greater than or equal to 1. We used multivariable regression to measure the adjusted association between ED crowding and door-to-antibiotic time (elapsed time from ED arrival to first antibiotic initiation). Using Markov multistate models, we also investigated the association between ED crowding and pre-antibiotic care processes.

Résultats : Among 3,572 eligible sepsis patients, 70% arrived when the ED occupancy rate was greater than or equal to 0.5 and 14% arrived to an overcrowded ED. Median door-to-antibiotic time was 158 minutes (interquartile range 109 to 216 minutes). When the ED was overcrowded, 46% of patients received antibiotics within 3 hours of ED arrival compared with 63% when it was not (difference 14.4%; 95% confidence interval 9.7% to 19.2%). After adjustment, each 10% increase in ED occupancy rate was associated with a 4.0-minute increase (95% confidence interval 2.8 to 5.2 minutes) in door-to-antibiotic time and a decrease in the odds of antibiotic initiation within 3 hours (odds ratio 0.90; 95% confidence interval 0.88 to 0.93). Increasing ED crowding was associated with slower initial patient assessment but not further delays after the initial assessment.

Conclusion : ED crowding was associated with increased sepsis antibiotic delay. Hospitals must devise strategies to optimize sepsis antibiotic administration during periods of ED crowding.

Conclusion (proposition de traduction) : La surcharge d'activité du services des urgences était associée à une augmentation du délai pour l'administration d'antibiotiques dans le sepsis.
Les hôpitaux devraient concevoir des stratégies pour optimiser les délais d'administration d'antibiotiques dans le sepsis pendant les périodes de surcharge d'activité aux urgences.

Commentaire : Voir les articles suivants qui plaident pour la mise en place d’une filière (Sepsis team, chaîne ou réseau de prise en charge) entre les urgences et la réanimation pour débuter précocement le traitement dans le sepsis :
• Sebat F, Johnson D, Musthafa AA, Watnik M, Moore S, Henry K, et al. A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest. 2005 May;127(5):1729-43  
• Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007 Aug;35(8):1928-36  
• Dellinger RP, Schorr C. Severe sepsis in an emergency department: prevalence, rapide identification, and appropriate treatment. Crit Care Med. 2007 Oct;35(10):2461-2  

Challenging the One-Hour Bundle Goal for Sepsis Antibiotics.
Talan DA, Yealy DM. | Ann Emerg Med.  2019 Apr;73(4):359-362
Keywords: Aucun

Infectious Disease

Editorial : In this edition of Annals, Spiegel et al address the lack of evidence supporting the 2018 Surviving Sepsis Campaign 1-hour care bundle. That bundle sets septic care targets to occur within 1 hour of emergency department (ED) arrival. Spiegel et al discuss various aspects of the newest Surviving Sepsis Campaign bundle, including resuscitative approaches; we focus on the 1-hour antibiotic target. The basis for this antibiotic delivery goal rests with data supporting the notion that for each hour of delay for a septic patient, the risk of progression to worse forms of sepsis or death increases.
Most of the time, the ED care team gets it right; they look early and often, and they intervene when they recognize sepsis. Seek to be prompt, but do not pay homage to a set interval. Obviously septic patients allow straightforward care decisions; for many others, taking a slightly longer time to administer antibiotics while gaining more insight is likely the safest approach overall by improving diagnostic accuracy plus antibiotic decisionmaking.

Conclusion : The 2018 Surviving Sepsis Campaign 1-hour care bundle threshold—notably, the expectation to initiate antibiotics for all patients with eventual sepsis diagnoses within this interval—is simplistic and not currently supported as the optimal approach. It is time to take a more informed approach to administration of empiric antibiotics for patients with suspected sepsis in the ED.

Conclusion (proposition de traduction) : Le seuil pour l'ensemble du processus de soins d'une heure édicté par la Surviving Sepsis Campaign 2018 - notamment en ce qui concerne l'administrer des antibiotiques à tous les patients avec un diagnostic de sepsis dans cet intervalle - est simpliste et ne constitue pas actuellement l'approche optimale à adopter.
Il est temps d'adopter une approche fondée sur des preuves pour l'administration d'antibiotiques probabiliste aux patients présentant une suspicion de sepsis aux urgences.

Does the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Improve Survival in Septic Adults?.
Sanghvi S, Podlog M, Aycock RD. | Ann Emerg Med.  2019 Apr;73(4):363-365
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : The authors searched PubMed, EMBASE, Scopus, Web of Science, and without language restrictions from inception to November 28, 2017. They also searched the references of analyzed studies and other review articles.

Méthode : Investigators included randomized trials and observation studies of patients aged 16 years or older with sepsis, severe sepsis, and septic shock that compared mortality rates in patients receiving versus not receiving one or more of the following SEP-1 interventions: serial lactate measurements, a crystalloid infusion of 30 mL/kg, or assessment of volume status and tissue perfusion. Studies of central venous pressure and ScvO2 measurements were excluded, as were those that did not include a usual care control group. Nonrandomized observational studies were included only if they had a before-after or a concurrent control design.

Résultats : Two authors extracted data with a standardized tool, with a third author checking the extracted data for accuracy. Data extracted included time from admission to intervention, proportion of patients receiving the intervention, measured level (if the intervention was a measurement), amount administered (if the intervention was a treatment), and bundle composition and administration. For each study, the authors examined the appropriateness and timeliness of antibiotic administrations between control and intervention groups and whether adjunctive aids were administered. The primary outcome was mortality, reported as the relative risk or odds ratio of death. Authors assessed risk of bias with the Cochrane Risk of Bias Tool1 and the Newcastle-Ottawa Scale.2 All components of either tool had to be graded low risk of bias for the study to be rated low risk overall.

Conclusion : Logistically, SEP-1 is a complicated measurement tool associated with a high reporting burden. It requires manual chart abstraction, with each case taking an average of 1 to 2 hours for review. This require- ment promotes a focus on high- quality documentation rather than high-quality care. Although CMS’s initiative was aimed to decrease the morbidity and mortality associated with sepsis, no high- or moderate-level evidence exists that demonstrates that the measures accomplish that objective. Bundled care may have a place in the man- agement of septic patients, but CMS’s SEP-1 should be a clinical tool that is used as an adjunct to clinical judgment.

Conclusion (proposition de traduction) : Sur le plan logistique, SEP-1 est un outil de mesure complexe associé à une lourde charge de déclaration. Elle nécessite une extraction manuelle des données des dossiers, chaque cas prenant en moyenne 1 à 2 heures pour être examiné.
Cette exigence incite à mettre l'accent sur un recueil de données de haute qualité plutôt que sur des soins de haute qualité. Bien que l’initiative des « Centers for Medicare & Medicaid Services » visait à réduire la morbidité et la mortalité associées au sepsis, il n’existait pas de données probantes élevées ou modérées démontrant que les mesures permettaient d’atteindre cet objectif. Les processus de soins peuvent avoir une place dans la prise en charge des patients en sepsis, mais le SEP-1 des « Centers for Medicare & Medicaid Services » doit être un outil clinique utilisé en complément du jugement clinique.

Identification of Clinical Characteristics Associated With High-Level Care Among Patients With Skin and Soft Tissue Infections.
Mower WR, Kadera SP, Rodriguez AD, Vanderkraan V, Krishna PK, Chiu E, Wilson MJ, Gupta M, Krishnadasan A, Moran GJ, Talan DA. | Ann Emerg Med.  2019 Apr;73(4):366-374
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : Serious adverse outcomes associated with skin and soft tissue infections are uncommon, and current hospitalization rates appear excessive. It would be advantageous to be able to differentiate between patients who require high-level inpatient services and those who receive little benefit from hospitalization. We sought to identify characteristics associated with the need for high-level inpatient care among emergency department patients presenting with skin and soft tissue infections.

Méthode : We conducted a nonconcurrent review of existing records to identify emergency department (ED) patients treated for skin and soft tissue infections. For each case, we recorded the presence or absence of select criteria and whether the patient needed high-level care, defined as ICU admission, operating room surgical intervention, or death as the primary outcome. We applied recursive partitioning to identify the principal criteria associated with high-level care.

Résultats : We identified 2,923 patients, including 84 experiencing high-level events. Recursive partitioning identified 6 variables associated with high-level outcomes: abnormal computed tomography, magnetic resonance imaging, or ultrasonographic imaging result; systemic inflammatory response syndrome; history of diabetes; previous infection at the same location; older than 65 years; and an infection involving the hand. One or more of these variables were present in all 84 patients requiring high-level care.

Conclusion : A limited number of simple clinical characteristics appear to be able to identify skin and soft tissue infection patients who require high-level inpatient services. Further research is needed to determine whether patients who do not exhibit these criteria can be safely discharged from the ED.

Conclusion (proposition de traduction) : Un nombre limité de caractéristiques cliniques simples (résultat anormal d'un scanner, d'une imagerie par résonance magnétique ou d'imagerie ultrasonographique ; syndrome de réponse inflammatoire systémique ; antécédents de diabète ; infection antérieure au même endroit ; plus de 65 ans ; et une infection de la main) semblent permettre d'identifier les patients atteints d'infections de la peau et des tissus mous qui nécessitent des services hospitaliers de haut niveau. D'autres recherches sont nécessaires pour déterminer si les patients qui ne répondent pas à ces critères peuvent quitter l'urgence en toute sécurité.

The Canadian Community Utilization of Stroke Prevention Study in Atrial Fibrillation in the Emergency Department (C-CUSP ED).
Parkash R, Magee K, McMullen M, Clory M, D'Astous M, Robichaud M, Andolfatto G, Read B, Wang J, Thabane L, Atzema C, Dorian P, Kaczorowski J, Banner D, Nieuwlaat R, Ivers N, Huynh T, Curran J, Graham I, Connolly S, Healey J. | Ann Emerg Med.  2019 Apr;73(4):382-392
Keywords: Aucun


Introduction : Lack of oral anticoagulation prescription in the emergency department (ED) has been identified as a care gap in atrial fibrillation patients. This study seeks to determine whether the use of a tool kit for emergency physicians with a follow-up community-based atrial fibrillation clinic resulted in greater oral anticoagulation prescription at ED discharge than usual care.

Méthode : This was a before-after study in 5 Canadian EDs in 3 cities. Patients who presented to the ED with atrial fibrillation were eligible for inclusion. The before phase (1) was retrospective; 2 after phases (2 and 3) were prospective: phase 2 used an oral anticoagulation prescription tool for emergency physicians and patient education materials, whereas phase 3 used the same prescription tool, patient materials, atrial fibrillation educational session, and follow-up in an atrial fibrillation clinic. Each phase was 1 year long. The primary outcome was the rate of new oral anticoagulation prescription at ED discharge for patients who were oral anticoagulation eligible and not receiving oral anticoagulation at presentation.

Résultats : A total of 631 patients were included. Mean age was 69 years (SD 14 years), 47.4% were women, and 69.6% of patients had a CHADS2 score greater than or equal to 1. The rate of new oral anticoagulation prescription in phase 1 was 15.8% compared with 54.1% and 47.2%, in phases 2 and 3, respectively. After multivariable adjustment, the odds ratio for new oral anticoagulation prescription was 8.03 (95% confidence interval 3.52 to 18.29) for phase 3 versus 1. The 6-month rate of oral anticoagulation use was numerically but not significantly higher in phase 3 compared with phase 2 (71.6% versus 79.4%; adjusted odds ratio 2.30; 95% confidence interval 0.89 to 5.96). The rate of major bleeding at 6 months was 0%, 0.8%, and 1% in phases 1, 2, and 3, respectively.

Conclusion : An oral anticoagulation prescription tool was associated with an increase in new oral anticoagulation prescription in the ED, irrespective of whether an atrial fibrillation clinic follow-up was scheduled. The use of an atrial fibrillation clinic was associated with a trend to a higher rate of oral anticoagulation at 6-month follow-up.

Conclusion (proposition de traduction) : Un outil de prescription d'anticoagulants oraux a été associé à une augmentation des nouvelles prescriptions d'anticoagulants oraux aux urgences, qu'un suivi clinique de la fibrillation atriale ait été prévu ou non. L'utilisation d'une approche clinique de la fibrillation auriculaire a été associée à la tendance d'une augmentation du taux d'anticoagulation orale lors du suivi à 6 mois.

What Signs Increase the Likelihood of Acute Aortic Dissection?.
Chien N, Casey PE, Gottlieb M. | Ann Emerg Med.  2019 Apr;73(4):400-402
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : The authors searched PubMed, MEDLINE, EMBASE, and the Cochrane databases from January 1968 to July 2016 for eligible studies, without language or age restrictions. The reference lists of all included studies, as well as articles citing the included studies on Google Scholar, were also searched. Additionally, the authors searched OpenSIGLE for conference abstracts and both ProQuest and DissOnline for dissertations and theses.

Méthode : The authors included studies of adult patients presenting to the emergency department (ED) with suspected acute aortic dissection that reported data on historical features, physical examination findings, or basic investigations (ie, chest radiograph, WBC count, or electrocardiography), with an outcome assessing the accuracy of these features. All patients must have received a reference standard, which could include computed tomography (CT), magnetic resonance imaging (MRI), or transesophageal echocardiography. Patients with a confirmed diagnosis of acute aortic dissection before enrollment were excluded. Two authors independently reviewed studies for inclusion, with disagreements resolved by discussion with inclusion of a third reviewer if agreement could not be reached.

Résultats : Two authors independently abstracted data from the individual studies, with disagreements resolved by discussion and, as necessary, in consultation with a third reviewer. Quality assessment was performed with the Quality Assessment of Diagnostic Accuracy Studies–2 and the Cochrane Risk of Bias tools. A bivariate random- effects model was used to calculate summary estimates. Heterogeneity was assessed with the I2 statistic and visually with forest plots.

Conclusion : This systematic review demonstrated that focal neurologic deficits, pulse deficits, and hypotension were suggestive of aortic dissection, whereas the majority of other traditional risk factors and symptoms (eg, history of hypertension, syncope, chest pain, abdominal pain, tearing pain, migrating pain) were weak predictors of aortic dissection. Although the high specificities with some of the included studies may help to increase one’s clinical suspicion of acute aortic dissection, the sensitivities were inadequate to exclude the disease.
Finally, the study prevalence of acute aortic dissection in this review was higher than what is observed in a typical community setting. As a result, the study population may not reflect the lower-risk population more common in most EDs, which may limit the applicability and generalizability when lower-risk populations are evaluated.

Conclusion (proposition de traduction) : Cette revue systématique a démontré que les déficits neurologiques focaux, les déficits du pouls et l’hypotension suggéraient une dissection aortique, alors que la majorité des autres facteurs de risque et symptômes traditionnels (p. ex. antécédents d'hypertension, syncope, douleur thoracique, douleur abdominale, douleur violente, douleur migratoire) étaient de faibles prédicteurs de la dissection aortique. Bien que les hautes spécificités de certaines des études incluses puissent contribuer à augmenter les suspicions cliniques de dissection aortique aiguë, les sensibilités étaient insuffisantes pour exclure la maladie.
Enfin, la prévalence de la dissection aortique aiguë dans cette revue était plus élevée que celle observée dans un contexte communautaire typique. Par conséquent, la population à l'étude peut ne pas refléter la population à faible risque plus commune dans la plupart des services d'urgence, ce qui peut limiter l'applicabilité et la généralisation lorsque des populations à faible risque sont évaluées.

In Patients With Acute Myocardial Infarction and No Hypoxemia, Does Oxygen Therapy Improve Outcomes Compared With No Supplemental Oxygen?.
Long B, April MD. | Ann Emerg Med.  2019 Apr;73(4):403-405
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Authors performed a systematic review and meta-analysis according to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta- analyses statements. Investigators searched MEDLINE, Web of Science, and Cochrane Collaboration of Clinical Trials, with no language restrictions. Authors searched reference lists of included studies, review articles, meta-analyses, and cardiovascular conferences and proceedings for other relevant studies.

Méthode : Authors included randomized controlled trials and observational studies evaluating outcomes in adults with acute myocardial infarction and no hypoxemia (definition dependent on individual study). Investigators included studies only if authors reported outcomes for patients in both the oxygen therapy arm and no oxygen therapy arm.

Résultats : Two investigators independently extracted data from included studies. Primary outcomes included all-cause mortality, recurrent ischemia or myocardial infarction, heart failure, and arrhythmia, which authors assessed with intention-to- treat analysis. Authors calculated random-effects summary risk ratios with 95% confidence intervals with DerSimonian and Laird models; they used a fixed-effect model for secondary analysis. Investigators assessed heterogeneity with I2 and publication bias with Egger’s method. Authors assessed evidence quality with the Cochrane tool for individual studies and the Grading of Recommendations Assessment, Development and Evaluation tool for evaluating overall evidence quality of each outcome.

Conclusion : Oxygen therapy does not reduce the risk of all-cause mortality, recurrent ischemia or myocardial infarction, heart failure, or arrhythmias compared with no supplemental oxygen therapy for patients with acute myocardial infarction and normal oxygen saturation.

Conclusion (proposition de traduction) : L'oxygénothérapie ne réduit pas le risque de mortalité toutes causes confondues, d'ischémie récurrente ou d'infarctus du myocarde, d'insuffisance cardiaque ou d'arythmies par rapport à l'absence d'oxygénothérapie complémentaire pour les patients ayant un infarctus aigu du myocarde et une saturation en oxygène normale.

