Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope?.
Clark CL, Gibson TA, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Diercks DB, Hollander JE, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. | Acad Emerg Med. 2019 May;26(5):528-538
DOI: https://doi.org/10.1111/acem.13709
Keywords: Aucun

Original contributions

Introduction : An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The objective of this study was to determine if hscTnT and NT-proBNP drawn in the ED are independently associated with 30-day death/serious cardiac outcomes in adult patients presenting with syncope.

Méthode : A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30-day all-cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods.

Résultats : The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%-5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP > 2,000 ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings.

Conclusion : hscTnT and NT-proBNP are independent predictors of 30-day death and serious outcomes in older ED patients presenting with syncope.

Conclusion (proposition de traduction) : Le hscTnT et le NT-proBNP sont des prédicteurs indépendants de la mortalité à 30 jours et des évènements graves chez les patients âgés présentant une syncope au service des urgences.

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey.
Reibling ET, Green SM, Phan T, Lopez-Gusman E, Fierro L, Davis A, Sugarman T, Futernick M. | Acad Emerg Med. 2019 May;26(5):539-548
DOI: https://doi.org/10.1111/acem.13619
Keywords: Aucun

Original articles

Introduction : We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California.

Méthode : We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact.

Résultats : We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control.

Conclusion : In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

Conclusion (proposition de traduction) : Dans cette enquête menée à l'échelle de l'État, nous avons constaté une prévalence substantielle de limitations de la pratique - créées principalement par les directeurs d'anesthésie locaux - qui limitent la capacité des médecins d'urgence à fournir une sédation procédurale à leurs patients conformément aux directives de l'ACEP.
La sédation profonde était interdite dans 18 % des services d'urgence. Nos répondants décrivent les conséquences néfastes pour les soins aux patients.

Single Maintenance and Reliever Therapy (SMART) Regimen for Management of Persistent Asthma.
Mohan A, Kearney GD, Miller AC. | Acad Emerg Med. 2019 May;26(5):567-570
DOI: https://doi.org/10.1111/acem.13659
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Asthma is a chronic respiratory disease affecting 235 million people worldwide,1 burdening both patients, their families, and society in terms of lost work and school, lessened quality-of-life, avoidable emergency department (ED) visits, hospitalizations, and deaths. Data from the Centers for Disease Control and Prevention report that asthma affects roughly 8% of the U.S. population (approximately 26 million people), accounting for 2 million ED visits, 480,000 hospitalizations, and 3,400 deaths annually with an economic burden of about $82 billion.
Given the shortage of primary care physicians, the ED is the primary source of care for many asthmatics, with asthma-related ED visits increasing by 13% over the past decade.5,6 Emergency physicians must be familiar with various proper treatment strategies. Single maintenance and reliever therapy (SMART) is an emerging strategy aimed at reducing asthma exacerbations. The aim of this evidence-based medicine summary is to familiarize emergency physicians with the SMART regimen. While we are keenly aware that some may perceive controller medication to be a primary care provider issue, the onus of mitigating asthma’s $82 billion footprint falls on all involved providers.

Conclusion : moderate quality evidence suggests that SMART decreases asthma exacerbation. However, possible harms associated with this treatment have not been assessed or reported. Therefore, we have assigned a Yellow color recommendation (Unclear if Benefits) to this strategy.

Conclusion (proposition de traduction) : Des données de qualité moyenne suggèrent que le schéma SMART (ndlr : implique que le patient utilise un inhalateur comme traitement d’entretien et de dépannage) diminuent l'exacerbation de l'asthme. Toutefois, les effets secondaires possibles associés à ce traitement n'ont pas été évalués ni signalés. Par conséquent, nous avons assigné une recommandation de couleur jaune (Incertain en ce qui conserne les avantages) à cette stratégie.

Commentaire : La stratégie SMART implique que le patient utilise le Symbicort comme traitement d’entretien et de dépannage, il dispose donc d’un seul inhalateur.
Le patient doit prendre une dose fixe journalière, la dose de budésonide ayant été ajustée en fonction de la maîtrise de l’asthme (ex : Symbicort 200 mcg, une inhalation deux fois par jour). En plus de cette dose, le patient peut employer le Symbicort pour soulager rapidement les symptômes aigus de l’asthme (ex : Symbicort 200 mcg, une inhalation deux fois par jour et au besoin). Cette stratégie vise donc le soulagement rapide des symptômes et l’intensification du traitement anti-inflammatoire au moment opportun. La dose maximale recommandée est de huit inhalations par jour.
Les études démontrent que cette nouvelle stratégie prolonge le délai d’apparition de la première exacerbation grave et réduit le nombre et la fréquence des exacerbations. De plus, le nombre des effets secondaires n’était pas plus élevé avec l’utilisation de cette nouvelle stratégie. Toutefois, l’amélioration de la maîtrise de l’asthme et de la qualité de vie du patient qui utilisait la stratégie SMART étaient similaires à celles procurées par les autres approches dites « traditionnelles ».
La particularité de cette stratégie réside dans l’emploi du médicament de secours, puisque le même inhalateur sera employé à la fois pour le traitement d’entretien et pour le traitement de dépannage. Le Symbicort remplace ainsi le salbutamol ou la terbutaline pour les symptômes aigus.
Cette nouvelle approche ne s’applique pas à tous les patients. Il faut tout d’abord s’assurer que la personne ait un asthme non maîtrisé par une dose faible ou modérée de corsticostéroïde inhalé en monothérapie et qu’il soit capable d’utiliser le dispositif d’administration du Symbicort, soit le Turbuhaler.

Prevalence of Pulmonary Embolism in Patients Presenting With Syncope.
Long B, Koyfman A, Gottlieb M. | Acad Emerg Med. 2019 May;26(5):571-573
DOI: https://doi.org/10.1111/acem.13700  | Télécharger l'article au format  
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Syncope accounts for 1% to 3% of emergency department (ED) visits and 1% to 6% of hospital admissions.
Previously, pulmonary embolism (PE) wasthought to account for a small minority of patientswith syncope. However, a recent study by Prandoni and colleagues reported a high prevalence of PE in admitted patients with syncope (3.8% of ED patients and 17.3% of hospitalized patients). Evaluating for PE in all patients with syncope carries significant risks including radiation exposure, contrast-induced nephropathy, and adverse events from anticoagulation therapy.

Conclusion : Results of the current meta-analysis suggest a low prevalence of PE in patients presenting with syncope: 0.8% (95% confidence interval [CI]=0.5%–1.3%) inED patients (number needed to screen=125) and1.0% (95% CI=0.5%–1.9%) in hospitalized patients(number needed to screen=100), with an overall prevalence of 0.9% (95% CI=0.6%–1.3%).

Conclusion (proposition de traduction) : Les résultats de la méta-analyse actuelle suggèrent une faible prévalence d’EP chez les patients présentant une syncope : 0,8 % (intervalle de confiance à 95% [IC] = 0,5 à 1,3 %) des patients aux urgences (nombre nécessaire au dépistage = 125) et 1,0 % ( IC à 95 % = 0,5 à 1,9 %) chez les patients hospitalisés (nombre de personnes à examiner = 100), avec une prévalence globale de 0,9 % (IC à 95 % = 0,6 à 1,3 %).

Diagnostic Accuracy of Ultrasound for Confirmation of Endotracheal Tube Placement.
Long B, Koyfman A, Gottlieb M. | Acad Emerg Med. 2019 May 2
DOI: https://doi.org/10.1111/acem.13773
Keywords: Aucun

The Brass Tacks: Concise Reviews of Published Evidence

Editorial : Endotracheal intubation is a common intervention in the emergency department (ED) and prehospital setting. Direct visualization of endotracheal tube (ETT) placement through the vocal cords is limited at times, and esophageal intubation can be dangerous if not recognized. Therefore, additional methods (e.g., lung auscultation, esophageal detector devices, capnography) are necessary for confirmation of tube placement. However, these methods are not always reliable. Point-of-care ultrasonography (POCUS) has increasingly been used as a potential confirmatory tool for ETT confirmation. The 2015 Advanced Cardiac Life Support guidelines state that POCUS may be a useful adjunct for ETT confirmation.

Conclusion : Based on the existing evidence, POCUS appears to be highly sensitive and specific for guiding and verifying ETT placement. POCUS is easily available, rapid, noninvasive, and does not depend on ventilation for confirmation. Therefore, we have assigned a color recommendation of green (benefit > harm) to this technique.

Conclusion (proposition de traduction) : D'après les données probantes existantes, l'échographie au point d'intervention semble être un outil très sensible et spécifique pour guider et vérifier le placement du tube endotrachéal. L'échographie au point d'intervention est facilement accessible, rapide, non invasif et ne dépend pas de la ventilation pour la confirmation. C'est pourquoi nous avons attribué à cette technique une recommandation de couleur verte (avantage > inconvénient).

Jacquet J, Catala G, Machiels JP, Penaloza A. | Ann Fr Med Urgence. 2019 Mai;9(3):173-183
DOI: https://doi.org/10.3166/afmu-2019-0133
Keywords: Neutropenia; Febrile; Outpatient; Risk; MASCC

Mise au point / Update

Editorial : La neutropénie fébrile (NF) est une situation fréquemment rencontrée aux urgences avec un taux de mortalité non négligeable variant de 5 à 40 %. Cette variabilité importante met en avant l’importance de stratifier le risque afin de permettre un traitement ambulatoire per os de certains patients à faible risque. En plus du MASCC (The Multinational Association for Supportive Care in Cancer) score, d’autres outils permettent d’évaluer ce risque ou sont à l’étude dans ce but, tels que le dosage de la CRP, la procalcitonine ou encore le score CISNE. Après une prise en charge rapide aux urgences incluant l’administration sans délai d’un traitement adéquat, la poursuite de l’antibiothérapie per os à domicile est envisageable chez les patients à faible risque. La combinaison amoxicilline–acide clavulanique et ciprofloxacine est le plus souvent recommandée, mais la moxifloxacine ou la lévofloxacine en monothérapie peuvent également être utilisées pour les patients traités à domicile. Le retour à domicile permet de réduire fortement les coûts engendrés par l’hospitalisation, de diminuer le risque d’infection nosocomiale et d’améliorer la qualité de vie des patients avec NF à faible risque. Dans cette optique, plusieurs critères doivent être remplis, et une discussion avec le patient reste primordiale à la prise de décision. Parmi ceux-ci, nous retiendrons notamment un score MASCC supérieur à 21, une durée attendue de neutropénie inférieure à sept jours, l’accord du patient et de son entourage ainsi que la proximité entre le domicile et un service de soin adapté.