Commentaire : Voir l'article AVOID de Stub D, Smith K, Bernard S and al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50  
Cette étude AVOID a rapporté une augmentation de la taille d’infarctus chez les patients mis sous oxygène et ayant présenté un infarctus du myocarde avec sus-décalage du segment ST.
Les recommandations 2017 de l'ESC (2017 ESC Guidelines for the management of acute myocardial infarction in patients presentingwithST-segmentelevation. Eur Heart J. 2018 Jan 7;39(2):119-177  ) ont conclu que l’oxygénothérapie dans le syndrome coronarien aigu avec sus-ST n'était indiquée que lors d’une hypoxémie, c’est-à-dire en cas de saturation en oxygène de moins de 90 % (< 9° %) ou d’une détresse respiratoire associée au SCA.

Emergency Medicine Journal

Accuracy of nature of call screening tool in identifying patients requiring treatment for out of hospital cardiac arrest.
Green JD, Ewings S, Wortham R, Walsh B. | Emerg Med J.  2019 Apr;36(4):203-207
Keywords: cardiac arrest; chain of survival and prehospital care; despatch; emergency ambulance systems; triage


Introduction : A new pre-triage screening tool, Nature of Call (NoC), has been introduced into the telephone triage system of UK ambulance services which employ National Health Service Pathways (NHSP). Its function is to provide rapid recognition of patients who may need immediate ambulance dispatch for out-of-hospital cardiac arrest (OHCA) and withholding dispatch for other calls while further triage is undertaken. In this study, we evaluated the accuracy of NoC and NHSP in identifying patients with potentially treatable or imminent OHCA.

Méthode : This retrospective, observational study reviewed consecutive calls to a UK ambulance service between October 2016 and February 2017 in which NOC, and then NHSP were applied sequentially. Only those calls for which a corresponding electronic Patient Clinical Record was available were included. Sensitivity and specificity of NOC and NHSP for recognition of an OHCA were determined by comparing allocated priority dispositions with an OHCA Treatment Registry (OHCATR).

Résultats : Of 96 423 calls received, 71 373 were reviewed. For 590 (0.8%) of these calls, the patients received treatment for OHCA. NOC identified 458 OHCATR patients; NHSP identified 467; together they identified 496. NoC captured 29 patients not identified by NHSP; NHSP captured 38 patients not identified by NOC. For NOC sensitivity was 77.6% (95% CI 74.1 to 80.8) and specificity 86.9% (95% CI 86.6 to 87.1). NHSP sensitivity was 79.2% (95% CI 75.7 to 82.2) and specificity 93.4% (95% CI 93.2 to 93.6). NoC and NHSP combined had a sensitivity of 84.1% (95% CI 80.9 to 86.8) and specificity of 85.3% (95% CI 85.1 to 85.6).

Conclusion : NoC and NHSP call categorisation each achieved similar sensitivity for the identification of OHCATR, identifying most of the same patients, but each captured unique patients. Using both methods sequentially improved accuracy. The 16% of OHCATR patients not identified by either method present a challenge to ambulance dispatch systems.

Conclusion (proposition de traduction) : La catégorisation des appels selon la nature de l'appel et les voies d'accès aux services de santé nationaux ont atteint une sensibilité similaire pour l'identification dans registre de la prise en charge des arrêts cardiaques extra-hospitaliers, identifiant la plupart des mêmes patients, mais chaque patient inclus est unique. L'utilisation des deux méthodes a permis d'améliorer séquentiellement la précision. Les 16 % des patients du Registre de traitement des arrêts cardiaques non identifiés par l'une ou l'autre méthode représentent un défi pour les systèmes de répartition des ambulances.

Commentaire : Le NHS Pathways est un logiciel de triage utilisé par le système de la santé publique (National Health Service) du Royaume-Uni pour trier les appels téléphoniques publics de soins médicaux et d'urgence.

Prehospital analysis of northern trauma outcome measures: the PHANTOM study.
Smith CA, Hardern RD, LeClerc S, Howes RJ. | Emerg Med J.  2019 Apr;36(4):213-218
Keywords: prehospital care, doctors In Phc; prehospital care, helicopter retrieval; trauma, research


Introduction : To compare the mortality and morbidity of traumatically injured patients who received additional prehospital care by a doctor and critical care paramedic enhanced care team (ECT), with those solely treated by a paramedic non-ECT.

Méthode : A retrospective analysis of Trauma Audit and Research Network (TARN) data and case note review of all severe trauma cases (Injury Severity Score ≥9) in North East England from 1 January 2014 to 1 December 2017 who were treated by the North East Ambulance Service, the Great North Air Ambulance Service or both. TARN methods were used to calculate the number of unexpected survivors or deaths in each group (W score (Ws)). The Glasgow Outcome Scores were contrasted to evaluate morbidity.

Résultats : The ECT group treated 531 patients: there were 17 unexpected survivors and no unexpected deaths. The non-ECT group treated 1202 patients independently: there were no unexpected survivors and 31 unexpected deaths. The proportion of patients requiring critical care interventions differed between the two groups 49% versus 33% (CI for difference 12% to 20%). In the ECT group, the Ws was 3.22 (95% CI 0.79 to 5.64). In the non-ECT group, the Ws was -2.97 (95% CI -1.22 to -4.71). The difference between the Ws was 6.18 (95% CI 3.19 to 9.17). There was no evidence of worse morbidity in the ECT group.

Conclusion : This is the first UK ECT service to demonstrate a risk-adjusted mortality benefit in trauma patients with no detriment in morbidity: our results demonstrate an additional 3.22 survivors per 100 severe trauma casualties when treated by an ECT. The authors encourage other ECT services to conduct similar research.

Conclusion (proposition de traduction) : Il s'agit du premier service de soins améliorés en équipe au Royaume-Uni à démontrer un bénéfice sur le taux de mortalité ajusté chez les patients traumatisés sans préjudice sur la morbidité : nos résultats montrent 3,22 survivants supplémentaires pour 100 victimes de traumatismes graves traités par une équipe de soins améliorés. Les auteurs encouragent d'autres équipes de soins améliorés à mener des recherches semblables.

Impact of instructor professional background and interim retesting on knowledge and self-confidence of schoolchildren after basic life support training: a cluster randomised longitudinal study.
Haseneder R, Skrzypczak M, Haller B, Beckers SK, Holch J, Wank C, Kochs E, Schulz CM. | Emerg Med J.  2019 Apr;36(4):239-244
Keywords: education; pre-hospital; resuscitation; resuscitation, training; teaching


Introduction : To increase the rate of bystander resuscitation, basic life support (BLS) training for schoolchildren is now recommended on a broad level. However, debate continues about the optimal teaching methods. In this study, we investigated the effects of a 90 min BLS training on female pupils' BLS knowledge and self-confidence and whether learning outcomes were influenced by the instructors' professional backgrounds or test-enhanced learning.

Méthode : We conducted a cluster randomised, longitudinal trial in a girls' grammar school in Germany from 2013 to 2014. Pupils aged 10-17 years were randomised to receive BLS training conducted by either emergency physicians or medical students. Using a multiple-choice questionnaire and a Likert-type scale, BLS knowledge and self-confidence were investigated before training (t0), 1 week (t1) and 9 months after training (t2). To investigate whether test-enhanced learning influenced learning outcomes, the questionnaire was administered 6 months after the training in half of the classrooms. The data were analysed using linear mixed-effects models.

Résultats : The study included 460 schoolchildren. BLS knowledge (mean number of correct answers) increased from 5.86 at t0 to 9.24 at t1 (p<0.001) and self-confidence (mean score on the Likert-type scale) increased from 8.70 at t0 to 11.29 at t1 (p<0.001). After 9 months, knowledge retention was good (8.94 at t2; p=0.080 vs t1), but self-confidence significantly declined from t1 to 9.73 at t2 (p<0.001). Pupils trained by medical students showed a slight but statistically significant greater increase in the knowledge at both t1 and t2, whereas instructors' background did not influence gain or retention of self-confidence. Retesting resulted in a marginally, non-significantly better retention of knowledge.

Conclusion : BLS training led to short-term gains in knowledge and self-confidence. Although knowledge was retained at 9 months after the training session, self-confidence significantly decreased. Interim testing did not appear to impact retention of knowledge or self-confidence. Medical students should be considered as instructors for these courses given their favourable learning outcomes and greater availability.

Conclusion (proposition de traduction) : La formation à la réanimation cardio-pulmonaire de base a permis d'acquérir à court terme des connaissances et de la confiance en soi. Bien que les connaissances aient été conservées 9 mois après la séance de formation, la confiance en soi a considérablement diminué. Les évaluations intérimaires ne semblent pas avoir d'impact sur la rétention des connaissances ou la confiance en soi.
Les étudiants en médecine devraient être considérés comme des instructeurs pour ces cours étant donné leurs résultats d'apprentissage favorables et leur plus grande disponibilité.

BET 1: High-flow nasal oxygen therapy in bronchiolitis.
Jaconelli T, Rajah F. | Emerg Med J.  2019 Apr;36(4):248-249
Keywords: Aucun


Editorial : A shortcut review was carried out to establish whether high-flow nasal oxygen was better than standard oxygen therapy in infants with signs and symptoms of bronchiolitis at reducing the need for escalation of therapy. Three papers 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. It is concluded that high-flow nasal oxygen has a role in the management of bronchiolitis and may reduce the need for escalation of therapy with patients with bronchiolitis under the age of 1 year.

Méthode : Pubmed advanced search 14 March 2019. (((high flow all fields) AND oxygen inhala- tion therapy [MeSH Terms])) AND ((bron- chiolitis[MeSH Terms]) OR bronchiolitis all fields) 71 results all cited refs included. The Cochrane Library date of searching 14 March 2019 (takes in Embase). MeSH term—bronchiolitis explode all trees AND high flow Title Abstract Keyword 79 records no unique relevancies.

Conclusion : High-flow oxygen has a role in the management of bronchiolitis and may reduce the need for escalation of therapy with patients with bronchiolitis under the age of 1 year.

Conclusion (proposition de traduction) : L'oxygénothérapie à haut débit joue un rôle dans la prise en charge thérapeutique de la bronchiolite et peut réduire la nécessité d'une intensification du traitement chez les enfants de moins d'un an présentants une bronchiolite.

BET 2: Pain management in patients who show awareness during CPR.
Lundsgaard RS, Lundsgaard KS. | Emerg Med J.  2019 Apr;36(4):249-250
Keywords: Aucun


Editorial : A shortcut review was carried out to establish whether pin management or sedation is indicated to improve outcome in patients who show signs of awareness during cardiopulmonary resuscitation (CPR). Seven papers 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. It is concluded that awareness during CPR or CPR-induced consciousness is rare but increasingly reported. Further research is needed before definite guidance can be given. Local advice should be followed.

Conclusion : Awareness during cardiopulmonary resuscitation (CPR) or CPR-induced consciousness is rare but increasingly reported. Further research is needed before definite guidance can be given. Local advice should be followed.

Conclusion (proposition de traduction) : La prise de conscience au cours d'une réanimation cardiorespiratoire (RCP) ou induite par la RCP est rare mais de plus en plus rapportée. Des recherches supplémentaires sont nécessaires avant de pouvoir donner des recommandations précises. Les protocoles locaux doivent être suivis.

European Journal of Emergency Medicine

Analysing blood from intraosseous access: a systematic review.
Jousi M, Laukkanen-Nevala P, Nurmi J. | Eur J Emerg Med.  2019 Apr;26(2):77-85
Keywords: Aucun


Editorial : Intraosseous (IO) access is used widely as an optional vascular route for critically ill patients. It is still unclear whether the IO access can be used as a source for emergency blood samples. The aim of this study was to systematically review the existing literature on the usability of IO blood samples for analysing the parameters relevant to emergency care. We performed a data search from the Medline and Embase databases, the Cochrane Library and the Clinical trials registry. Animal studies and studies with healthy and ill adults and children were included in the search. The data were collected and reported following the PRISMA guidelines. The PROSPERO database registration number of this review is CRD42017064194. We found 27 studies comparing the blood samples from the IO space with arterial or venous samples, but only three of them followed the recommended guidelines for method comparison studies. The study populations were heterogeneous, and the sample sizes were relatively small (14, 17 and 20 individuals) in the three studies. The results of specific laboratory parameters were scarce and discordant. The evidence on the agreement between IO and arterial and venous samples is still weak. Existing studies with healthy volunteers and animal models provide important insight into the analyses of IO samples, but more evidence, especially from haemodynamically unstable patients, is needed for wider implementation of IO blood sampling in critically ill patients.

Conclusion : Twenty-seven studies were found in which the blood samples from the IO space were compared with arterial or venous samples, but only three of these studies followed the recommended statistical guidelines for method comparison studies. The study populations were het- erogeneous, and the sample sizes were relatively small in the three studies. Studies with healthy volunteers and animal models provide important insight into the matter, but evidence from haemodynamically unstable patients is needed for implementation of IO blood sampling in critically ill emergency patients. Even if some guidelines recommend carrying out a laboratory analysis from IO samples, the level of evidence on the agreement is still weak.

Conclusion (proposition de traduction) : Vingt-sept études ont été trouvées dans lesquelles les échantillons de sang de l'abord intra-osseux ont été comparés à des échantillons artériels ou veineux, mais seulement trois de ces études ont suivi les directives statistiques recommandées pour les études comparatives de méthodes. Les populations étudiées étaient hétérogènes et la taille des échantillons était relativement petite dans les trois études. Des études sur des volontaires sains et des modèles animaux fournissent des informations importantes à ce sujet, mais des données probantes sur des patients hémodynamiquement instables sont nécessaires à la mise en œuvre d'un prélèvement sanguin de l'abord intra-osseux chez des patients en phase critique. Même si certaines directives recommandent de réaliser une analyse de laboratoire à partir d'échantillons de l'abord intra-osseux, le niveau de preuve de l'accord est encore faible.

Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department.
Öhman J, Harjola VP, Karjalainen P, Lassus J. | Eur J Emerg Med.  2019 Apr;26(2):112-117
Keywords: Aucun

Original articles

Introduction : The aim of this study was to evaluate the performance of a rapid cardiothoracic ultrasound protocol (CaTUS), combining echocardiographically derived E/e' and lung ultrasound (LUS), for diagnosing acute heart failure (AHF) in patients with undifferentiated dyspnea in an emergency department (ED).

Résultats : We enrolled 100 patients with undifferentiated dyspnea from a tertiary care ED, who all had CaTUS done immediately upon arrival in the ED. CaTUS was positive for AHF with an E/e' > 15 and congestion, that is bilateral B-lines or bilateral pleural fluid, on LUS. In addition, an inferior vena cava index was also recorded to analyze whether including a central venous pressure estimate would add diagnostic benefit to the CaTUS protocol. All 100 patients had a brain natriuretic peptide (BNP) sample withdrawn, and 96 patients underwent chest radiography in the ED, which was analyzed later by a blinded radiologist. The reference diagnosis of AHF consisted of either a BNP of more than 400 ng/l or a BNP of less than 100 ng/l in combination with congestion on chest radiography and structural heart disease on conventional echocardiography.CaTUS had a sensitivity of 100% (95% confidence interval: 91.4-100%), a specificity of 95.8% (95% confidence interval: 84.6-99.3%), and an area under the curve of 0.979 for diagnosing AHF (P<0.001). The diagnostic accuracy of CaTUS was higher than of either E/e' or LUS alone. Adding the inferior vena cava index to CaTUS did not improve diagnostic accuracy. CaTUS seemed helpful also for differential diagnostics of dyspnea, mainly regarding pneumonias and pulmonary embolisms.

Conclusion : CaTUS, combining E/e' and LUS, provided excellent accuracy for diagnosing AHF.

Conclusion (proposition de traduction) : Le protocole d’échographie cardiothoracique, combinant l’analyse échographique de l'onde E/e' et l'échographie pulmonaire, a fourni une excellente précision pour le diagnostic de l’insuffisance cardiaque aiguë.

The utility of clinical ultrasonography in identifying distal forearm fractures in the pediatric emergency department.
Galletebeitia Laka I, Samson F, Gorostiza I, Gonzalez A, Gonzalez C. | Eur J Emerg Med.  2019 Apr;26(2):118-122
Keywords: Aucun

original articles

Introduction : The aim of this study is to evaluate the utility of Point-Of-Care Ultrasound (POCUS) for diagnosing distal forearm fractures in pediatric emergency departments (ED).

Méthode : A prospective observational study was carried out in children aged younger than 15 years attended in an ED with an indication of radiography because of a suspected distal forearm fracture. The POCUS was performed considering cortical irregularity or disruption compatible with fracture. Then, the radiography was requested and the patient was evaluated by an ED traumatologist. Both tests were blinded to each other. The radiograph was considered to be the reference diagnostic test. Diagnostic validation tests were performed.

Résultats : A total of 115 patients [mean age: 9.1 (SD: 3.1) years; 50.4% males] were included, with 57 of these presenting fractures: 42 (73.7%) single bone fractures and 15 (26.3%) combined fractures of the radius and ulna. As such, 72 fractures were detected (prevalence 31.3%). The sensitivity and specificity of POCUS for detecting fractures were 94.4% [95% confidence interval (CI): 86.4-98.5] and 96.8% (95% CI: 92.8-99.0), respectively. The positive and negative predictive values were 93.2% (95% CI: 84.7-97.7) and 97.5% (95% CI: 93.6-99.3), respectively.

Conclusion : POCUS enables the clinical diagnosis of distal forearm fractures in ED. In addition, this is a highly accurate technique that can be applied easily by the ED pediatrician. As such, its inclusion as part of the physical examination could improve the accuracy of the clinical diagnosis and the global management of the patient.