Conclusion (proposition de traduction) : La prise en charge d’un patient en NF doit être rapide et efficace. Après le diagnostic, le clinicien doit évaluer le risque de complications en s’aidant d’outils tels que le score MASCC, le score CISNE et d’autres facteurs indépendants de mauvais pronostic et instaurer un traitement antibiotique adéquat. Un retour à domicile pour les patients à faible risque peut être discuté après une période d’observation de stabilité clinique de minimum quatre heures, étant donné l’efficacité comparable des traitements ambulatoires et hos- pitaliers chez ces patients, et ne peut être proposé que si une infrastructure adéquate existe, en tenant compte des préfé- rences du patient.

Aubrion A, Morin M, Roupie1 E, Macrez R. | Ann Fr Med Urgence. 2019 Mai;(9)3:149-155
DOI: https://doi.org/10.3166/afmu-2019-0131
Keywords: Appropriate hospitalization; Inappropriate but justified hospitalization; Appropriateness; Evaluation protocol; Length of stay

Article Original / Original Article

Introduction : L’overcrowding — ou surcharge — des services d’urgence hospitaliers est un problème de santé international, qui impacte la qualité des soins et la durée moyenne de séjour (DMS). Cette surpopulation est liée majoritairement au manque d’accès aux lits d’hospitalisation. Notre objectif principal était d’étudier la pertinence des admissions hors unité d’hospitalisation de courte durée (UHCD) ayant une DMS inférieure à 24 heures.

Méthode : Notre étude observationnelle descriptive rétrospective sur l’année 2016 concernait les patients hospitalisés hors UHCD de DMS de moins de 24 heures. La grille AEPf (Appropriateness Evaluation Protocole adaptée en France par la Haute Autorité de santé) utilisée permet de les séparer en trois groupes : hospitalisations pertinentes (gravité clinique ou soins), non pertinentes mais justifiées (organisationnelles), non pertinentes et non justifiées (hébergement). Les comparaisons étaient réalisées par test de Chi2.

Résultats : Sur 1 006 admissions, selon la grille AEPf, 786 (78 %) sont pertinentes (sévérité clinique, actes diagnostiques ou thérapeutiques, surveillance, etc.). Pour les 220 hospitalisations non pertinentes, 210 (95 %) sont justifiées par des contraintes organisationnelles (avis spécialisés, actes d’imagerie, procédures). Quatre-vingt-dix-neuf (47 %) d’entre eux auraient pu rentrer à domicile si l’organisation des soins l’avait permis. Pour 83 (39 %) de ces hospitalisations non pertinentes, la structure la plus adaptée reste l’hôpital. Seulement dix (1 %) de ces 1 006 hospitalisations sont non pertinentes et non justifiées. Le service d’hospitalisation était adéquat pour 805 patients (80 %).

Conclusion : The rate of appropriate and justified hospitalization from emergency department with a length of stay less than 24 h (out of acute emergency care unit) is high. In order to avoid relevant but non-justified hospitalization, several organizational health cares may need to be improved.

Conclusion (proposition de traduction) : Le taux d’hospitalisations pertinentes ou justifiées, de DMS de moins de 24 heures, depuis notre service est élevé. Il existerait quelques leviers organisationnels permettant d’éviter le recours à une hospitalisation.

Are Antibiotics Effective in the Treatment of Children With Prolonged Wet Cough?.
Long B, April MD. | Ann Emerg Med. 2019 May;73(5):453-455
DOI: https://doi.org/10.1016/j.annemergmed.2018.10.010  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : Authors identified trials from the Cochrane Airways Trials Register, CENTRAL, MEDLINE OvidSP, and EMBASE OvidSP through September 2017, with no language restrictions. They evaluated reference lists of primary and review articles for additional studies. Finally, they searched ClinicalTrials.gov and the World Health Organization trial portal.

Méthode : Two authors independently reviewed relevant studies and selected trials for inclusion. A third author adjudicated disagreements through discussion. The meta-analysis included all randomized controlled trials comparing antibiotics with placebo or no treatment among children younger than 18 years who had no known pulmonary conditions and prolonged wet cough (defined as cough >10 days with presence of lower airway secretions). Investigators planned to evaluate short-term treatment (<14 days), long-term antibiotics (>14 days), and intravenous antibiotics provided for at least 5 days. The authors excluded trials comparing 2 or more antibiotics without a placebo arm.