Conclusion (proposition de traduction) : L'échographie au point d'intervention permet le diagnostic clinique des fractures de l'avant-bras distal dans les services d'urgence. De plus, il s’agit d’une technique extrêmement précise qui peut être facilement appliquée par le pédiatre des services d’urgence. En tant que tel, son inclusion dans l'examen physique pourrait améliorer la précision du diagnostic clinique et la gestion globale du patient.

Are on-scene blood transfusions by a helicopter emergency medical service useful and safe? A multicentre case-control study.
Peters JH, Smulders PSH, Moors XRJ, Bouman SJM, Meijs CMEM, Hoogerwerf N, Edwards MJR. | Eur J Emerg Med.  2019 Apr;26(2):128-132
Keywords: Aucun

Original articles

Introduction : In the prehospital setting, crystalloid fluids are frequently used, but only erythrocytes are capable of transporting oxygen to tissues. The aim of this study was to establish the efficacy and safety of the prehospital use of uncross matched type O rhesus-negative packed red blood cells (URBC) by the Dutch physician-staffed helicopter emergency medical service. We hypothesized that prehospital URBC transfusions are safe and more effective with respect to survival than resuscitations with crystalloids.

Méthode : The effects of prehospital URBC transfusions were studied by comparing a cohort of patients (>18 years) who were treated with a combination of URBC and crystalloid fluids with a matched control group of patients who received crystalloid fluids alone.

Résultats : Among 73 adults who received prehospital URBC transfusions, 50 (68%) patients were included. No transfusion reactions were observed. No effect of prehospital transfusion on 24-h or 30-day survival was found. Haemoglobin levels at presentation to the emergency department were higher in the URBC cohort. The two groups had similar cumulative erythrocyte requirements within the first 24 h.

Conclusion : Neither survival benefits nor a decreased incidence of shock on admission were observed after prehospital helicopter emergency medical service URBC transfusions. There were no prehospital transfusion reactions in this study; therefore, URBC transfusions were deemed to be safe. A prospective randomized study is warranted to evaluate the effect of early URBC transfusions and transfusions with preheated URBC on the survival of patients with severe prehospital haemorrhagic shock.

Conclusion (proposition de traduction) : Ni avantages de survie ni diminution de l'incidence de choc à l'admission n'ont été observés après des transfusions de globules rouges dans les services médicaux préhospitaliers en hélicoptère. Il n’y a pas eu de réactions transfusionnelles préhospitalières dans cette étude ; par conséquent, les transfusions de globules rouges ont été jugées sans danger.
Une étude prospective randomisée est justifiée pour évaluer l'effet des transfusions précoces de globules rouges et des transfusions de globules rouges préchauffés sur la survie des patients présentant un choc hémorragique préhospitalier sévère.

Beware of the force of the horse: mechanisms and severity of equestrian-related injuries.
Van Balen PJ, Barten DG, Janssen L, Fiddelers AAA, Brink PR, Janzing HMJ. | Eur J Emerg Med.  2019 Apr;26(2):133-138
Keywords: Aucun

Original articles

Introduction : Equestrian-related injuries (ERIs) are relatively severe compared with injuries in other popular sports. Previous studies on epidemiology of ERIs vary widely and mainly focus on incidence instead of severity of the injury.
PURPOSE: The aim of this study was to determine incidence, mechanisms and severity of ERIs in two Dutch hospitals (level 1 and level 2 trauma centers) over a 5-year period.

Méthode : All patients with ERIs who visited the emergency departments of VieCuri Medical Centre in Venlo and Maastricht University Medical Centre+ in Maastricht, The Netherlands, between July 2010 and June 2015 were retrospectively included. Clinical data were extracted from medical records.

Résultats : Most ERIs occurred in mounted riders (646 events; 68%); 94.9% of which involved a fall. Being kicked (42.5%) or trapped (30.1%) was the most common cause of injury in unmounted riders. Most frequently injured body parts were the upper extremities (43.8%) in mounted riders and lower extremities (40.5%) in the unmounted group. A relatively high percentage of facial injuries (9.7%) were found in the unmounted group. Seventeen per cent of all ERIs required admission. The median Injury Severity Score was 5 in the admitted population and 1 in the total population.

Conclusion : Horseback riding is a risky activity. Prior studies particularly studied admitted patients in level 1 trauma centers outside of Europe and demonstrated a high risk of significant injury. However, our study demonstrates that these studies in selected groups might have overestimated the severity of Equestrian-related injuries in the general population.

Conclusion (proposition de traduction) : L'équitation est une activité risquée. Des études antérieures ont particulièrement étudié les patients admis dans des centres de traumatologie de niveau 1 situés en dehors de l'Europe et ont démontré un risque élevé de blessure grave.
Cependant, notre étude démontre que ces études dans des groupes sélectionnés pourraient avoir surestimé la gravité des blessures liées aux sports équestres dans la population générale.

Internal and Emergency Medicine

Is there a role for lumbar puncture in early detection of subarachnoid hemorrhage after negative head CT?.
Tulla M, Tillgren T, Mattila K. | Intern Emerg Med.  2019 Apr;14(3):451-457
Keywords: Cerebrospinal fluid; Computed tomography; Headache; Lumbar puncture; Subarachnoid hemorrhage


Introduction : To investigate the role of lumbar puncture (LP) after a negative head computed tomography (CT) when ruling out subarachnoid hemorrhage (SAH) within 24 h of symptom onset.

Méthode : In a single-center, retrospective cohort study, we studied a consecutive series of patients from 2011 to 2015. All patients underwent CT or CT following LP to rule out SAH. Patients were categorized into four groups depending on the time of symptom onset to initial head CT: 0-6 h, 6-12 h, 12-24 h, and over 24 h. Experienced radiologists interpreted all CT scans. We investigated the sensitivity, specificity, and negative predictive value (NPV) of noncontrast CT in detecting SAH.

Résultats : Of 539 patients with suspected SAH and negative CT, 280 (51.9%) had their CT performed within 24 h of symptom onset. None of these patients had SAH. Five (1.9%) out of 259 patients with CT performed after 24 h of symptom onset had SAH diagnosed, and two turned out to be aneurysmal. When CT was performed within 24 h of symptom onset it had a sensitivity of 100% (95% CI 95-100%), specificity of 98% (95% CI 96-99.7%), and NPV of 100% (95% CI 98-100%) in detecting SAH.

Conclusion : Modern CT scanners seem to have high sensitivity and specificity in the diagnosis of SAH when performed within 24 h of symptom onset. Beyond this point, CT seems to lack sensitivity and further investigation with LP is required.

Conclusion (proposition de traduction) : Les tomodensitomètres modernes semblent présenter une sensibilité et une spécificité élevées dans le diagnostic de hémorragie méningée aigüe lorsqu'ils sont effectués dans les 24 heures suivant l'apparition des symptômes.
Au-delà de ce point, la tomodensitométrie semble manquer de sensibilité et des investigations supplémentaires dont la ponction lombaire sont nécessaires.

Prognostic value of sepsis-induced coagulation abnormalities: an early assessment in the emergency department.
Innocenti F, Gori AM, Giusti B, Tozzi C, Donnini C, Meo F, Giacomelli I, Ralli ML, Sereni A, Sticchi E, Zari M, Caldi F, Tassinari I, Zanobetti M, Marcucci R, Pini R. | Intern Emerg Med.  2019 Apr;14(3):459-466
Keywords: Coagulation abnormalities; Prognostic stratification; Sepsis


Introduction : To evaluate if the assessment of coagulation abnormalities at ED admission could improve prognostic assessment of septic patients.

Méthode : This report utilizes a portion of the data collected in a prospective study, with the aim to identify reliable biomarkers for an early sepsis diagnosis. In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis severe sepsis/septic shock. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24): D-dimer, thrombin-antithrombin complex (TAT) and prothrombin fragment F1 + 2 levels were analyzed. The primary end-points were day-7 and in-hospital mortality. Day-7 mortality rate was 16%.

Résultats : D-dimer (T0: 4661 ± 4562 µg/ml vs 3190 ± 7188 µg/ml; T6: 4498 ± 4931 µg/ml vs 2822 ± 5623 µg/ml; T24 2905 ± 2823 µg/ml vs 2465 ± 4988 µg/ml, all p < 0.05) and TAT levels (T0 29 ± 45 vs 22 ± 83; T6 21 ± 22 vs 15 ± 35; T24 16 ± 19 vs 13 ± 30, all p < 0.05) were higher among non-survivors compared to survivors. We defined an abnormal coagulation activation (COAG+) as D-dimer > 500 µg/ml and TAT > 8 ng/ml (for both, twice the upper normal value). Compared to COAG-, COAG+ patients showed higher lactate levels at the earliest evaluations (T0: 3.3 ± 2.7 vs 2.5 ± 2.3, p = 0.041; T6: 2.8 ± 3.4 vs 1.8 ± 1.6, p = 0.015); SOFA score was higher after 24 h (T24: 6.7 ± 3.1 vs 5.4 ± 2.9, p = 0.008). At T0, COAG+ patients showed a higher day-7 mortality rate (HR 2.64; 95% CI 1.14-6.11, p = 0.023), after adjustment for SOFA score and lactate level.

Conclusion : Presence of abnormal coagulation at ED admission shows an independent association with an increased short-term mortality rate.

Conclusion (proposition de traduction) : La présence d'une anomalie de la coagulation à l'admission aux urgences montre une association indépendante avec une augmentation du taux de mortalité à court terme.

Pitfalls in the triage and evaluation of patients with suspected acute ethanol intoxication in an emergency department.
Dugas S, Favrod-Coune T, Poletti PA, Huwyler T, Richard-Lepouriel H, Simon J, Sarasin FP, Rutschmann OT. | Intern Emerg Med.  2019 Apr;14(3):467-473
Keywords: Alcoholic intoxication; Emergency service (Hospital); Left without being seen; Triage


Introduction : Acute ethanol intoxication (AEI) is frequent in emergency departments (EDs). These patients are at risk of mistriage, and to leave the ED without being seen. This study's objective was to describe the process and performance of triage and trajectory for patients with suspected AEI.

Méthode : Retrospective, observational study on adults admitted with a suspected AEI within 1 year at the ED of an urban teaching hospital. Data on the triage process, patients' characteristics, and their ED stay were extracted from electronic patient records. Predictors for leaving without being seen were identified using logistic regression analyzes.

Résultats : Of 60,488 ED patients within 1 year, 776 (1.3%) were triaged with suspected AEI. This population was young (mean age 38), primarily male (64%), and professionally inactive (56%). A large proportion were admitted on weekends (45%), at night (46%), and arrived by ambulance (85%). The recommendations of our triage scale were entirely respected in a minority of cases. In 22.7% of triage situations, a triage reason other than "alcohol abuse/intoxication" (such as suicidal ideation, head trauma or other substance abuse) should have been selected. Nearly, half of the patients (49%) left without being seen (LWBS). This risk was especially high amongst men (OR 1.56, 95% CI 1.12-2.19), younger patients (< 26 years of age; OR 1.97, 95% CI 1.16-3.35), night-time admissions (OR 1.97, 95% CI 1.16-3.35), and patients assigned a lower emergency level (OR 2.32, 95% CI 1.58-3.42).

Conclusion : Despite a standardized triage protocol, patients admitted with suspected AEI are at risk of poor assessment, and of not receiving optimal care.

Conclusion (proposition de traduction) : Malgré un protocole de triage normalisé, les patients admis pour une suspicion d'intoxication éthylique aiguë risquent d'être mal évalués et de ne pas recevoir les meilleurs soins.

Rapid rule-out of suspected acute coronary syndrome in the Emergency Department by high-sensitivity cardiac troponin T levels at presentation.
Fabbri A1, Bachetti C, Ottani F, Morelli A, Benazzi B, Spiezia S, Cortigiani M, Dorizzi R, Jaffe AS, Galvani M. | Intern Emerg Med.  2019 Apr;14(3):403-410
Keywords: Emergency department; Myocardial infarction; Suspected non-ST-segment elevation acute coronary syndrome; Undetectable high-sensitivity cardiac troponin T


Introduction : The reliability of initial high-sensitivity cardiac troponin T (hs-cTnT) under limit-of-detection in ruling-out short- and long-term acute coronary events in subjects for suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not definitely settled.

Méthode : In a retrospective chart review analysis, 1001 subjects with hs-cTnT ≤ 14 ng/L out of 4053 subjects with hs-cTnT measured at Emergency Department (ED) presentation were recruited. The main outcome measure is fatal or non-fatal myocardial infarction (MI) within 30 days; secondary outcomes are MI or major acute coronary events (MACE) as a combination of MI or re-hospitalization for unstable angina within 1 year.

Résultats : In subjects with hs-cTnT < 5 ng/L [32.6% of cases, mean age 63 years (interquartile range 23)], no cases (0%, NPV 100%) had MI within 30 days, 2 cases (0.6%, NPV 99.4%) MI at 1-year, and 11 cases (3.4%, NPV 96.6%) MACE at 1-year. Patients with hs-cTnT < 5 ng/L would have benefited from a shortened decision (9.30 h and 53% overnight ED stay saved).

Conclusion : Hs-cTnT < 5 ng/L is confirmed as safe for patients and comfortable for physicians in ruling out MI or MACE both at short and long term, suggesting that a sizable number of patients can be rapidly discharged without unnecessary diagnostic tests and ED observation.

Conclusion (proposition de traduction) : Hs-cTnT < à 5 ng/L est confirmé comme étant sans danger pour les patients et sûr pour les médecins pour exclure un infarctus du myocarde ou des événements coronariens aigus majeurs à court et à long terme, ce qui suggère qu'un nombre non négligeable de patients pruraient sortir rapidement sans tests de diagnostic inutiles et observation au service des urgences.

Short- vs long-course antibiotic therapy for pneumonia: a comparison of systematic reviews and guidelines for the SIMI Choosing Wisely Campaign.
Furlan L, Erba L, Trombetta L, Sacco R, Colombo G, Casazza G, Solbiati M, Montano N, Marta C, Sbrojavacca R, Perticone F, Corazza GR, Costantino G. | Intern Emerg Med.  2019 Apr;14(3):377-394
Keywords: Antibiotic treatment; Choosing wisely; Guidelines; Infection; Pneumonia; Systematic review


Introduction : Reduction of the inappropriate use of antibiotics in clinical practice is one of the main goals of the Società Italiana di Medicina Interna (SIMI) choosing wisely campaign. We conducted a systematic review of secondary studies (systematic reviews and guidelines) to verify what evidence is available on the duration of antibiotic treatment in Pneumonia.

Méthode : A literature systematic search was performed to identify all systematic reviews and the three most cited and recent guidelines that address the duration of antibiotic therapy in pneumonia. Moreover, a meta-analysis of non-duplicate data from randomized controlled trials (RCTs) considered in the enrolled systematic reviews was performed together with a trial sequential analysis to identify the need for further studies.

Résultats : Two systematic reviews on antibiotic duration in community-acquired pneumonia (CAP) for a total of 17 RCTs (2764 patients) were enrolled in our study. Meta-analysis of non-duplicate RCTs show a non-significant difference in rate of treatment failure between short (≤ 7 days) and long (> 7 days) antibiotic treatment course: RR 1.05 (95% CI, 0.82-1.36). The trial sequential analysis suggests that further data would not affect current evidence or become clinically relevant. Selected guidelines suggest consideration of a short course, with a low grade of evidence and without citing the already published systematic reviews.

Conclusion : Antibiotic treatment of CAP for ≤ 7 days is not associated with a higher rate of treatment failure than longer courses and should thus be taken in consideration. Guidelines should upgrade the evidence on this topic.

Conclusion (proposition de traduction) : Le traitement antibiotique de la pneumonie communautaire pendant ≤ 7 jours n'est pas associé à un taux d'échec du traitement plus élevé que les traitements plus longs et doit donc être pris en compte.
Les recommandations devraient améliorer les preuves sur ce sujet.

International Journal of Emergency Medicine

Differences in initial electrocardiographic findings between ST-elevation myocardial infarction due to left main trunk and left anterior descending artery lesions.
Fujii T, Hasegawa M, Miyamoto J, Ikari Y. | Int J Emerg Med.  2019 December;12:12
DOI:  | Télécharger l'article au format  
Keywords: Electrocardiography; ST-elevation myocardial infarction; Left main trunk; Left anterior descending artery; ST-segment elevation; ST-segment depression

Original Research

Introduction : Early discrimination of ST-elevation myocardial infarction (STEMI) due to a left main trunk (LMT) lesion provided by straightforward electrocardiographic criteria is useful for prompt treatment. The purpose of this study is to investigate differences in electrocardiographic findings between STEMI due to lesions of LMT and those of left anterior descending artery (LAD).

Méthode : Initial electrocardiogram (ECG) recordings of 435 patients with analyzable ECGs from a cohort of 940 consecutive STEMI patients were analyzed retrospectively for presence of LMT lesions (LMT, n = 39), proximal (pLAD, n = 224) and distal LAD lesions (dLAD, n = 172). ST-segment deviations in 12 leads were assessed among 3 groups without bundle branch block (n = 17 in LMT, n = 180 in pLAD, and n = 159 in dLAD).

Résultats : Magnitudes of ST-segment deviations showed significant differences in leads II, III, aVR aVL, aVF, and V2–V6 across the three groups. This difference suggested two possible characteristic findings in the LMT group, allowing it to be distinguished from the pLAD or dLAD group; (A) larger magnitude of ST-segment depression in lead II than that of ST-segment elevation in lead V2 (47.1% in LMT vs. 0.6% in pLAD vs. 1.3% in dLAD, P < 0.0001), and (B) ST-segment depression in lead V5 (58.8% in LMT vs. 6.7% in pLAD vs. 2.5% in dLAD, P < 0.0001). These findings exhibited superior negative predictive value over conventional ST-segment elevation in lead aVR.

Conclusion : A large reciprocal ST-segment depression in inferior leads and ST-segment depression in lead V5 are useful ECG findings allowing determination of STEMI due to an LMT lesion.

Conclusion (proposition de traduction) : Un sous-décalage réciproque du segment ST dans les dérivations inférieures et un sous-décalage du segment ST dans la dérivation V5 sont des résultats ECG utiles permettant de diagnostiquer un infarctus du myocarde avec élévation du segment ST en raison d'une lésion du tronc principal gauche.

Journal of Antimicrobial Chemotherapy

Tolerability of high-dose ceftriaxone in CNS infections: a prospective multicentre cohort study.
Le Turnier P, Le Turnier P, Navas D, Garot D, Guimard T, Bernard L, Tattevin P, Vandamme YM, Hoff J, Chiffoleau A, Dary M, Leclair-Visonneau L, Grégoire M, Pere M, Boutoille D, Sébille V, Dailly E, Asseray 1; High-Dose Ceftriaxone CNS Infections Study Group. | J Antimicrob Chemother.  2019 April;74(4):1078–1085
Keywords: Aucun


Introduction : Ceftriaxone is widely used to treat community-acquired CNS bacterial infections. French guidelines for meningitis in adults promote 75-100 mg/kg/day ceftriaxone without an upper limit for dosage, yet little is known about the pharmacology and tolerability of such regimens.

Méthode : A multicentre prospective cohort study was conducted in adult patients to assess the adverse drug reactions (ADRs) of high-dose ceftriaxone (i.e. daily dosage ≥ 4 g or ≥ 75 mg/kg) in CNS infections and to analyse their related factors. Drug causality was systematically assessed by an expert committee who reviewed the medical charts of all included patients.

Résultats : A total of 196 patients were enrolled over a 31 month period. Median dosage and duration of ceftriaxone were 96.4 mg/kg/day (7 g/day) and 8 days, respectively. Nineteen ceftriaxone-related ADRs (mainly neurological) occurred in 17 patients (8.7%), with only one case of treatment discontinuation (biliary pseudolithiasis). In univariate analysis, older age, male gender, renal impairment and high trough ceftriaxone plasma concentration were associated with ceftriaxone-related ADRs.

Conclusion : High-dose ceftriaxone for CNS infection administered as recommended by French guidelines in adults was well tolerated overall, suggesting these recommendations could be applied and generalized. In patients with advanced age or renal insufficiency, prescription should be done with caution and therapeutic drug monitoring could be useful.

Conclusion (proposition de traduction) : La ceftriaxone à forte dose dans le traitement de l'infection du système nerveux central, administrée conformément aux recommandations des directives françaises en vigueur chez l'adulte, a été bien tolérée dans l'ensemble, ce qui suggère que ces recommandations pourraient être appliquées et généralisées. Chez les patients présentant un âge avancé ou une insuffisance rénale, la prescription doit être faite avec prudence et une surveillance thérapeutique du médicament pourrait être utile.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Evaluation de la tolérance des doses élevées de Ceftriaxone au cours du traitement des infections du SNC  . Rédigé par le Dr Jean-Pierre Bru.
Interprétation/commentaires :
Peu d’informations étaient disponibles quant à la tolérance de fortes doses de ceftriaxone. D’autant que les recommandations nord-américaines ou européennes ne proposent pas de doses aussi élevées (4 g/j). Ce travail est donc bienvenu pour nous rassurer quant à la sécurité à l’emploi de ces doses de ceftriaxone. On ne discutera pas ici le bien fondé de nos recommandations…

La Revue Sage-Femme

Schmitz T, Sentilhes L, Lorthe E, Gallot D, Madar H, Doret-Dion M, Beucher G, Charlier C, Cazanave C, Delorme P, Garabedian C, Azria E, Tessier V, Senat MV, Kayem G. | Rev Sage-femme.  2019 April;18(2):107-114
Keywords: Aucun

Recommandations pour la pratique clinique

Introduction : Déterminer la prise en charge des patientes avec une rupture prématurée des membranes avant 37 semaines d’aménorrhée (SA).

Méthode : Synthèse de la littérature à partir des bases de données PubMed et Cochrane et des recommandations des sociétés et collèges français et étrangers.

Résultats : En France, la fréquence de la rupture prématurée des membranes (RPM) est de 2 à 3 % avant 37 SA (Niveau de preuve [NP] 2) et de moins de 1 % avant 34 SA (NP2). La prématurité et l’infection intra-utérine sont les complications majeures de la RPM avant terme (NP2). La prolongation de la durée de latence est bénéfique (NP2). Par rapport aux autres causes de prématurité, la RPM avant terme n’est pas associée à un sur-risque évident de morbi-mortalité néonatale, sauf en cas d’infection intra-utérine, qui est associée à une augmentation des morts fœtales in utero (NP3), des infections néonatales précoces (NP2) et des entérocolites ulcéronécrosantes (NP2). Le diagnostic de la RPM avant terme est principalement clinique (accord professionnel). En cas de doute diagnostique, il est recommandé d’utiliser les tests de détection d’IGFBP-1 ou de PAMG-1 (accord professionnel). Il est recommandé d’hospitaliser les patientes lors du diagnostic de RPM avant terme (accord professionnel). Il n’existe pas d’argument suffisant pour recommander ou ne pas recommander une tocolyse initiale (grade C). Si une tocolyse était prescrite, il est recommandé de ne pas la prolonger plus de 48 heures (grade C). Il est recommandé d’administrer une cure anténatale de corticoïdes si l’âge gestationnel est inférieur à 34 SA (grade A) et du sulfate de magnésium en cas d’accouchement imminent avant 32 SA (grade A). Il est recommandé de prescrire une antibioprophylaxie à l’admission (grade A) pour réduire la morbidité néonatale et maternelle (NP1). L’amoxicilline, les céphalosporines de 3ème génération et l’érythromycine (accord professionnel) peuvent être utilisées en monothérapie, ou l’association érythromycine–amoxicilline (accord professionnel), pour une durée de 7 jours (grade C). Toutefois, un arrêt précoce de l’antibioprophylaxie semble acceptable en cas de prélèvement vaginal initial négatif (accord professionnel). Il n’est pas recommandé de prescrire comme antibioprophylaxie l’association amoxicilline-acide clavulanique (accord professionnel), des aminosides, des glycopeptides, des céphalosporines de première ou deuxième génération, de la clindamycine ou du métronidazole (accord professionnel).

Discussion : La prise en charge à domicile des patientes cliniquement stables après au moins 48 heures de surveillance hospitalière est possible (accord professionnel). Au cours de la surveillance, il est recommandé d’identifier les éléments cliniques et biologiques évocateurs d’une infection intra-utérine (accord professionnel). Il n’est pas possible d’émettre de recommandations sur la fréquence de cette surveillance (accord professionnel). En cas d’examen de surveillance isolément positif chez une patiente asymptomatique (CRP augmentée, hyperleucocytose, prélèvement vaginal positif), il n’est pas recommandé d’initier systématiquement une antibiothérapie (accord professionnel). En cas d’infection intra-utérine, il est recommandé d’administrer immédiatement une antibiothérapie associant une bêtalactamine à un aminoside (grade B), par voie intraveineuse (grade B) et de faire naître l’enfant (grade A). La césarienne en cas d’infection intra-utérine est réservée aux indications obstétricales habituelles (accord professionnel). Il est recommandé d’avoir une attitude expectative en cas de RPM non compliquée avant 37 SA (grade A), même en cas de prélèvement positif pour le streptocoque B, sous couvert d’une antibioprophylaxie à l’admission (accord professionnel). L’ocytocine et les prostaglandines sont deux options envisageables pour le déclenchement du travail en cas de RPM avant terme (accord professionnel).

Conclusion (proposition de traduction) : La prise en charge de la rupture prématurée des membranes avant terme non compliquée repose sur l’expectative jusqu’à 37 SA (grade A).

Commentaire : Republication de : Rupture prématurée des membranes avant terme : recommandations pour la pratique clinique du CNGOF — Texte court. Gynécologie Obstétrique Fertilité & Sénologie , Volume 46, Issue 12, December 2018, Pages 998-1003

Le Praticien en Anesthésie Réanimation

Estebe JP | Prat Anesth Reanim.  2019 April;23(2):72-76
Keywords: Lidocaine; Postoperative analgesia; Opioid free anaesthesia

Mise au point

Editorial : L’administration intraveineuse continue de lidocaïne s’est imposée comme une modalité de prise en charge de la douleur du fait d’une épargne morphinique, d’un raccourcissement de la durée de l’iléus postopératoire et de la durée d’hospitalisation en chirurgie viscérale. La lidocaïne possède, d’autre part, des effets anti-inflammatoires qui rendent compte de son action. En raison d’un risque toxique, il n’est pas recommandé d’associer une technique d’anesthésie locorégionale avec l’administration intraveineuse de lidocaïne.

Conclusion (proposition de traduction) : Si les mécanismes d’action de la lidocaïne restent encore incomplètement compris, son bénéfice analgésique, en particulier lors d’administration IV continue est trop important pour ne pas faire partie de l’arsenal thérapeutique d’une analgésie multimodale pouvant aller jusqu’à l’anesthésie sans morphinique (OFA). Son effet s’intègre parfaitementdans les programmes de RRAC et s’accompagne d’une amélioration de la satisfaction des patients.

Commentaire : Voir l'article sur le même sujet : Intravenous lidocaine. Best Practice & Research Clinical Anaesthesiology 2017 dec;31:513-521  . Rédigé par le Dr Jean-Pierre Estebe en décembre 2017.

Bernard F, Rieul G, Fusco N, Hugot P, Guillou N, Muselle H. | Prat Anesth Reanim.  2019 April;23(2):77-81
Keywords: Hypnosis; Regional anaesthesia


Editorial : Les processus hypnotiques modifient la façon d’être conscient au monde. Ils sont initiés par la focalisation de l’attention qui permet de rendre le sujet sensible aux suggestions qui lui sont faites. L’observation ou l’obtention d’un tel état permet au médecin anesthésiste de délivrer lors des suggestions en rapport avec son objectif de soin. Dans le cadre de l’anesthésie locorégionale, des suggestions de confort, d’analgésie et de facilité peuvent ainsi être dispensées et aider à la réalisation de l’anesthésie. Parallèlement, pendant toute la réalisation de l’anesthésie, l’hypnose permet de focaliser l’attention du patient sur des éléments neutres ou agréables choisis par lui ou le médecin. Tout est rendu plus facile par des techniques simples qui évitent le recours à des médicaments.

Conclusion (proposition de traduction) : On pense trop souvent à l’hypnose en anesthésie comme à une procédure d’analgésie qui vient remplacer une autre méthode alors qu’elle est avant tout un adjuvant toujours disponible, sans effet secondaire. L’hypnose n’est pas unprocessus de type « on-off » mais une approche polymorphe, souple et dynamique. Qu’il s’agisse d’hypnose formelle ou informelle, elle est un allié utile et efficace dans de nombreuses circonstances, dont en particulier : l’anesthésie locorégionale.

Pediatric Emergency Care

Use of Imaging in Children With Witnessed Physical Abuse.
Melville JD, Hertz SK, Steiner RD, Lindberg DM; ExSTRA Investigators. | Pediatr Emerg Care.  2019 Apr;35(4):245-248
Keywords: Aucun

Original Articles

Introduction : Physicians are occasionally asked to evaluate children who are reported to have been victims of witnessed abuse, but who have no injuries noted on examination. The rate of injury in these patients is presently unknown. This is important because abuse allegations are brought for both altruistic and other reasons. This study compares the use of skeletal survey and neuroimaging in well-appearing and clearly injured children reported to be victims of witnessed child abuse.

Méthode : Retrospectively planned secondary analysis of the Examination of Siblings to Recognize Abuse cohort of children referred to a child abuse pediatrician with concerns for physical abuse. Children were selected who presented to a medical provider with a history of witnessed child abuse including shaking. Rates of radiographically evident injuries are noted among children with and without injuries noted on physical examination.

Résultats : Among 2890 children evaluated by a child abuse pediatrician, 90 children (3.1%) presented with a history of witnessed abuse. Among these, 51 children (57%) had injuries noted on physical examination; 9 (29%) of 31 skeletal surveys and 9 (35%) of 26 neuroimaging studies revealed injuries. Of 39 children (43%) with witnessed abuse and normal examination, 3 (10%) of 30 skeletal surveys and 2 (8%) of 25 neuroimaging studies revealed an injury.

Conclusion : A significant minority of children evaluated for allegations of witnessed abuse will have occult injuries identified radiographically. Absence of injury on examination should not deter physicians from obtaining otherwise indicated skeletal surveys and neuroimaging in children reported to have experienced witnessed abuse.

Conclusion (proposition de traduction) : Une minorité significative d'enfants évalués pour des allégations de maltraitance auront des blessures occultes identifiées par la radiographie.
L'absence de lésion à l'examen clinique ne doit pas dissuader les médecins de demander des examens du squelette et de la neuro-imagerie autrement indiqués, chez les enfants qui seraient suspects de maltraitance.

Epidemiology of Fractures in Children Younger Than 12 Months.
Rodà D, Trenchs V, Curcoy AI, Martínez AD, Pou J, Luaces C. | Pediatr Emerg Care.  2019 Apr;35(4):256-260
Keywords: Aucun

Original articles

Introduction : The aim of this study is to determine the prevalence and characteristics of fractures in young infants attended at the pediatric emergency department (PED).

Méthode : This is a retrospective study for 2 years (2011-2012) of children younger than 12 months attended with a fracture at the PED. Age, sex, site and type of fracture, mechanism of injury, time interval before seeking medical attention, and management were analyzed.

Résultats : One hundred one patients were included. They represented 0.3% (95% confidence interval, 0.2%-0.4%) of all children younger than 12 months attended at the PED. The median age was 7.7 months (interquartile range, 5.2-10.1 months); 58 (57.4%) were boys. The most common fracture was skull fracture (58, 57.4%), mostly parietal, followed by long bone fractures (27, 26.7%); transverse and torus fractures were the most common types, located at the diaphysis and distal metaphysis, respectively. The principal mechanism reported was falling (83, 82.2%) mainly from furniture. Fifty-one patients (50.1%) were attended in the first 6 hours after injury. Sixty-five patients (64.4%) were admitted at the hospital and the other 9 (8.9%) were controlled in outpatient visits. One of them was injured because of negligence and another was diagnosed with osteoporosis.

Conclusion : Fractures in young infants are uncommon at the PED, the skull fracture being the most common. Pediatricians should alert caretakers of the risks in normal development to prevent these injuries. Fractures caused by child abuse should always be discarded.

Conclusion (proposition de traduction) : Les fractures chez les jeunes enfants sont rares au service des urgences pédiatriques, la fracture du crâne étant la plus fréquente. Les pédiatres devraient alerter les soignants des risques pour un développement normal afin de prévenir ces blessures. Une maltraitance à l'origine de ces fractures devraient toujours être écartées.

Factors Predicting Asthma in Children With Acute Bronchiolitis.
Waseem M, Akobo SI, Shaikh F, DelaCruz A, Henriquez W, Leber M. | Pediatr Emerg Care.  2019 Apr;35(4):265-267
Keywords: Aucun

Original articles

Introduction : The aim of this study was to determine if there is an association between bronchiolitis and future development of asthma in children younger than 2 years.

Méthode : We reviewed the medical records of 1991 patients younger than 2 years presenting to the emergency department from January 2000 to December 2010 who received a clinical diagnosis of acute bronchiolitis. Their demographic information, the number of bronchiolitis episodes, and family history of asthma were recorded. The primary care clinic records of these children were reviewed for a period of 1 year following their presentation to the emergency department to determine if they had received a diagnosis of asthma. A stepwise logistic regression was performed to determine what factors were associated with future asthma development.

Résultats : We reviewed the medical record of 1991 children with the diagnosis of bronchiolitis for subsequent development of asthma. The following variables were identified as predictors of subsequent asthma: male sex (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.05-1.55), family history of asthma (OR, 1.6; 95% CI, 1.33-1.95), atopy (OR, 1.4; 95% CI, 1.12-1.83), age older than 5 months (OR, 1.4 95% CI, 1.13-1.66), more than 2 episodes of bronchiolitis (OR, 2.4; 95% CI, 1.79-3.07), and allergies (OR1.6; 95% CI, 1.14-2.14).

Conclusion : In this limited sample, the predictor variables for asthma were male sex, age older than 5 months, more than 2 episodes of bronchiolitis, a history of atopy, and allergies.

Conclusion (proposition de traduction) : Dans cet échantillon limité, les variables prédictives de l'asthme étaient le sexe masculin, l'âge supérieur à 5 mois, plus de 2 épisodes de bronchiolite, des antécédents d'atopie et d'allergies.

Current Approach to the Management of Forearm and Elbow Dislocations in Children.
Gottlieb M, Suleiman LI. | Pediatr Emerg Care.  2019 Apr;35(4):293-298
Keywords: Aucun

CME Review Article

Editorial : Pediatric orthopedic injuries are a common reason for presentation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in the emergency department. Radial head subluxations are discussed with a focus on current evidence for imaging, reduction techniques, and follow-up. Elbow dislocations, although less common than radial head subluxations, are also addressed, highlighting imaging, reduction, immobilization, and follow-up recommendations.