Résultats : Two authors independently extracted data from included studies. Authors contacted the investigators of included studies for missing data when possible. Primary outcomes included children not cured or substantially improved according to the following hierarchy: objective measurements of cough indices, symptoms as assessed by the child, symptoms as assessed by parents or caregivers, symptoms as assessed by clinicians, airway markers obtained by bronchoalveolar lavage, sputum volume alone, and lung function test results alone. Secondary outcomes included disease progression requiring further medical therapy and antibiotic adverse effects. Authors calculated odds ratios with 95% confidence intervals (CIs) with fixed-effects models and calculated the number needed to treat for an additional beneficial outcome. Authors planned a priori subgroup analyses for children younger than 7 years, control type, variation in duration of treatment, and antibiotic type and planned sensitivity analyses. Investigators assessed heterogeneity with the I2 and Khi2 tests, and 2 authors independently assessed risk of bias based on the Cochrane Handbook for Systematic Reviews of Interventions, with disagreements resolved by either consensus or discussion with a third author. Authors assessed evidence quality with Grading of Recommendations Assessment, Development and Evaluation considerations.

Conclusion : Antibiotics may improve clinical cure and reduce progression of illness in children with prolonged wet cough.

Conclusion (proposition de traduction) : Les antibiotiques peuvent améliorer la guérison clinique et réduire la progression de la maladie chez les enfants présentant une toux grasse prolongée.

Commentaire : Voir l'article : Antibiotics for prolonged wet cough in children. In: Cochrane Database Syst Rev. 2018 Jul 31;7:CD004822  . (téléchargeable en pdf   à partir du 31-07-2019). Rédigé par Marchant JM, Petsky HL, Morris PS & Chang AB.

Do Glucocorticoids Improve Symptoms and Reduce Return Visits or Admission Rates Among Children With Croup?.
April MD, Long B. | Ann Emerg Med. 2019 May;73(5):459-461
DOI: https://doi.org/10.1016/j.annemergmed.2018.10.030  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : Authors searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid MEDLINE, Ovid EMBASE, ClinicalTrials.gov, and the World Health Organization International Trials Registry Platform. Authors searched ClinicalTrials.gov and apps.who.int/trialsearch for ongoing studies. All searches ran from database inception through April 3, 2018. Authors also scanned the reference lists of relevant systematic reviews and all included studies.

Méthode : The review included randomized controlled trials of patients (0 to 18 years) with a diagnosis of croup, defined as a syndrome of hoarseness, barking cough, and stridor, that compared outcomes of glucocorticoids versus pharmacologic alternatives, including placebo. Authors included studies of both outpatients (including emergency department [ED] patients) and inpatients. Included studies needed to report at least one of the following outcomes: changes in croup score; return visits, admissions, or both; hospital length of stay; patient improvement; use of additional treatments; and adverse events. There were no exclusion criteria based on language, publication status, trial conduct, reporting quality, or risk of bias. Two authors independently reviewed the full text of all potentially relevant articles. A third author arbitrated any disagreements in regard to study inclusion.

Résultats : One author extracted data from each study, whereas a second independently verified extraction to identify errors or omissions. Included studies used alternative croup scores, including the Westley score, the Downes score, or author-created scores. Consequently, the meta-analysis authors calculated treatment effect in regard to croup scores, using a standardized mean difference. They compared the binary outcome of return visits or admissions as a risk ratio with 95% confidence intervals (CIs). For return visits or admissions, authors calculated the number needed to treat for an additional beneficial outcome. Two review authors independently assessed risk of bias for each study by using the Cochrane Risk of Bias Tool, quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach, and heterogeneity with the I2 statistic. They also evaluated treatment effect in subgroup analyses stratifying calculations according to inpatient versus outpatient settings (including the ED), as well as sensitivity analyses.

Conclusion : Compared with placebo, glucocorticoids improve symptoms of croup at 2 through 24 hours and reduce rates of return visits and admissions among children with croup.

Conclusion (proposition de traduction) : Par rapport au placebo, les glucocorticoïdes atténuent les symptômes du croup en 2 à 24 heures et réduisent les taux de reconsultations et d'admissions chez les enfants atteints de croup.

Commentaire : La dexaméthasone était le corticoïde évalué dans la plupart de ces essais cliniques (Russell KF, Liang Y, O’Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup. Cochrane Database Syst Rev 2011;(1):CD001955  ).

Premedication With Midazolam or Haloperidol to Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double-Blind Clinical Trial.
Akhlaghi N, Payandemehr P, Yaseri M, Akhlaghi AA, Abdolrazaghnejad A. | Ann Emerg Med. 2019 May;73(5):462-469
DOI: https://doi.org/10.1016/j.annemergmed.2018.11.016
Keywords: Aucun

Pain Management and Sedation

Introduction : We evaluate the effect of midazolam and haloperidol premedication for reducing ketamine-induced recovery agitation in adult patients undergoing procedural sedation. We also compare physician satisfaction and recovery time.