Introduction : After completion of this CME article, readers should be better able to:
1. Describe the historical and physical examination findings suggestive of radial head subluxation and elbow dislocation.
2. Differentiate reduction techniques for radial head subluxation and elbow dislocation.
3. Explain the disposition and follow up recommendations for patients after reduction of a radial head subluxation and elbow dislocation.
Pediatric orthopedic injuries are a common presentation to emergency departments. Among these injuries, radial head subluxation and elbow dislocation are 2 important upper extremity dislocations. It is essential for providers to understand the diagnostic strategies, reduction techniques, and postreduction management for these common conditions. Each injury is discussed sequentially in the following sections.

Conclusion : Pediatric orthopedic injuries are a common presentation that require urgent evaluation and management. This article discussed 2 important upper extremity injuries, radial head subluxation and elbow dislocation, with a focus on diagnostic strategies, reduction techniques, and postreduction management.

Conclusion (proposition de traduction) : Les blessures orthopédiques chez les enfants sont une présentation courante qui nécessite une évaluation et une gestion urgentes. Cet article traite de 2 blessures importantes aux membres supérieurs, la subluxation de la tête radiale et la luxation du coude, en mettant l'accent sur les stratégies de diagnostic, les techniques de réduction et la gestion de la post-réduction.

Prehospital and Disaster Medicine

The Impact of Backboard Placement on Chest Compression Quality: A Mannequin Study.
Sanri E, Karacabey S. | Prehosp Disaster Med.  2019 Apr;34(2):182-187
Keywords: ACLS Advanced Cardiac Life Support; AHA American Heart Association; BLS Basic Life Support; CC chest compression; CPR cardiopulmonary resuscitation; EM Emergency Medicine; backboard; chest compression; chest compression depth; chest compression rate; mannequin

Original Research

Introduction : High-quality chest compressions (CCs) are associated with high survival rates and good neurological outcomes in cardiac arrest patients. The 2015 American Heart Association (AHA; Dallas, Texas USA) Guidelines for Resuscitation defined and recommended high-quality CCs during cardiopulmonary resuscitation (CPR). However, CPR providers struggle to achieve high-quality CCs. There is a debate about the use of backboards during CPR in literature. Some studies suggest backboards improve CC quality, whereas others suggest that backboards can cause delays. This is the first study to evaluate all three components of high-quality CCs: compression depth, recoil depth, and rate, at the same time with a high number of subjects. This study evaluated the impact of backboards on CC quality during CPR. The primary outcome was the difference in successful CC rates between two groups.

Méthode : This was a randomized, controlled, single-blinded study using a high-fidelity mannequin. The successful CC rates, means CC depths, recoil depths, and rates achieved by 6th-grade undergraduate medical students during two minutes of CPR were compared between two randomized groups: an experimental group (backboard present) and a control group (no backboard).

Résultats : Fifty-one of all 101 subjects (50.5%) were female, and the mean age was 23.9 (SD = 1.01) years. The number and the proportion of successful CCs were significantly higher in the experimental group (34; 66.7%) when compared to the control group (19; 38.0%; P = .0041). The difference in mean values of CC depth, recoil depth, and CC rate was significantly higher in the experiment group.

Conclusion : The results suggest that using a backboard during CPR improves the quality of CCs in accordance with the 2015 AHA Guidelines.

Conclusion (proposition de traduction) : Les résultats suggèrent que l'utilisation d'un plan dur pendant la RCP améliore la qualité des compressions thoraciques conformément aux directives de 2015 de l'AHA.

The American Journal of Emergency Medicine

Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study.
Okada Y, Matsuyama T, Morita S, Ehara N, Miyamae N, Jo T, Sumida Y, Okada N, Kitamura T, Iiduka R.. | Am J Emerg Med.  2019 Apr;37(4):565-570
Keywords: Aucun

Original Contribution

Introduction : In cases of severe accidental hypothermia (AH) in urban areas, the prognostic factors are unknown. We identified factors associated with in-hospital mortality in patients with moderate-to-severe AH in urban areas of Japan.

Méthode : The J-Point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients whose core body temperature was 32 °C or less on admission. In-hospital death was the primary outcome of this study. We investigated the association between each candidate prognostic factor and in-hospital death by applying the multivariate logistic regression analyses with adjusted odds ratios (AORs) and their 95% confidence interval [CI] as the effect variables.

Résultats : Of 572 patients registered in the J-point registry, 358 hypothermic patients were eligible for analyses. Median body temperature was 29.2 °C (interquartile range, 27.0 °C-30.8 °C). In-hospital deaths comprised 26.3% (94/358) of all study patients. Factors associated with in-hospital death were age ≥ 75 years (AOR, 3.09; 95% CI, 1.31-7.27), need for assistance with activities of daily living (ADL; AOR, 3.06; 95% CI, 1.68-5.59), hemodynamic instability (AOR, 2.49; 95% CI, 1.32-4.68), and hyperkalemia (≥5.6 mEq/L; AOR, 2.65; 95% CI, 1.13-6.21).

Conclusion : The independent prognostic factors associated with in-hospital mortality of patients with moderate-to-severe AH in urban areas of Japan were age ≥ 75 years, need for assistance with ADL, hemodynamic instability, and hyperkalemia.

Conclusion (proposition de traduction) : Les facteurs de pronostic indépendants associés à la mortalité à l'hôpital des patients souffrant d'hypothermie accidentelle modérée à sévère dans les zones urbaines du Japon étaient les suivants : âge ≥ 75 ans, besoin d'aide pour les activités de la vie quotidienne, instabilité hémodynamique et hyperkaliémie.

Prehospital advanced cardiac life support by EMT with a smartphone-based direct medical control for nursing home cardiac arrest.
Kim C, Choi HJ, Moon H, Kim G, Lee C, Cho JS, Kim S, Lee K, Choi H, Jeong W. | Am J Emerg Med.  2019 Apr;37(4):585-589
Keywords: Administration; Advanced cardiac life support; Emergency medical system; Epinephrine; Intravenous; Out-of-hospital cardiac arrest

Original contribution

Introduction : To compare the survival to discharge between nursing home (NH) cardiac arrest patients receiving smartphone-based advanced cardiac life support (SALS) and basic life support (BLS).

Méthode : The SALS registry includes data on cardiac arrest from 7 urban and suburban areas in Korea between July 2015 and December 2016. We include adult patients (>18) with out-of-hospital cardiac arrest (OHCA) of medical causes and EMS attended and dispatched in. SALS is an advanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction. Prehospital resuscitation method was key exposure (SALS, BLS). The primary outcome was survival to discharge.

Résultats : A total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than the BLS group (4.0% vs 1.7%), but the difference was not significant (P = 0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (P = 0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, P = 0.001; good neurologic outcome: 6.8% vs 3.3%, P < 0.001).

Conclusion : As a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and that with good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved, however those of NH patients were not significantly increased.
Considering a financial burden, it is more realistic to provide SALS services with a focus on cardiac arrest likely to be survived rather than providing it to all OHCA patients including NH patients.

Conclusion (proposition de traduction) : Grâce à l'assistance médicale préhospitalière directe aux ambulanciers paramédicaux par le biais d'appels vidéo à distance, le taux de survie à la sortie et celui avec de bons résultats neurologiques (CPC 1, 2) pour les patients à domicile se sont améliorés de manière significative, toutefois pas pour ceux qui résidait en maison de retraite sans augmenter significativement.
Considérant un coût financier, il est plus réaliste de fournir des services de réanimation cardiaques avancés basés sur un smartphone, en mettant l'accent sur les arrêts cardiaques susceptibles de survivre, plutôt que de les fournir à tous les patients en arrêt cardiaque préhospitaliers, y compris les patients en maison de retraite.

Relative tachycardia is associated with poor outcomes in post-cardiac arrest patients regardless of therapeutic hypothermia.
Ko JI, Kim KS, Suh GJ, Kim K, Kwon WY, Shin J, Jo YH, Jung YS, Kim T, Shin SM. | Am J Emerg Med.  2019 Apr;37(4):590-595
Keywords: Cardiac arrest; Heart rate; Prognosis; Therapeutic hypothermia

Original contribution

Introduction : To investigate whether the relationship between heart rate and neurological outcome is independent of therapeutic hypothermia (TH) and whether heart rate is related to hemodynamic instability post-cardiac arrest.

Méthode : Retrospective review of an out-of-hospital cardiac arrest registry was performed. The primary exposure was heart rate quartiles at 24 h post-cardiac arrest. The primary outcome was a poor neurological outcome, which was defined as having a cerebral performance category (CPC) of 3-5 at 28 days. Secondary outcomes were mean blood pressure and serum lactate at 24 h and Sequential Organ Failure Assessment (SOFA) scores at admission.

Résultats : In total, 155 patients were enrolled. The proportion of patients with a poor CPC was significantly greater in higher heart rate quartiles; similar results were observed in patients who did and did not undergo TH. Serum lactate levels at 24 h were significantly higher in the 3rd and 4th quartile groups than in the 1st quartile group. Additionally, SOFA scores were significantly higher in the 4th quartile group than in the 1st and 3rd quartile groups.

Conclusion : Relative tachycardia is associated with poor neurological outcomes in post-cardiac arrest patients, independent of TH, and with higher serum lactate levels and admission SOFA scores.

Conclusion (proposition de traduction) : Une tachycardie relative est associée à de mauvais résultats neurologiques chez les patients ayant présenté un arrêt cardiaque, indépendamment de l'hypothermie thérapeutique et à des taux de lactate sérique et des scores SOFA d'admission plus élevés.

The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture.
Fu CY, Chan SY, Wang SY, Hsieh CH, Liao CH, Huang JF, Hsu YP, Kang SC. | Am J Emerg Med.  2019 Apr;37(4):603-607
Keywords: Angioembolization; Pelvic fracture; Retroperitoneal hemorrhage

Original contribution

Introduction : Conventionally, pelvic fracture-related acute retroperitoneal hemorrhage (ARH) is life threatening and difficult to control. However, the use of angioembolization to treat fracture-associated ARH improves the hemodynamic stability of patients with pelvic fractures. The role of angioembolization in the management of patients with pelvic fracture-related ARH was examined.

Méthode : We retrospectively reviewed a large case series of patients with pelvic fractures between January 2010 and December 2014. Comparisons were made between patients with and without ARH. In addition, the characteristics of mortality were delineated, whereas the causes of death in patients with pelvic fracture were discussed and analyzed.

Résultats : A total of 1070 patient records were reviewed during the 60-month study period, and the overall mortality rate of pelvic fracture was 7.7% (82/1070). However, there were only seven patients who died due to uncontrolled ARH (0.7%). The patients with ARH had more injuries to other organs than did the patients without ARH (head: 79.7% vs. 31.7%, p < 0.001; chest: 50.3% vs. 10.9%, p < 0.001; abdomen: 72.0% vs. 22.7%, p < 0.001; spine: 12.6% vs. 4.4%, p < 0.001; extremities: 69.2% vs. 44.3%, p < 0.001).

Conclusion : The treatment for pelvic fracture patients declared dead upon arrival remains limited. However, pelvic fracture-related ARH could be controlled effectively with angioembolization. In addition to ARH, injuries to other organs may play a key role in the mortality of patients with pelvic fractures.

Conclusion (proposition de traduction) : Le traitement des patients présentant une fracture du bassin et déclarés morts à leur arrivée reste limité. Cependant, une embolisation artérielle pouvait permettre de maîtriser efficacement une hémorragie rétropéritonéale aiguë liée à une fracture du bassin. En plus des hémorragies rétropéritonéales aiguës, des lésions d'autres organes peuvent jouer un rôle clé dans la mortalité des patients présentant des fractures du bassin.

Effect of hypertension across the age group on survival outcomes in out-of-hospital cardiac arrest.
Jung E, Park JH, Ro YS, Song KJ, Ryu H4, Lee SC, Shin SD. | Am J Emerg Med.  2019 Apr;37(4):608-614
Keywords: Age; Hypertension; Out-of-hospital cardiac arrest

Original contribution

Introduction : There are few studies on the effects hypertension has on survival outcomes in out-of-hospital-cardiac arrest (OHCA) patients, although hypertension is a major risk factor for the incidence of cardiac arrest. This study aims to investigate whether hypertension is associated with survival outcomes in cardiac arrest patients across age groups.

Méthode : This study was conducted using the national cardiac arrest registry of OHCA patients who survived to hospital admission from 2012 to 2016. The clinical histories of hypertension were obtained from patients' medical records. The endpoint was cerebral performance category (CPC) 1 and 2 (good CPC) and survival to discharge. Multivariable logistic regression analysis was performed on the data collected. The final model with an interaction term was evaluated to compare the effects of hypertension across age groups.

Résultats : A total 11,610 patients (61.0% hypertensive patients and 39.0% non-hypertensive patients) were included. The group over 80 years old with hypertension were more likely to have good neurologic recovery (AOR 2.53 [1.43-4.50]) and those under 65 years old with hypertension were more likely to survive to hospital discharge with statistical significance (AOR 1.19 [1.04-1.35]).

Conclusion : Hypertension does not imply poor survival outcomes independently for all ages, as those over 80 years of age can have rather good neurological outcomes.

Conclusion (proposition de traduction) : L'hypertension n'implique pas de mauvais résultats de survie indépendamment pour tous les âges, car les personnes âgées de plus de 80 ans peuvent avoir des résultats neurologiques plutôt bons.

Risk factors of upper gastrointestinal hemorrhage with acute coronary syndrome.
Wang N, Li T, Du Q. | Am J Emerg Med.  2019 Apr;37(4):615-619
Keywords: Acute coronary syndrome; Elderly patients; Mortality; Upper gastrointestinal hemorrhage

Original contribution

Introduction : Research showed that the mortality of upper gastrointestinal hemorrhage (UGH) complicated with acute coronary syndrome (ACS) was higher than single UGH in elderly patients. This study aimed to determine the risk factors that associated with an increased risk of ACS occurrence after UGH.

Méthode : A population-based nested case-control study was conducted analyzing the hospital information system database of Shengjing Hospital of China Medical University from September 1, 2009 to December 31, 2014. We included 3217 elderly patients who experienced a UGH, among which 152 cases were identified and matched 604 selected controls. Multivariate conditional logistic regression models were used to characterize risk factors associated with ACS occurrence and death after UGH.

Résultats : Diabetes (odds ratio (OR) = 1.84, 95% confidence interval (CI) 1.13-2.71, P = 0.039), smoking (OR = 1.87, 95% CI 1.19-2.73, P = 0.028), vasopressin or terlipressin use (OR = 1.51, 95% CI 1.02-2.14, P = 0.043), liver cirrhosis (OR = 2.43, 95% CI 1.45-4.38, P = 0.013), hemoglobin level (OR = 2.36, 95% CI 1.65-3.79, P = 0.014) and history of ACS (OR = 1.98, 95% CI 1.13-3.49, P = 0.017) increased risk of ACS incidence in elderly patients with UGH. Moreover, diabetes (OR = 2.14, 95% CI 1.15-4.21, P = 0.041), smoking (OR = 2.93, 95% CI 1.17-5.31, P = 0.043) and hemoglobin levels (OR = 1.95, 95% CI 1.24-3.16, P = 0.038) were independent variables for the mortality underwent UGH with ACS in elderly patients.

Conclusion : History of diabetes, vasopressin or terlipressin use, smoking, liver cirrhosis, hemoglobin level and history of ACS are risk factors to develop ACS in elderly patients with UGH. Importantly, diabetes, smoking and lower hemoglobin level are key variables for mortality.

Conclusion (proposition de traduction) : Les antécédents de diabète, l'utilisation de vasopressine ou de terlipressine, de tabagisme, une cirrhose du foie, un taux d'hémoglobine et des antécédents de SCA sont des facteurs de risque de développer un SCA cchez les patients âgés présentant une hémorragie digestive haute. Fait important, un diabète, un tabagisme et un taux d'hémoglobine bas sont des variables clés de la mortalité.

Gender disparities in percutaneous coronary intervention in out-of-hospital cardiac arrest.
Jeong JS, Kong SY, Shin SD, Ro YS, Song KJ, Hong KJ, Park JH, Kim TH. | Am J Emerg Med.  2019 Apr;37(4):632-638
Keywords: Gender disparity; Out-of-hospital cardiac arrest; Percutaneous coronary intervention; Post-resuscitation treatment

Original contribution

Introduction : Quality of post-arrest care is considered a significant factor for overall survival and neurological outcomes in out-of-hospital cardiac arrest (OHCA). However, previous studies suggested gender differences in invasive treatments including percutaneous coronary intervention (PCI). In this study, we evaluated gender disparities in the delivery of PCI among OHCA patients.

Méthode : All adults OHCA patients with presumed cardiac etiology and sustained ROSC between 2013 and 2016 were included in the study. Main exposure was gender and primary outcome was PCI treatment. Multivariable logistic regression was used to analyze the association between gender and PCI treatment, adjusting for patient, community, prehospital, and hospital factors. The time interval from return of spontaneous circulation (ROSC) to PCI and survival outcomes were also analyzed as secondary and tertiary outcomes.

Résultats : A total of 20,675 patients were included for final analysis. Multivariable analysis showed that female patients were significantly less likely to receive PCI compared to males with adjusted odds ratio (OR) of 0.40 (95% CI 0.30-0.53). However, among those who received PCI, there were no significant associations between gender and time from ROSC to PCI (≤90 vs. >90 min). Overall survival outcomes were not significantly associated with gender after adjusting for PCI and other confounding factors (OR = 0.87, 95% CI 0.71-1.08 for survival to discharge and OR = 0.87, 95% CI 0.70-1.08 for good neurological recovery).