Méthode : We randomized emergency department patients older than 18 years who needed procedural sedation to receive 1 of the following 3 interventions in double-blind fashion 5 minutes before receiving intravenous ketamine at 1 mg/kg: intravenous distilled water, intravenous midazolam at 0.05 mg/kg, or intravenous haloperidol at 5 mg. Our main study outcomes were recovery agitation as assessed by the maximum observed Pittsburgh Agitation Scale score and by the Richmond Agitation-Sedation Scale score at 5, 15, and 30 minutes after ketamine administration. Our secondary outcomes were clinician satisfaction and recovery duration.

Résultats : We enrolled 185 subjects. The maximum Pittsburgh Agitation Scale score was significantly less with midazolam compared with placebo (difference 3; 95% confidence interval 1.27 to 4.72) and with haloperidol compared with placebo (difference 3; 95% confidence interval 1.25 to 4.75), and Richmond Agitation-Sedation Scale scores at 5, 15, and 30 minutes trended lower with the active agents. Midazolam and haloperidol significantly delayed recovery but did not alter overall clinician satisfaction.

Conclusion : For adult procedural sedation, premedication with either midazolam 0.05 mg/kg or haloperidol 5 mg intravenously significantly reduces ketamine-induced recovery agitation while delaying recovery.

Conclusion (proposition de traduction) : Pour la sédation procédurale chez l'adulte, une prémédication par du midazolam à 0,05 mg/kg ou de l'halopéridol à 5 ​​mg par voie intraveineuse réduit de manière significative l'agitation induite au réveil par la kétamine tout en retardant la récupération.

Commentaire : L'analyse de l'article par Lee P & Murray H. Midazolam or haloperidol premedication reduced ketamine-induced recovery agitation and increased ED recovery time. Ann Intern Med. 2019 May 21;170(10):JC57   concluent que : « Le midazolam et l'halopéridol ont prolongé le temps de récupération de 17 et 32 ​​minutes, respectivement. Les praticiens doivent savoir que la réduction de l'agitation du patient s'accompagne d'un temps de récupération prolongé, affectant le flux de patients aux urgences et aggravant potentiellement la surcharge d'activité des urgences. ».

Is the Level of Sedation Depth in the Early Postintubation Period Associated With Worse Patient Outcomes?.
Gottlieb M, Patel KA, McDowell WG. | Ann Emerg Med. 2019 May;73(5):488-490
DOI: https://doi.org/10.1016/j.annemergmed.2018.11.031  | Télécharger l'article au format  
Keywords: Aucun

Pain Management and Sedation

Introduction : The Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews and Effects, EMBASE, MEDLINE, and Scopus were searched from inception through October 2016. A manual search of the reference lists of included articles and conference proceedings of major critical care, emergency medicine, surgery, trauma, and anesthesiology meetings was also performed. There were no language restrictions.

Méthode : Studies were screened by 2 independent reviewers, with disagreements resolved by consensus with the addition of a third reviewer. Both randomized controlled trials and nonrandomized studies (including prospective and retrospective cohort analyses, cross-sectional studies, and before-after trials) were included. Studies included adult patients receiving invasive ventilation and had to report objective measures of sedation depth (eg, the Richmond Agitation- Sedation Scale, the Glasgow Coma Scale [GCS]). The primary outcome was in-hospital mortality. Secondary outcomes included rates of delirium, duration of mechanical ventilation, hospital and ICU length of stay, and frequency of tracheostomy placement.

Résultats : Data were extracted with standardized forms. Quality was assessed with the Cochrane Collaboration Risk of Bias Tool for clinical trials, whereas observational studies were assessed with the Newcastle- Ottawa Scale. A random-effects model was used to calculate pooled effect sizes and corresponding 95% confidence intervals. Odds ratios were calculated for binary outcomes and overall effect estimates were generated with the z test. Heterogeneity was assessed with the I2 statistic.

Conclusion : Compared with deep sedation, light sedation early in the postintubation course is associated with reduced mortality, decreased length of ICU stay, and fewer days of mechanical ventilation.

Conclusion (proposition de traduction) : Comparativement à la sédation profonde, une sédation légère au début de la période postintubation est associée à une réduction de la mortalité, à une diminution de la durée du séjour aux soins intensifs et à une diminution du nombre de jours de ventilation mécanique.

Is Low-Dose Ketamine an Effective Alternative to Opioids for Acute Pain?.
Kirschner JM, Hunter BR. | Ann Emerg Med. 2019 May;73(5):e47-e49
DOI: https://doi.org/10.1016/j.annemergmed.2018.11.001  | Télécharger l'article au format  
Keywords: Aucun

Pain Management and Sedation

Introduction : A medical librarian searched MEDLINE, EMBASE, Scopus, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects from inception through February 2017. The Cochrane Central Register of Controlled Trials, ClinicalTrials. gov, and the World Health Organization International Clinical Trials Registry Platform were searched for gray literature, and bibliographies were searched for additional citations. Only English- language studies were included.

Méthode : Two reviewers screened all titles and abstracts, and discrepancies were resolved by discussion or an adjudicator. Included studies were randomized trials of low-dose intravenous ketamine less than or equal to 0.5 mg/kg compared with intravenous opioids in adult ED patients with acute pain ( 1 week’s duration). Studies had to report a change in either a visual analog scale or numeric rating scale score within 60 minutes.