Conclusion : Among sustained ROSC patients following OHCA, female patients were significantly less likely to undergo PCI than males. Further studies are warranted to reduce gender disparities in caring for post-arrest patients.

Conclusion (proposition de traduction) : Parmi les patients qui récupèrent une activité cardiaque spontanée (RACS) après un arrêt cardiaque extrahospitalier, les patients de sexe féminin étaient significativement moins susceptibles que les hommes de bénéficier d'une angioplastie coronarienne. D'autres études sont nécessaires pour réduire les disparités entre les sexes dans les soins aux patients après un arrêt cardiaque.

Prehospital non-invasive ventilation in acute respiratory failure is justified even if the distance to hospital is short.
Hensel M, Strunden MS2, Tank S3, Gagelmann N4, Wirtz S5, Kerner T. | Am J Emerg Med.  2019 Apr;37(4):651-656
Keywords: Acute respiratory failure; Cardiogenic pulmonary edema; Chronic obstructive pulmonary disease; Non-invasive ventilation; Prehospital care

Original contribution

Introduction : Evaluation of the efficacy of prehospital non-invasive ventilation (NIV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema (CPE).

Méthode : Consecutive patients who were prehospitally treated by Emergency Physicians using NIV were prospectively included. A step-by-step approach escalating NIV-application from continuous positive airway pressure (CPAP) to continuous positive airway pressure supplemented by pressure support (CPAP-ASB) and finally bilevel inspiratory positive airway pressure (BIPAP) was used. Patients were divided into two groups according to the prehospital NIV-treatment-time (NIV-group 1: ≤15 min, NIV-group 2: >15 min). In addition, a historic control group undergoing standard care was created. Endpoints were heart rate, peripheral oxygen saturation, breathing rate, systolic blood pressure, and a dyspnea score.

Résultats : A total of 99 patients were analyzed (NIV-group 1: n = 41, NIV-group 2: n = 58). The control group consisted of 30 patients. The majority of NIV-patients (90%) received CPAP-ASB, while CPAP without ASB was conducted in 8% and BIPAP-ventilation in 2% of all cases. Technical application of NIV lasted 6.1 ± 3.8 min. NIV-treatment-time was as follows: NIV-group 1: 13.1 ± 3.2 min, NIV-group 2: 22.8 ± 5.9 min. Differences between baseline- and hospital admission values of all endpoints showed significantly better improvement in NIV-groups compared to the control group (p < 0.001). The stabilizing effect of NIV in terms of vital parameters was comparable between both NIV-groups, independent of the duration of treatment (n.s.).

Conclusion : Prehospital NIV-treatment should be performed in patients with COPD-exacerbation and CPE, even if the distance between emergency scene and hospital is short.

Conclusion (proposition de traduction) : Un traitement préhospitalier par VNI doit être entrepris chez les patients présentant une exacerbation de BPCO ou un OAP, même si la distance entre le lieu d'intervention et l'hôpital est courte.

The diagnostic and prognostic value of platelet indices in gastrointestinal bleeding.
Senel T, Ates I, Demir BF, Arikan MF, Karaahmetoglu S, Altiparmak E, Yilmaz N. | Am J Emerg Med.  2019 Apr;37(4):657-663
Keywords: Forrest classification; Gastrointestinal system hemorrhage; Platelet indices

Original contribution

Introduction : We aimed to investigate the association between platelet indices [platelet, plateletcrit (PCT), mean platelet volume (MPV) and platelet distribution width (PDW)] and gastrointestinal bleeding (GIB), as well as determine its severity and prognosis.

Méthode : 500 patients with GIB who were admitted to hospital between March 2014 and February 2017 and diagnosed with "Gastrointestinal System Bleeding", as well as114 healthy individuals were retrospectively included in the study. Patients' platelet indices were recorded after one week and one month from their files.

Résultats : Platelet, PCT, MPV and PDW levels were determined to be higher in the patients with bleeding, when compared to the control group (p < 0.001). Within the first week, a significant reduction was determined in patients' platelet, PCT, MPV and PDW values compared to the admission values (p < 0.001). In initial-month controls, a significant reduction was determined in the platelet indices compared to the initial-week values (p < 0.001). A significant association between bleeding severity and increased platelet indexes was determined. Increasing age, female gender, the presence of comorbidities, high levels of platelet indexes, low levels of hemoglobin, and albumin values were all found to be associated with a poor prognosis. PCT, MPV, and PDW were determined as being the independent risk factors that predict the odds of GIB, alongside the independent predictors that predict risk of bleeding severity and the prognosis.

Conclusion : We think that platelet indices may be used in diagnosis of GIB, as well as in predicting bleeding severity and the prognosis.

Conclusion (proposition de traduction) : Nous pensons que les indices plaquettaires peuvent être utilisés dans le diagnostic des saignements gastro-intestinaux, ainsi que dans la prévision de la gravité des saignements et du pronostic.

Commentaire : Les différents indices plaquettaires sont le taux de plaquettes [Pq], le volume plaquettaire moyen [VPM] et l'indice de distribution plaquettaire [IDR-CV].
On retrouve l'utilisation des indices plaquettaires comme indice diagnostique et pronostique dans différentes pathologies : les cancers colorectaux
  , l'embolie pulmonaire
  , la pré-éclampsie
Dans les études un VPM élevé est associé aux formes sévères, le rapport Pq/lymphocytes et le VPM constituent des facteurs prédictifs de mortalité précoce.

Skin mottling score and capillary refill time to assess mortality of septic shock since pre-hospital setting.
Jouffroy R, Saade A, Tourtier JP, Gueye P, Bloch-Laine E, Ecollan P, Carli P, Vivien B. | Am J Emerg Med.  2019 Apr;37(4):664-671
Keywords: Capillary refill time; Mortality; Pre-hospital setting; Septic shock; Skin mottling score

Original contribution

Introduction : The early identification of septic shock patients at high risk of poor outcome is essential to early initiate optimal treatments and to decide on hospital admission. Biomarkers are often used to evaluate the severity. In prehospital settings, the availability of biomarkers, such as lactate, is restricted. In this context, clinical tools such as skin mottling score (SMS) and capillary refill time (CRT) are more suitable. In this study, we describe prehospital SMS and CRT's ability to predict mortality of patients with septic shock initially cared in the prehospital setting by a mobile intensive care unit.

Méthode : Patients with septic shock who received prehospital medical care admitted to the intensive care unit were retrospectively analyzed.

Résultats : Sixty-three patients were included. The origin of sepsis was mainly pulmonary (67%). Overall mortality reached 36%. No significant difference was observed in the duration of prehospital medical care between alive and deceased patients. Mean prehospital value of SMS was 3 ± 2 and mean prehospital value of CRT was 5 ± 1 s. A significant association was found between mortality and prehospital SMS (p = 0.02, OR[CI95] = 1.50 [1.08-2.15]) and prehospital CRT (p = 0.04, OR[CI95] = 1.53 [1.04-2.37]). After adjusting for confounding factors using propensity score, the relative risk of death was 6.58 for SMS > 2 and 2.03 for CRT > 4 s.

Conclusion : In this study, we report an association between prehospital SMS and CRT, and mortality of patients with septic shock. SMS and CRT are simple tools that could be used to optimize the triage and to decide early intensive care admission.

Conclusion (proposition de traduction) : Dans cette étude, nous rapportons une association entre le score de marbrures cutanées préhospitalier et le temps de remplissage capillaire, et la mortalité des patients présentant un choc septique. Le score de marbrures cutanées et le temps de remplissage capillaire sont des outils simples qui pourraient être utilisés pour optimiser le triage et décider de l'admission précoce en soins intensifs.

Commentaire : Evaluation de l’hypoperfusion tissulaire par le temps de recoloration cutanée :
Après vidange par compression du lit capillaire, un retard de recoloration de la peau est dû à une diminution de sa perfusion, expliquant la corrélation entre un TRC « normal », « ralenti » ou « très lent » et un choc « absent », « faible à modéré » ou « sévère ».
Technique de mesure
Le TRC se mesure en décubitus dorsal, sur la pulpe de l’index (ou le majeur ou l’annulaire), le membre supérieur au niveau du cœur. Une pression modérée est appliquée par le pouce et l’index de l’observateur durant cinq secondes avant de mesurer le temps nécessaire à la pulpe pour retrouver sa couleur initiale, trois mesures devant être moyennées.
Valeurs normales
Pendant très longtemps, on a utilisé le TRC en considérant des valeurs pathologiques au-delà de deux secondes. Ce seuil a, tardivement, été validé, mais uniquement chez l’enfant et l’adulte jeune de sexe masculin. Chez la femme et les individus des deux sexes de plus de 65 ans, la limite du TRC normal est, respectivement, de trois et quatre secondes. in: Lakhala K and al. Couleur et température de la peau dans l’insuffisance circulatoire aiguë. Réanimation 2009;18:261—266  .
L’allongement du temps de recoloration peut signifier une diminution locale (par exemple hypothermie, notamment si la température ambiante est < à 21° C) ou générale (choc…) du débit sanguin.
Il existe une certaine subjectivité avec une reproductibilité interobservateur allant de médiocre à bonne (Brabrand M and al. Capillary refill time: a study of interobserver reliability among nurses and nurse assistants. Eur J Emerg Med. 2011 Feb;18(1):46-9  ). Une mesure par caméra digitale permet d’améliorer l’analyse du TRC (Shavit I and al. A novel imaging technique to measure capillary-refil time: improving dagnostic accuracy for dehydratation in young children with gastrenteritis. Pediatrics. 2006 Dec;118(6):2402-8  ).
Exemple de caméra digitale
   pour le calcul du temps de recoloration cutané numérique.

QTc prolongation as a marker of 30-day serious outcomes in older patients with syncope presenting to the Emergency Department.
White JL, Chang AM, Hollander JE, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. | Am J Emerg Med.  2019 Apr;37(4):685-689
Keywords: Aucun

Original contribution

Introduction : Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope.

Méthode : This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED.

Résultats : The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis.

Conclusion : In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes.

Conclusion (proposition de traduction) : Dans une cohorte de patients âgés présentant une syncope, l’augmentation du QTc était un marqueur de survenu d'un évènement graves composites à 30 jours, mais ne permettait pas de prédire indépendamment ces résultats.

Esmolol does not affect circulation negatively during resuscitation..
Ringgaard VK, Wemmelund KB, Sloth E, Juhl-Olsen P. | Am J Emerg Med.  2019 Apr;37(4):690-695
Keywords: Aucun

Original contribution

Introduction : We hypothesized that esmolol would lower the end-tidal partial pressure of CO2 (ETCO2) and decrease coronary perfusion pressure as compared with epinephrine in a porcine model of cardiac arrest.

Méthode : The primary endpoint was ETCO2. Secondary endpoints were the rate of ROSC and all invasive pressures and their derivatives as men- tioned below.

Résultats : A total of seven pigs developed ROSC, none in the epinephrine group, three in the esmolol group and four in the placebo group; p = 0.151 for no effect of groups.
Coronary perfusion pressure increased immediately after initiation of chest compressions. In the esmolol group, coronary perfusion pressure peaked during the second ALS cycle and the epinephrine- and placebo groups reached their peak values during the third ALS cycle. Coronary perfusion pressure declined afterwards to a definitive nadir during the tenth ALS cycle in all groups. There was no significant difference in peak values between groups (p = 0.168). The slopes were significantly different over time between groups (p = 0.003). When comparing individual groups only the epinephrine- and the esmolol groups were significantly different (p b 0.001).
Mean arterial pressure (MAP) was similar at baseline across groups (p = 0.985). MAP decreased during cardiac arrest, increased to a new maximum during the first ALS cycle and declined steadily throughout the remaining experiment. In the epinephrine group, the peak was 39 mmHg (33–42), the esmolol group peaked at 36 mmHg (32–41) and the placebo group's maximum was 30 mmHg (26–37) (p = 0.157 for no difference). No significant difference was found over time be- tween groups (p = 0.985).
Mean pulmonary artery pressures were similar at baseline between groups. mPAP increased with cardiac arrest to a new plateau and after- wards declined to a minimum during the tenth ALS cycle. In the epinephrine group mPAP rose to 37 mmHg (28–62) during the first ALS cycle and decreased to 32 mmHg (24–42) during the tenth ALS cycle. In the esmolol group, mPAP increased to 36 mmHg (28–45) during the first ALS cycle and decreased to 30 mmHg (22–41) in the tenth ALS cycle. In the placebo group, mPAP increased to 34 mmHg (27–42) during the first ALS cycle and decreased to 23 mmHg (17–29) during the tenth ALS cycle. There was no significant difference between groups (p = 0.226).

Conclusion : End-tidal CO2 was improved in the esmolol group compared to the epinephrine group and coronary perfusion pressure was significantly higher over time. Other critical hemodynamic parameters were either improved by esmolol or showed no significant difference when compar- ing to both epinephrine and placebo. Overall this study found that esmolol did not affect circulation negatively during resuscitation and therefore does not disfavor its use as a resuscitative drug.

Conclusion (proposition de traduction) : L'EtCO2 était amélioré dans le groupe esmolol par rapport au groupe épinéphrine et la pression de perfusion coronaire était significativement plus élevée au fil du temps. L'esmolol a amélioré d'autres paramètres hémodynamiques critiques ou n'a montré aucune différence significative par rapport à l'épinéphrine et au placebo.
Dans l’ensemble, cette étude a montré que l’esmolol n’avait pas d’effet négatif sur la circulation sanguine pendant la réanimation et n’avait donc pas pour effet de défavoriser son utilisation en tant que médicament de réanimation.

Diagnostic performance of emergency physician-performed point-of-care ultrasonography for acute appendicitis: A meta-analysis.
Lee SH, Yun SJ. | Am J Emerg Med.  2019 Apr;37(4):696-705
Keywords: Acute appendicitis; Emergency physician; Meta-analysis; Pediatric; Point-of-care ultrasonography

Original contribution

Introduction : To assess the sensitivity and specificity of emergency physician-performed point-of-care ultrasonography (EP-POCUS) for diagnosing acute appendicitis (AA).

Méthode : The PubMed and EMBASE databases were searched, and the diagnostic performance of EP-POCUS was evaluated using bivariate modeling and hierarchical summary receiver operating characteristic curves. Subgroup analysis was performed for pediatric patients to compare EP-POCUS and radiologist-performed ultrasonography (RADUS). Meta-regression analyses were performed according to patient and study characteristics.

Résultats : In 17 studies (2385 patients), EP-POCUS for diagnosing AA exhibited a pooled sensitivity of 84% (95% confidence interval [CI]: 72%-92%) and a pooled specificity of 91% (95% CI: 85%-95%), with even better diagnostic performance for pediatric AA (sensitivity: 95%, 95% CI: 75%-99%; specificity: 95%, 95% CI: 85%-98%). A direct comparison revealed no significant differences (p = 0.18-0.85) between the diagnostic performances of EP-POCUS (sensitivity: 81%, 95% CI: 61%-90%; specificity: 89%, 95% CI: 77%-95%) and RADUS (sensitivity: 74%, 95% CI: 65%-81%; specificity: 97%, 95% CI: 93%-98%). The meta-regression analyses revealed that study location, AA proportion, and mean age were sources of heterogeneity. Higher sensitivity and specificity tended to be associated with an appendix diameter cut-off value of 7 mm and the EP as the initial operator.

Conclusion : The diagnostic performances of EP-POCUS and RADUS were excellent for AA, with EP-POCUS having even better performance for pediatric AA. Accurate diagnoses may be achieved when the attending EP is the initial POCUS operator and uses a 7-mm cut-off value.

Conclusion (proposition de traduction) : Les performances diagnostiques de l'échographie au point d'intervention réalisée par un urgentiste ou par un radiologue étaient excellentes pour l'appendicite aiguë, l'échographie au point d'intervention réalisée par l'urgentiste obtenant des performances encore meilleures pour l'appendicite aiguë de l'enfant.
Des diagnostics précis peuvent être obtenus lorsque le médecin urgentiste est l'opérateur initial de l'échographie au point d'intervention et utilise une valeur seuil de 7 mm.

Variation in the accuracy of ultrasound for the detection of intubation by endotracheal tube size.
Gottlieb M, Holladay D, Nakitende D, Hexom B, Patel U, Serici A, Shah SC, Bailitz J. | Am J Emerg Med.  2019 Apr;37(4):706-709
Keywords: Endotracheal; Intubation; Size; Ultrasound

Original contribution

Introduction : Rapid and accurate confirmation of endotracheal tube (ETT) placement is a fundamental step in definitive airway management. Multiple techniques with different limitations have been reported. Recent studies have evaluated the accuracy, time to performance, and physician confidence for ultrasound in both cadaveric models and live patients. However, no study to date has measured the effect of ETT size. Our study is the first to measure the accuracy of ultrasound for ETT confirmation based on ETT size.

Méthode : This study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumferences. Cadavers were intubated in a random sequence with respect to both the location of intubation (i.e., tracheal vs esophageal) and sizes of ETT. Three ETT sizes were utilized: 6.0-, 7.0-, and 8.0-mm. Blinded sonographers assessed the location of the ETT using the static technique. Accuracy of sonographer identification, time to identification, and operator confidence were assessed.

Résultats : 453 assessments were performed. Overall, ultrasound was 99.1% (95% CI 97.8% to 99.7%) accurate in identification of correct location of intubation. The mean time to placement was 6.45 s (95% CI 5.62 to 7.28). The mean operator confidence level was 4.72/5.0 (95% CI 4.65 to 4.78). There was no significant difference between ETT sizes with respect to any of the outcomes.