Résultats : Mean visual analog scale or numeric rating scale score, mean changes, and SDs were abstracted for all points less than or equal to 120 minutes, although details of data abstraction were not reported. The primary outcome was change in mean pain score at 10 minutes or closest point to 10 minutes with available data. The secondary outcome of adverse events was not predefined, but all adverse events reported in the individual trials were recorded. The difference in change in visual analog scale or numeric rating scale score between ketamine and opioids was meta- analyzed with random-effects models. Results were reported with 95% confidence intervals. The quality of individual trials was assessed with the Cochrane Risk of Bias Tool.

Conclusion : In adult emergency department (ED) patients with acute pain, low-dose intravenous ketamine (0.3 to 0.5 mg/kg) may provide pain relief within 10 minutes that is similar to that of single-dose intravenous morphine (0.1 mg/kg).

Conclusion (proposition de traduction) : Chez les patients adultes de l'urgence souffrant de douleur aiguë, une faible dose de kétamine par voie intraveineuse (0,3 à 0,5 mg/kg) peut soulager la douleur en 10 minutes, ce qui est semblable à la dose unique de morphine intraveineuse (0,1 mg/kg).

Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update.
Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. | Ann Emerg Med. 2019 May;73(5):470-480
DOI: https://doi.org/10.1016/j.annemergmed.2018.12.012
Keywords: Aucun

Pain Management and Sedation

Editorial : We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation.

Conclusion : Propofol is a short-acting sedative hypnotic that satisfies the requirements for effective ED sedation as outlined by ACEP, the American Academy of Pediatrics, the Pediatric Emergency Research Canada, and the Pediatric Emergency Care Applied Research Network. The literature supports the safety and efficacy of propofol for a variety of ED procedures requiring deep sedation. The use of propofol for moderate sedation has been described and is associated with fewer adverse events than deep sedation. Targeting any given sedation endpoint with propofol is frequently associated with overshooting; thus, preparing to manage deeper levels of sedation than intended is mandatory.
Propofol has sedative and amnestic properties, but does not provide analgesia. Given the lack of analgesic properties, coadministration of propofol with analgesic agents is common.
Adverse effects associated most frequently with propofol sedation include respiratory depression, central or obstructive apnea, hemodynamic compromise, and injection pain.

Conclusion (proposition de traduction) : Le propofol est un hypnotique sédatif de courte durée d’action qui répond aux critères de sédation efficace définis par l’American College of Emergency Physicians (ACEP), l’American Academy of Pediatrics, le Pediatric Emergency Research Canada et le Pediatric Emergency Care Applied Research Network.
La littérature confirme l'innocuité et l'efficacité du propofol dans diverses procédures d'urgence nécessitant une sédation profonde. L'utilisation de propofol pour la sédation modérée a été décrite et est associée à moins d'événements indésirables que la sédation profonde. Le fait de cibler un critère de sédation donné avec le propofol est souvent associé à un dépassement ; par conséquent, il est impératif de se préparer à gérer des niveaux de sédation plus profonds que prévu.
Le propofol a des propriétés sédatives et amnésiantes, mais ne procure pas d'analgésie. Étant donné l'absence de propriétés analgésiques, l'administration concomitante de propofol et d'agents analgésiques est courante.
Les effets indésirables les plus fréquemment associés à la sédation avec le propofol comprennent la dépression respiratoire, l'apnée centrale ou obstructive, la dépression hémodynamique et la douleur au site d'injection.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.
Green SM, Roback MG, Krauss BS, Miner JR, Schneider S, Kivela PD, Nelson LS, Chumpitazi CE, Fisher JD, Gesek D, Jackson B, Kamat P, Kowalenko T, Lewis B, Papo M, Phillips D, Ruff S, Runde D, Tobin T, Vafaie N, Vargo J 2nd, Walser E, Yealy DM, O'Connor RE. | Ann Emerg Med. 2019 May;73(5):e51-e65
DOI: https://doi.org/10.1016/j.annemergmed.2019.02.022  | Télécharger l'article au format  
Keywords: Aucun

Pain Management and Sedation

Editorial : The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Conclusion : This document provides guidance for practitioners of unscheduled, time-sensitive procedural sedation, as defined above. We did not seek to address scheduled elective procedural sedation, the administration of analgesics to achieve analgesia or sedatives to achieve anxiolysis or sedation in the absence of a concurrent procedure, and minimal sedation given its negligible patient risk.
We intend this guideline to be applicable to the practice of all emergency providers, and have incorporated multidisciplinary input in the belief that it will be useful to other practitioners of unscheduled procedural sedation.

Conclusion (proposition de traduction) : Le présent document fournit des conseils aux praticiens qui pratiquent la sédation non programmée et urgente, telle que définie ci-dessus. Nous n'avons pas cherché à aborder la sédation chirurgicale non urgente programmée, l'administration d'analgésiques pour obtenir une analgésie ou de sédatifs pour obtenir une anxiolyse ou une sédation en l'absence d'une intervention simultanée, et la sédation minimale étant donné le risque négligeable pour le patient.
Nous avons l'intention d'appliquer cette ligne directrice à la pratique de tous les fournisseurs de soins d'urgence, et nous avons incorporé des données multidisciplinaires avec la conviction qu'elle sera utile à d'autres praticiens de la sédation non planifiée.