Conclusion : The diagnostic accuracy of ultrasound for ETT confirmation did not vary with the use of different ETT sizes. Further studies are needed to determine if the accuracy would change with more novice providers or in specific patient populations.

Conclusion (proposition de traduction) : La précision diagnostique de l'échographie pour la confirmation du placement tube trachéal ne variait pas avec l'utilisation de différentes tailles de tubes endotrachéaux. D'autres études sont nécessaires pour déterminer si la précision changerait avec davantage de prestataires novices ou chez des populations de patients spécifiques.

Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED.
Murano T, Brucato-Duncan D, Ramdin C, Keller S. | Am J Emerg Med.  2019 Apr;37(4):726-729
Keywords: Anterior; Antibiotics; Epistaxis; Packing; Prophylactic

Brief Reports

Introduction : Emergency Department (ED) patients presenting with spontaneous epistaxis who have anterior nasal packing are routinely prescribed systemic prophylactic antibiotics in spite of the lack of supporting evidence-based literature. Although there is literature that discusses infection rates with nasal packing for epistaxis and prophylactic antibiotics prescribing practices of otolaryngologists, this is the first study to our knowledge that examines the practices of emergency physicians.
OBJECTIVES: The main objective of this study was to compare the infection rate between patients who were and were not prescribed prophylactic systemic antibiotics for anterior nasal packing in spontaneous epistaxis and to examine current management practices of antibiotic prescribing for these patients.

Méthode : A retrospective review of ED patients ≥ 18 years old with the discharge diagnosis of epistaxis was performed over a 5-year period. Patients who had multiple visits to the ED for epistaxis or recent nasal or sinus surgery were excluded.

Résultats : Over half of the patients, 57/106 (53.7%), who had anterior packing were prescribed prophylactic systemic antibiotics. Of these patients, 69/106 (65%) returned for a follow-up visit. There were no documented infections for any of these patients regardless of whether or not they were prescribed antibiotics. There was no significant difference with respect to rate of infection found between these two groups (the p-value = 0.263).

Conclusion : The absence of infection supports previous findings and suggests that prophylactic antibiotic use for nasal packing in spontaneous epistaxis patients is not necessary. Further randomized controlled studies are necessary to definitively support this practice change.

Conclusion (proposition de traduction) : L'absence d'infection corrobore les résultats précédents et suggère que l'utilisation d'une antibioprophylaxie après le méchage nasal chez les patients présentant une épistaxis spontanée n'est pas nécessaire.
D'autres études contrôlées randomisées sont nécessaires pour confirmer définitivement ce changement de pratique.

Commentaire : En france, la recommandation de pratique clinique : « Prise en charge des épistaxis de l’adulte »   rédigé par la Société Française d’Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou, en septembre 2016, propose dans sa recommandation n° 18 :
En cas de tamponnement, l'antibiothérapie n’est pas systématique. Elle est indiquée en cas de tamponnement antérieur avec un matériel non résorbable dont la durée est supérieure à 48h et/ou lorsqu’il y a une autre indication d’antibioprophylaxie (valvulopathie, déficit immunitaire…). L’association amoxicilline-acide clavulanique est recommandée pendant le méchage et les 5 jours après le déméchage. En cas d’allergie à la pénicilline, la clarithromycine est recommandée. (Grade C).

Benzodiazepines vs barbiturates for alcohol withdrawal: Analysis of 3 different treatment protocols.
Nelson AC, Kehoe J, Sankoff J, Mintzer D, Taub J, Kaucher KA. | Am J Emerg Med.  2019 Apr;37(4):733-736
Keywords: Alcohol withdrawal; Benzodiazepines; Diazepam; Lorazepam; Phenobarbital

Brief reports

Introduction : Alcohol withdrawal treatment varies widely. Benzodiazepines are the standard of care, with rapid onset and long durations of action. Recent drug shortages involving IV benzodiazepines have required incorporation of alternative agents into treatment protocols. Phenobarbital has similar pharmacokinetics to select benzodiazepines frequently used for alcohol withdrawal. The objective of this study is to describe the effectiveness and safety of our institutional protocols during three time periods utilizing benzodiazepines and barbiturates for the acute treatment of alcohol withdrawal in the emergency department.

Méthode : Adult patients presenting to the ED for acute alcohol withdrawal from April 1st, 2016 to January 31st, 2018 were reviewed. Patients who received at least one dose of treatment were included. Treatments were based on availability of medication and given protocol at time of presentation. The primary outcome was the rate of ICU admission.

Résultats : 300 patient encounters were included. Overall baseline characteristics were equal across groups, except for age. There was no difference in rate of ICU admission from the ED between groups (D:8, L&P:11, P:13 patients, p = 0.99). Rate of mechanical ventilation was no different across all groups (D:1, L&P:3, P:3 patients, p = 0.55).

Conclusion : During benzodiazepine shortages, phenobarbital is a safe and effective treatment alternative for alcohol withdrawal. Incorporating phenobarbital into a benzodiazepine based protocol or as sole agent led to similar rates of ICU admission, length of stay, and need for mechanical ventilation in patients treated for alcohol withdrawal in the emergency department.

Conclusion (proposition de traduction) : En cas de pénurie de benzodiazépines, le phénobarbital est une alternative thérapeutique sûre et efficace dans le sevrage alcoolique. L’incorporation de phénobarbital à un protocole à base de benzodiazépine ou en tant qu’agent exclusif a entraîné des taux similaires d’admission en USI, de durée du séjour et de nécessité de ventilation mécanique chez les patients traités pour sevrage alcoolique aux urgences.

Agreement between arterial and peripheral venous lactate levels in the ED: A systematic review.
van Tienhoven AJ, van Beers CAJ, Siegert CEH. | Am J Emerg Med.  2019 Apr;37(4):746-750
Keywords: Acid-base; Arterial blood gas; Emergency department; Lactate; Peripheral venous blood gas

Brief reports

Introduction : In the Emergency Department, lactate measurement is a useful tool to risk-stratify critically ill patients. However, it is unclear whether arterial or peripheral venous lactate levels can be used interchangeably for this purpose. In this systematic review, we provide an overview of studies investigating the agreement between arterial and peripheral venous lactate levels in the Emergency Department.

Méthode : PubMed, Embase, the Cochrane Central Register of Controlled Trials/Wiley, Web of Science/Clarivate Analytics, and references of selected articles were assessed for all studies comparing arterial and peripheral venous lactate levels in adult patients in the emergency department. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility using a standardized data-worksheet.

Résultats : Nine studies were included. Peripheral venous lactate levels tend to be higher than arterial lactate levels with mean differences ranging from 0.18 mmol/l to 1.06 mmol/l. Importantly, poorer agreement occurs in hyperlactatemia. At a cut-of level of 1.6 mmol/l, peripheral venous lactate can rule out arterial hyperlactatemia with a sensitivity between 94% and 100%. At a cut off value of 2 mmol/l, sensitivities of 97% and 100% were found.

Conclusion : Agreement between arterial and peripheral venous lactate is poor in hyperlactatemia, making peripheral venous lactate an unreliable parameter to use interchangeably in the ED. In clinical practice, peripheral venous lactate can be used as a screening tool to rule out arterial hyperlactatemia at a cut-off value of 2 mmol/l. However, hyperlactatemia should be confirmed using arterial sampling in case of a peripheral venous lactate level > 2 mmol/l.

Conclusion (proposition de traduction) : La concordance entre le lactate veineux périphérique et artériel est faible dans l'hyperlactatémie, ce qui fait du lactate veineux périphérique un paramètre peu fiable à utiliser en remplacement (ndlr : du prélèvement artériel) aux urgences. En pratique clinique, le lactate veineux périphérique peut être utilisé comme outil de dépistage pour exclure une hyperlactatémie artérielle à une valeur seuil de 2 mmol/l. Cependant, l'hyperlactatémie doit être confirmée par prélèvement artériel en cas de lactate veineux périphérique supérieur à 2 mmol/l.

Approach to cardiopulmonary resuscitation induced consciousness, an emergency medicine perspective.
Pourmand A, Hill B, Yamane D, Kuhl E. | Am J Emerg Med.  2019 Apr;37(4):751-756
Keywords: Awareness; CPR; Cardiac arrest; Cardiopulmonary resuscitation; Consciousness


Introduction : Cardiopulmonary resuscitation (CPR) remains the key intervention following cardiac arrest because of its ability to continue circulation. Recent focus on high quality compressions during CPR has coincided with more frequent encounters of CPR Induced Consciousness (CPRIC). CPRIC represents a poorly understood patient experience during CPR and defined as signs of consciousness and pain perception during CPR.

Méthode : Articles were selected using PubMed, MEDLINE, CINAHL and Scopus search for the keywords "cardiopulmonary resuscitation", "consciousness", "awareness", "resuscitation", "cardio-cerebral resuscitation", "agitation" and "patient experience" yielding 336 articles. Results and their references were assessed for relevance. Articles were filtered by English language and the keyword. Case reports and case series were included. All remaining articles were reviewed and findings were discussed.

Résultats : A total of ten articles were selected, which included data on 123 cases. Sample size varied per study from 1 to 112. Studies included cases of out-of-hospital cardiac arrest and in hospital cardiac arrest. Compressions were manually provided in most cases. Patient total recall was reported in 40% of cases. Use of sedation was reported in 40% of cases.

Conclusion : There is need for continued research to better describe, explain and manage the phenomena of CPRIC. From the articles reviewed here, it is clear that further investigation has the potential to properly elucidate the patient experience including lasting psychological effects of CPRIC. Importantly, there is need for more than recognition of CPRIC from national authorities. Future research efforts should focus on establishing guidelines for the use of sedation and physical restraints, as well as the potential impact of treating CPRIC on survival.

Conclusion (proposition de traduction) : Il faut poursuivre la recherche pour mieux décrire, expliquer et gérer les phénomènes de la conscience induite (avec mémorisation) par la réanimation cardio-pulmonaire. D'après les articles examinés ici, il est clair qu'un examen plus approfondi pourrait permettre d'élucider correctement l'expérience du patient, y compris les effets psychologiques durables de l'exposition de la conscience induite par la réanimation cardio-pulmonaire. Il est important de noter que les autorités nationales ne doivent pas se contenter de reconnaître l'existence de la conscience induite par la réanimation cardio-pulmonaire. Les efforts de recherche futurs devraient se concentrer sur l'établissement de recommandations pour l'utilisation de la sédation et des contentions physiques, ainsi que sur l'impact potentiel du traitement de la conscience induite par la réanimation cardio-pulmonaire sur la survie.

Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis.
Gottlieb M, Holladay D, Peksa GD. | Am J Emerg Med.  2019 Apr;37(4):757-761
Keywords: Dislocation; Musculoskeletal; Reduction; Shoulder; Ultrasound


Introduction : Shoulder dislocations are a common injury causing patients to present to the emergency department. Point-of-care ultrasound (POCUS) has the potential to reduce time, radiation exposure, and healthcare costs among patients presenting with shoulder dislocations. We performed this systematic review and meta-analysis to determine the diagnostic accuracy of ultrasound compared with plain radiography in the assessment of shoulder dislocations.

Méthode : PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles were assessed for all prospective and randomized control trials evaluating the accuracy of POCUS for identifying shoulder dislocation. Data were dual extracted into a predefined worksheet and quality analysis was performed with the QUADAS-2 tool. Data were summarized and a meta-analysis was performed with subgroup analyses by technique. Diagnostic accuracy of identifying associated fractures was assessed as a secondary outcome.

Résultats : Seven studies met our inclusion criteria, comprising 739 assessments with 306 dislocations. Overall, POCUS was 99.1% (95% CI 84.9% to 100%) sensitive and 99.9% (95% CI 88.9% to 100%) specific for the diagnosis of shoulder dislocation with a LR+ of 796.2 (95% CI 8.0 to 79,086.0) and a LR- of 0.01 (95% CI 0 to 0.17). There was no statistically significant difference between techniques. POCUS was also 97.9% (95% CI 10.5% to 100%) sensitive and 99.8% (95% CI 28.0% to 100%) specific for the diagnosis of associated fractures.

Conclusion : POCUS is highly sensitive and specific for the identification of shoulder dislocations and reductions, as well as associated fractures. POCUS may be considered as an alternate diagnostic method for the management of shoulder dislocations.

Conclusion (proposition de traduction) : L'échographie au point d'intervention est très sensible et spécifique pour l'identification des luxations et des réductions de l'épaule, ainsi que des fractures associées. L'échographie au point d'intervention peut être considéré comme une autre méthode de diagnostic pour la prise en charge des luxations de l'épaule.

The Journal of Emergency Medicine

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model.
Mckee JL, Mckee IA, Bouclin MD, Filips DF, Atkinson IJ, Ball CG, McBeth PB, Kirkpatrick MAW. | J Emerg Med.  2019 Apr;56(4):363-370
Keywords: hemorrhage; hemorrhage control; neck hemorrhage; penetrating neck injury

Original Contributions

Introduction : Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate.
OBJECTIVES: We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT).

Méthode : Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded.

Résultats : There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000).

Conclusion : The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Conclusion (proposition de traduction) : L'iTClamp et la sonde à ballonnet de Foley ont été associés à une perte de liquide significativement moindre que la pression manuelle directe dans un modèle cadavérique perfusé. L'iTClamp a pris beaucoup moins de temps à appliquer que la tamponnade par sonde à ballonnet de Foley. L'iTClamp et la sonde à ballonnet de Foley ont été plus efficaces que la simple pression manuelle directe. L'iTClamp offre une option supplémentaire pour gérer les saignements difficiles à contrôler dans le cou.

Evaluation and Management of Acute Compartment Syndrome in the Emergency Department.
Long B, Koyfman A, Gottlieb M. | J Emerg Med.  2019 Apr;56(4):386-397
Keywords: compartment syndrome; fasciotomy; orthopedics; pressure

Clinical Reviews

Introduction : Acute compartment syndrome (ACS) is a time-sensitive surgical emergency caused by increased pressure within a closed compartment. ACS can lead to significant morbidity and mortality if it is not rapidly identified and treated.
OBJECTIVE: This article provides an evidence-based review of the diagnosis and management of ACS, with focused updates for the emergency clinician.

Discussion : ACS is the result of decreased perfusion within a compartment and is associated with a number of risk factors, but it occurs most commonly after fractures or trauma to the involved area. It can present with a variety of findings, including pain out of proportion to the injury, paresthesias, pain with passive stretch, tenseness or firmness of the compartment, focal motor or sensory deficits, or decreased pulse or capillary refill time. Pain is typically the earliest finding in patients with ACS. Unfortunately, history and physical examination are typically unreliable and cannot rule out the diagnosis. Measurement of intracompartmental pressures using a pressure monitor is the most reliable test, though noninvasive means of diagnosis are under study. Treatment involves surgical consultation for emergent fasciotomy, as well as resuscitation and management of complications, such as rhabdomyolysis.

Conclusion : ACS is a dangerous medical condition requiring rapid diagnosis and management that can result in significant complications if not appropriately diagnosed and treated. Emergency clinician awareness and knowledge of this condition is vital to appropriate management.

Conclusion (proposition de traduction) : Le SCA est une affection médicale grave qui exige un diagnostic et une prise en charge rapides et qui peut entraîner des complications importantes si elle n'est pas diagnostiquée et traitée de façon adéquate. La sensibilisation et la connaissance de cette condition par les cliniciens des urgences est essentielle à une prise en charge appropriée.

Commentaire : Voir également l'article de Gottlieb M1, Adams S, Landas T. Current Approach to the Evaluation and Management of Acute Compartment Syndrome in Pediatric Patients. Pediatr Emerg Care. 2019 Jun;35(6):432-437
Acute compartment syndrome is an emergent condition caused by increased ICP within a closed compartment leading to tissue ischemia and necrosis. This article reviews the pathophysi- ology, historical and physical examination findings, diagnostic strategies, and treatment for this dangerous condition. Knowledge of these components can assist providers in effectively identifying and managing this condition (proposition de traduction : Le syndrome des loges aigu est une affection de plus en plus fréquente causée par l'augmentation de la pression à l'intérieur d'un compartiment fermé entraînant une ischémie et une nécrose tissulaire. Cet article passe en revue les résultats de l'examen physio-pathologique, historique et clinique, les stratégies diagnostiques et le traitement de cette situation clinique gravissime. La connaissance de ces composantes peut aider les intervenants à identifier et à gérer efficacement cette situation).

Unintentional Pediatric Marijuana Exposures Prior to and After Legalization and Commercial Availability of Recreational Marijuana in Washington State.
Thomas AA, Von Derau K, Bradford MC, Moser E, Garrard A, Mazor S. | J Emerg Med.  2019 Apr;56(4):398-404
Keywords: THC; intoxication; marijuana; pediatrics; poisoning

Selected Topics: Toxicology

Introduction : Washington State was one of the first states to legalize recreational marijuana. Increased availability of marijuana may result in more unintentional pediatric exposure, which often presents as altered mental status with unknown cause.
OBJECTIVES: To quantify unintentional pediatric marijuana exposures reported to the Washington Poison Center (WAPC) prior to and after legalization and commercial availability of recreational marijuana.

Méthode : Data were obtained from the WAPC database, toxiCALL®. Patients ≤ 9 years old with a reported marijuana exposure between July 2010 and July 2016 were included in the analysis. Patient and exposure characteristics were summarized and median exposure frequencies were calculated for the periods prior to and after legalization.

Résultats : There were 161 cases meeting the inclusion criteria that occurred between July 2010 and July 2016. Of these, 130 (81%) occurred in the 2.5-year period after legalization of recreational marijuana in January 2013. The median age of exposed children was 2 years (range 0-9 years). Eighty-one percent of the exposures occurred in the child's own home. The number of exposures per month increased after recreational marijuana was legalized in November 2012, and increased further once recreational marijuana shops were legally allowed to open in July 2014.

Conclusion : Reported unintentional pediatric marijuana exposure has increased in the state of Washington since recreational marijuana was legalized. As marijuana becomes more available, clinicians should be aware of the risk of unintentional pediatric marijuana exposure, and this should inform lawmakers regarding regulations around childhood exposure to marijuana.

Conclusion (proposition de traduction) : L'exposition involontaire déclarée de marijuana chez les enfants a augmenté dans l'État de Washington depuis la légalisation de la marijuana à des fins récréatives. À mesure que la marijuana devient plus disponible, les cliniciens devraient être conscients du risque d'exposition non intentionnelle de marijuana chez les enfants, ce qui devrait informer les législateurs sur la réglementation concernant l'exposition des enfants à la marijuana.

A Homemade, High-fidelity Ultrasound Model for Simulating Pneumonia with Parapneumonic Effusion and Empyema.
James V, Kee CY, Ong GY. | J Emerg Med.  2019 Apr;56(4):421-425
Keywords: animal model; empyema; pneumonia with pleural effusion; teaching; ultrasound

Ultrasound in Emergency Medicine

Introduction : Point-of-care ultrasonography (POCUS) is increasingly used for both diagnostic and guided procedures. Increasingly, POCUS has been used for identification of pneumonia and to assist in the differentiation of pleural effusions, as well as to guide thoracentesis. As such, there is a need for training with ideally high-fidelity lung ultrasound phantoms to ensure ultrasound proficiency and procedural competency. Unfortunately, most commercial ultrasound phantoms remain expensive and may have limited fidelity.
OBJECTIVE: Our aim was to create and describe a homemade, high-fidelity ultrasound phantom model for demonstrating pneumonia with pleural effusions for teaching purposes.

Discussion : An ultrasound phantom was constructed using a water-filled latex glove with a sliver of meat in it, covered over by a palm-sized piece of meat (skin and ribs are optional to increase ultrasonographic details and realism). This would appear like parapneumonic effusions with organized pneumonia under ultrasound examination. Creamer (or talc) can be added to the water in the glove to simulate empyema. The model can also be used to teach simple effusions and for ultrasound-guided thoracentesis and in clinical decision making.

Conclusion : Easily prepared, homemade high-fidelity ultrasound phantom models for instructions on identification of pleural effusions and ultrasound-guided pleural tap of parapneumonic effusion were made.

Conclusion (proposition de traduction) : Des modèles fantômes échographiques de haute fidélité, faits maison et faciles à réaliser, ont été créés pour l'identification des épanchements pleuraux et le guidage échographique de la ponction pleurale des épanchements parapneumoniques.

Pilot Study to Evaluate the Adjunct Use of a Povidone-Iodine Topical Antiseptic in Patients with Soft Tissue Abscesses.
Olson AS, Rosenblatt L, Salerno N, Odette J, Ren R, Emanuel T, Michalek J, Liu Q, Du L, Jahangir K, Schmitz GR. | J Emerg Med.  2019 Apr;56(4):405-412
Keywords: abscess; antiseptic; iodine; povidone; wound care

Selected Topics: Wound Care

Introduction : Povidone-iodine (PVP-I) antiseptic solutions have been shown to be effective against methicillin-resistant Staphylococcal aureus, a common cause of superficial skin abscesses.
OBJECTIVES: Our objective was to study the feasibility of using PVP-I as a treatment adjunct in patients with superficial skin abscesses and determine if it confers any benefit over incision and drainage (I&D) alone.

Méthode : This was a randomized controlled pilot study of adult patients with an uncomplicated skin abscess. Patients were randomized to PVP-I or standard treatment. All patients had I&D and abscess packing. Patients randomized to PVP-I were instructed on daily application of the agent to hands, wound, and surrounding skin with dressing changes. Subjects returned at 48-72 h and 7-10 days and followed-up by phone at 30 days. The primary outcome was clinical cure 7-10 days after I&D. The secondary outcomes were rate of development of new skin lesions and spread in household contacts within 30 days.

Résultats : Clinical cure occurred in 91.3% of patients in the standard group vs. 88.2% of patients in the PVP-I group (difference, 3.1%; 95% confidence interval [CI] -10.7 to 16.8; p = 0.53). There was a significantly higher adverse event rate in the group who received PVP-I (59.6%) vs. standard care (26.5%) (difference 33.1%, 95% CI 13.2-50.2; p < 0.001).

Conclusion : There was no difference in clinical cure rates among patients using PVP-I (88.2%) vs. standard care (91.3%) after I&D. There were no major adverse events, but the addition of PVP-I was commonly associated with local skin irritation.

Conclusion (proposition de traduction) : Il n'y avait pas de différence entre les taux de guérison clinique chez les patients utilisant la solution de povidone iodée (88,2%) et les soins standard (91,3%) après incision et drainage. Il n'y a pas eu d'effet indésirable majeur, mais l'ajout de solution de povidone iodée a généralement été associé à une irritation cutanée locale.

Commentaire : Les solutions de povidone iodée (Bétadine iodée) ont une activité bactéricide et ont été utilisées comme antiseptique pour le lavage des mains et l’irrigation dans les plaies chirurgicales afin de réduire les infections.
L'utilisation de solution de povidone iodée n'a pas amélioré les taux de guérison clinique chez les patients présentant des abcès cutanés superficiels. Il y avait significativement plus d'événements indésirables dans le groupe ayant utilisé la solution de povidone iodée.
Le référentiel américain est : Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52
Le référentiel français est : Prise en charge des infections cutanées bactériennes courantes

The REAL CRIC Trainer: Instructions for Building an Inexpensive, Realistic Cricothyrotomy Simulator With Skin and Tissue, Bleeding, and Flash of Air.
Kei J, Mebust DP, Duggan LV. | J Emerg Med.  2019 Apr;56(4):426-430
Keywords: airway; cricothyrotomy; education; procedure; simulation; trainer

Techniques and Procedures

Editorial : Surgical cricothyrotomy is a rare procedure but it must be mastered by any physician who is involved in advanced airway management. Lack of experience and practice, the high-stress nature of a "can't intubate, can't oxygenate" emergency, and the unavailability of realistic simulators all contribute to physician hesitance and inaptitude while employing cricothyrotomy during difficult and failed airways. The REAL CRIC Trainer was created to alleviate some of the barriers surrounding a surgical airway. It is designed to provide the user an affordable, easy to replicate, reusable, and extremely realistic experience in cricothyrotomy to prepare for this rare event.

Discussion : The REAL CRIC Trainer uses a 3-dimensional printed tracheal model that is covered with pork belly skin, replicating human neck tissue. Red dyed normal saline is connected to the pork belly using intravenous tubing to simulate bleeding as an incision is made into the porcine skin. A bag-valve-mask connected to an endotracheal tube and to the trachea model will simulate breathing and replicate the puff of air experienced as the cricothyroid membrane is pierced with a scalpel. This simulator is cost effective and easy to replicate. Detailed step-by-step instructions are provided so that physicians working in any specialty involved in advanced airway management can easily recreate this trainer.

Conclusion : This simulator makes it practical for physicians in a variety of clinical settings to incorporate its use into regular practice sessions, thereby assuring that physicians are ready to perform an emergent cricothyrotomy if necessary.

Conclusion (proposition de traduction) : Ce simulateur permet aux médecins de divers contextes cliniques d'intégrer son utilisation aux séances de pratique régulières, garantissant ainsi que les médecins sont prêts à effectuer une cricothyrotomie émergente si nécessaire.

Safety of Peripheral Line Administration of 3% Hypertonic Saline and Mannitol in the Emergency Department.
Mesghali E, Fitter S, Bahjri K, Moussavi K. | J Emerg Med.  2019 Apr;56(4):431-436
Keywords: emergency department; extravasation; hypertonic saline; intravenous; mannitol; medication safety

Pharmacology in Emergency Medicine

Introduction : Hypertonic saline (HTS) and mannitol are frequently utilized in the emergency department (ED) to manage elevations in intracranial pressure (ICP).
OBJECTIVE: The objective of this study was to compare the incidence of extravasation injury when HTS or mannitol was administered via peripheral i.v. line (PIV).

Méthode : This retrospective cohort study evaluated adult and pediatric patients given either 3% HTS or mannitol via PIV while in the ED. The primary outcome was extravasation incidence.

Résultats : One hundred and ninety-two patients were included, of which 85 (44%) received HTS and 107 (56%) received mannitol. Patients who received HTS were younger (27.5 ± 24.3 years vs. 53.9 ± 22.3 years; p < 0.001); 55.3% of patients given HTS received it for traumatic brain injury (TBI) versus 38.3% of patients given mannitol (p = 0.021); and 44.9% of patients given mannitol received it for intracerebral hemorrhage versus 21.2% of patients given HTS (p = 0.001). There was no incidence of extravasation in either group. Patients who received HTS had lower ICP measurement 24 h post admission (2.107 ± 5.5 mm Hg vs. 4.236 ± 8.1 mm Hg; p = 0.047) and higher Glasgow Coma Scale (GCS) score upon discharge (GCS 14; interquartile range [IQR] 3-15 vs. GCS 3; IQR 3-14.2; p = 0.004). In-hospital mortality was higher in the mannitol group (54.7% vs. 32.9%; p = 0.003). Duration of mechanical ventilation was shorter in those patients who received HTS (1 day; IQR 0-56 days vs. 2 days; IQR 0-56 days; p = 0.023).

Conclusion : There were no incidences of extravasation among patients given 3% HTS or mannitol. Clinicians should reconsider recommendations to restrict HTS or mannitol to central lines.

Conclusion (proposition de traduction) : Aucun effet indésirable en cas d'extravasation n'a été constaté chez les patients ayant reçu une solution saline hypertonique à 3% ou du mannitol.
Les cliniciens devraient revoir les recommandations imposant à limiter l'utilisation d'une solution saline hypertonique à 3% ou de mannitol par voie centrale.

The Lancet Respiratory Medicine

Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label trial.
Frat JP, Ricard JD, Quenot JP, Pichon N, Demoule A, Forel JM, Mira JP, Coudroy R, Berquier G, Voisin B, Colin G, Pons B, Danin PE, Devaquet J, Prat G, Clere-Jehl R, Petitpas F, Vivier E, Razazi K, Nay MA, Souday V, Dellamonica J, Argaud L, Ehrmann S, Gibelin A, Girault C, Andreu P, Vignon P, Dangers L, Ragot S, Thille AW; FLORALI-2 study group; REVA network. | Lancet Respir Med.  2019 Apr;7(4):303-312
Keywords: Aucun


Introduction : Non-invasive ventilation has never been compared with high-flow oxygen to determine whether it reduces the risk of severe hypoxaemia during intubation. We aimed to determine if preoxygenation with non-invasive ventilation was more efficient than high-flow oxygen in reducing the risk of severe hypoxaemia during intubation.

Méthode : The FLORALI-2 multicentre, open-label trial was done in 28 intensive care units in France. Adult patients undergoing tracheal intubation for acute hypoxaemic respiratory failure (a partial pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FiO2] ratio of ≤300 mm Hg) were randomly assigned (1:1; block size, four participants) to non-invasive ventilation or high-flow oxygen during preoxygenation, with stratification by PaO2/FiO2 ratio (≤200 mm Hg vs >200 mm Hg). Key exclusion criteria were intubation for cardiac arrest, altered consciousness (defined as a Glasgow coma score of less than eight points), other contraindications to non-invasive ventilation (recent laryngeal, oesophageal, or gastric surgery, and substantial facial fractures), pulse oximetry not available, pregnant or breastfeeding women, and refusal to participate. The primary outcome was the occurrence of severe hypoxaemia (pulse oximetry <80%) during the procedure, assessed in the intention-to-treat population.

Résultats : Between April 15, 2016, and Jan 8, 2017, 2079 patients were intubated in the 28 participating units, and 322 were enrolled. We excluded five patients with no recorded data, two who withdrew consent or were under legal protection, one who was not intubated, and one who had a cardiac arrest. Of the 313 patients included in the intention-to-treat analysis, 142 were assigned to non-invasive ventilation and 171 to high-flow oxygen therapy. Severe hypoxaemia occurred in 33 (23%) of 142 patients after preoxygenation with non-invasive ventilation and 47 (27%) of 171 with high-flow oxygen (absolute difference -4·2%, 95% CI -13·7 to 5·5; p=0·39). In the 242 patients with moderate-to-severe hypoxaemia (PaO2/FiO2 ≤200 mm Hg), severe hypoxaemia occurred less frequently after preoxygenation with non-invasive ventilation than with high-flow oxygen (28 [24%] of 117 patients vs 44 [35%] of 125; adjusted odds ratio 0·56, 0·32 to 0·99, p=0·0459). Serious adverse events did not differ between treatment groups, with the most common immediate complications being systolic arterial hypotension (70 [49%] patients in the non-invasive ventilation group vs 86 [50%] patients in the high-flow oxygen group) and chest infiltrate on x-ray (28 [20%] vs 33 [19%]), and the most common late complications being death at day 28 (53 [37%] vs 58 [34%]) and ventilator-associated pneumonia during ICU stay (31 [22%] vs 35 [20%]).

Conclusion : In patients with acute hypoxaemic respiratory failure, preoxygenation with non-invasive ventilation or high-flow oxygen therapy did not change the risk of severe hypoxaemia. Future research should explore the effect of preoxygenation method in patients with moderate-to-severe hypoxaemia at baseline.

Conclusion (proposition de traduction) : Chez les patients présentant une insuffisance respiratoire hypoxémique aiguë, la préoxygénation par ventilation non invasive ou oxygénothérapie à haut débit nasal (Optiflow) n'a pas modifié le risque d'hypoxémie grave.
Des recherches futures devraient explorer l'effet de la méthode de préoxygénation chez les patients présentant une hypoxémie modérée à sévère au départ.

The New England Journal of Medicine

Coronary Angiography after Cardiac Arrest without ST-Segment Elevation.
Lemkes JS, Janssens GN, van der Hoeven NW, , Dubois EA, Meuwissen M, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak R, Vlachojannis GJ, Eikemans BJW, van der Harst P, van der Horst ICC, Voskuil M, van der Heijden JJ, Beishuizen A, Stoel M, Camaro C, van der Hoeven H, Henriques JP, Vlaar APJ, Vink MA, van den Bogaard B, Heestermans TACM, de Ruijter W, Delnoij TSR, Crijns HJGM, Jessurun GAJ, Oemrawsingh PV, Gosselink MTM, Plomp K, Magro M and al.. | N Engl J Med.  2019 Apr 11;380(15):1397-1407
Keywords: Aucun


Introduction : Ischemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography and percutaneous coronary intervention (PCI) in the treatment of patients who have been successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains uncertain.

Méthode : In this multicenter trial, we randomly assigned 552 patients who had cardiac arrest without signs of STEMI to undergo immediate coronary angiography or coronary angiography that was delayed until after neurologic recovery. All patients underwent PCI if indicated. The primary end point was survival at 90 days. Secondary end points included survival at 90 days with good cerebral performance or mild or moderate disability, myocardial injury, duration of catecholamine support, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, major bleeding, occurrence of acute kidney injury, need for renal-replacement therapy, time to target temperature, and neurologic status at discharge from the intensive care unit.

Résultats : At 90 days, 176 of 273 patients (64.5%) in the immediate angiography group and 178 of 265 patients (67.2%) in the delayed angiography group were alive (odds ratio, 0.89; 95% confidence interval [CI], 0.62 to 1.27; P = 0.51). The median time to target temperature was 5.4 hours in the immediate angiography group and 4.7 hours in the delayed angiography group (ratio of geometric means, 1.19; 95% CI, 1.04 to 1.36). No significant differences between the groups were found in the remaining secondary end points.

Conclusion : Among patients who had been successfully resuscitated after out-of-hospital cardiac arrest and had no signs of STEMI, a strategy of immediate angiography was not found to be better than a strategy of delayed angiography with respect to overall survival at 90 days.

Conclusion (proposition de traduction) : Parmi les patients qui avaient été réanimés avec succès après un arrêt cardiaque extra-hospitalier et ne présentaient aucun signe de syndrome coronarien avec surélévation du segment ST, une stratégie d'angiographie immédiate ne s'est pas révélée meilleure qu'une stratégie d'angiographie différée en termes de survie globale à 90 jours.

Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation.
Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, Meeder JG, Lenderink T, Widdershoven J, Bucx JJJ, Rienstra M, Kamp O, Van Opstal JM, Alings M, Oomen A, Kirchhof CJ, Van Dijk VF, Ramanna H, Liem A, Dekker LR, Essers BAB, Tijssen JGP, Van Gelder IC, Crijns HJGM; RACE 7 ACWAS Investigators. | N Engl J Med.  2019 Apr 18;380(16):1499-150
Keywords: Aucun


Introduction : Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.

Méthode : In a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than -10.

Résultats : The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, -2.9 percentage points; 95% confidence interval [CI], -8.2 to 2.2; P = 0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.

Conclusion : In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.

Conclusion (proposition de traduction) : Chez les patients se présentant au service des urgences avec une fibrillation atriale symptomatique d'apparition récente, une approche attentiste était identique à la cardioversion précoce pour permettre un retour du rythme sinusal à 4 semaines.

Mois d'avril 2019