A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions.
Ljung L1, Lindahl B, Eggers KM, Frick M, Linder R, Löfmark HB, Martinsson A, Melki D, Sarkar N, Svensson P, Jernberg T. | Ann Emerg Med. 2019 May;73(5):491-499
DOI: https://doi.org/10.1016/j.annemergmed.2018.11.039
Keywords: Aucun

Cardiology

Introduction : We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care-related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.

Méthode : This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.

Résultats : A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference -20.4 to -11.4); median health care-related costs, from $1,748 to $1,079 (95% CI of difference -$953 to -$391). The number of clinical events was very low.

Conclusion : In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.

Conclusion (proposition de traduction) : Dans cette étude avant-après, la mise en œuvre clinique d'un algorithme à partir de la troponine à haute sensibilité à une heure combiné au score HEART a été associée à une réduction du taux d'admission et de la charge en soins, avec de très faibles taux d'événements cliniques indésirables.

Can S100B Serum Biomarker Testing Reduce Head Computed Tomography Scanning in Children With Mild Traumatic Brain Injury?.
Roumpf SK, Welch JL. | Ann Emerg Med. 2019 May;73(5):456-458
DOI: https://doi.org/10.1016/j.annemergmed.2018.10.012  | Télécharger l'article au format  
Keywords: Aucun

Pediatrics

Introduction : The authors searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Google Scholar from inception to March 15, 2017. In addition, the authors searched reference lists of relevant studies.

Méthode : The meta-analysis included prospective cohort studies of children with mild traumatic brain injury who had S100B biomarker testing compared with the reference standards of head computed tomography (CT) or clinical follow-up. Authors did not indicate how they defined intracranial lesions on head CT. Studies were excluded for the following reasons: adult patients, non-English language, Glasgow Coma Scale (GCS) score of less than or equal to 12, insufficient data for analysis, literature reviews, and magnetic resonance imaging as the reference standard.

Résultats : Two authors independently screened studies for inclusion, assessed quality, and extracted data. Discrepancies were resolved by a third author. Study quality and risk of bias were assessed with the Quality Assessment of Diagnostic Accuracy Studies–2 criteria. Primary meta-analysis was performed with random-effects models. Heterogeneity was assessed with forest plots, 95% confidence intervals (CIs), and I2 values. Because of potential variability from the use of different S100B serum assays, the authors performed a secondary meta-analysis on individual participant data from 4 studies that used the same S100B assay, the Cobas analyzer from Roche Diagnostics (Indianapolis, IN). Receiver operating characteristic cutoffs were calculated for a 100% sensitivity based on age (<2 versus >2 years) and blood draw times ( 3 versus >3 hours).

Conclusion : S100B serum biomarker has high sensitivity and negative predictive value for detecting traumatic intracranial lesions in children with mild traumatic brain injury. However, how to incorporate this into existing risk-stratification tools is unclear, and reduced availability of the test currently limits its practical application in the emergency department (ED)

Conclusion (proposition de traduction) : Le biomarqueur sérique S100B présente une sensibilité élevée et une valeur prédictive négative pour la détection de lésions intracrâniennes traumatiques chez les enfants présentant une lésion cérébrale traumatique légère.
Cependant, la manière de l’incorporer dans les outils de stratification des risques existants n’est pas claire et la disponibilité réduite du test limite actuellement son application pratique au service des urgences.

Effects of mean arterial pressure on arousal in sedated ventilated patients with septic shock: a SEPSISPAM post hoc exploratory study.
Jouan Y, Seegers V, Meziani F, Grelon F, Megarbane B, Anguel N, Mira JP, Dequin PF, Gergaud S, Weiss N, Legay F, Le Tulzo Y, Conrad M, Robert R, Gonzalez F, Guitton C, Tamion F, Tonnelier JM, Guezennec P, Van Der Linden T, Vieillard-Baron A, Radermacher P, Asfar P. | Ann Intensive Care.. 2019 May 9;9(1):54
DOI: https://doi.org/10.1186/s13613-019-0528-5  | Télécharger l'article au format  
Keywords: Arousal; Cerebral perfusion; Mean arterial pressure; Sedation; Septic shock; Vasopressors

Research

Introduction : It is unknown whether the recommended mean arterial pressure (MAP) target of 65 mmHg during initial resuscitation of septic shock is sufficient to maintain cerebral perfusion. Thus, we tested the hypothesis that a higher MAP target in patients with septic shock may improve level of arousal.

Méthode : We performed a post hoc exploratory analysis of the SEPSISPAM trial, which assessed the effect of a "high-target" level of MAP (80-85 mmHg) versus the recommended "low-target" MAP (65-70 mm Hg) on mortality in patients with septic shock. Among the 776 patients originally recruited in SEPSISPAM trial, we selected those who were mechanically ventilated and sedated and with available evaluation of arousal level assessed by the Richmond Agitation and Sedation Scale (RASS).

Résultats : We restricted our analysis to the period in which patients were treated with vasoactive drugs. Cumulative sedative drugs were assessed daily. A total of 532 patients were included in this study: 253 (47.6%) in the low-target group and 279 (52.4%) in the high-target group. Daily cumulative sedative drugs were similar in both groups. Compared to the low-target group, minimal and maximal RASS were significantly higher in the high-target group at day 2, 4 and 5. Furthermore, in order to consider the fact that multiple measures were done for each patient and to consider the global effect of time on these measures, we used a mixed linear regression and multivariate models: we confirmed that maximal RASS values were significantly higher in the high-target group.

Conclusion : In patients with septic shock who were mechanically ventilated and sedated, resuscitation with MAP target between 80 and 85 mmHg was associated with higher arousal level as compared to a MAP target between 65 and 70 mmHg.

Conclusion (proposition de traduction) : Chez les patients en état de choc septique sédatés/ventilés, la réanimation avec une PAM cible entre 80 et 85 mmHg a été associée à un niveau de réveil plus élevé comparativement à une PAM cible entre 65 et 70 mmHg.

ECG alterations suggestive of hyperkalemia in normokalemic versus hyperkalemic patients.
Varga C, Kálmán Z, Szakáll A, Drubits K, Koch M, Bánhegyi R, Oláh T, Pozsgai É, Fülöp N, Betlehem J. | BMC Emerg Med. 2019 May 31;19(1):33
DOI: https://doi.org/10.1186/s12873-019-0247-0
Keywords: ECG alterations; Hyperkalemia; Peaked T wave; Periarrest situation; Prehospital setting; Wide QRS

Research article

Introduction : In periarrest situations and during resuscitation it is essential to rule out reversible causes. Hyperkalemia is one of the most common, reversible causes of periarrest situations. Typical electrocardiogram (ECG) alterations may indicate hyperkalemia. The aim of our study was to compare the prevalence of ECG alterations suggestive of hyperkalemia in normokalemic and hyperkalemic patients.

Méthode : 170 patients with normal potassium (K+) levels and 135 patients with moderate (serum K+ = 6.0-7.0 mmol/l) or severe (K+ > 7.0 mmol/l) hyperkalemia, admitted to the Department of Emergency Medicine at the Somogy County Kaposi Mór General Hospital, were selected for this retrospective, cross-sectional study. ECG obtained upon admission were analyzed by two emergency physicians, independently, blinded to the objectives of the study. Statistical analysis was performed using SPSS22 software. χ2 test and Fischer exact tests were applied.

Résultats : 24% of normokalemic patients and 46% of patients with elevated potassium levels had some kind of ECG alteration suggestive of hyperkalemia. Wide QRS (31.6%), peaked T-waves (18.4%), Ist degree AV-block (18.4%) and bradycardia (18.4%) were the most common and significantly more frequent ECG alterations suggestive of hyperkalemia in severely hyperkalemic patients compared with normokalemic patients (8.2, 4.7, 7.1 and 6.5%, respectively). There was no significant difference between the frequency of ECG alterations suggestive of hyperkalemia in normokalemic and moderately hyperkalemic patients. Upon examining ECG alterations not typically associated with hyperkalemia, we found that prolonged QTc was the only ECG alteration which was significantly more prevalent in both patients with moderate (17.5%) and severe hyperkalemia (21.1%) compared to patients with normokalemia (5.3%).

Conclusion : A minority of patients with normal potassium levels may also exhibit ECG alterations considered to be suggestive of hyperkalemia, while more than half of the patients with hyperkalemia do not have ECG alterations suggesting hyperkalemia. These results imply that treatment of hyperkalemia in the prehospital setting should be initiated with caution. Multiple ECG alterations, however, should draw attention to potentially life threatening conditions.

Conclusion (proposition de traduction) : Une minorité de patients avec des taux de potassium normaux peuvent également présenter des altérations de l'ECG considérées comme évocatrices d'une hyperkaliémie, tandis que plus de la moitié des patients atteints d'hyperkaliémie ne présentent pas d'altérations de l'ECG suggérant une hyperkaliémie.
Ces résultats impliquent que le traitement de l'hyperkaliémie en milieu préhospitalier doit être instauré avec prudence. De multiples modifications de l'ECG, cependant, devraient attirer l'attention sur des conditions potentiellement mortelles.

#Epi: There is no place for the use of intravenous epinephrine as a standard component of cardiac arrest resuscitation care.
Welsford M, Buick JE, Drennan IR, Lin S, Atkinson PR. | CJEM. 2019 May;21(3):324-329
DOI: https://doi.org/10.1017/cem.2019.17
Keywords: Aucun

Commentary

Editorial : We continue the #CJEMDebate series with the topic of whether epinephrine (adrenalin) should continue to be routinely administered during the management of sud- den cardiac arrest (SCA), a debate that is particularly relevant following recent publications and the resulting conversations within emergency medical service (EMS) and emergency medicine circles. Are we causing more harm than good with continued routine use of epineph- rine during SCA? Or must we use every tool that shows any hope of improving outcomes in this patient group, in whom the failure of therapy is final? Does the latest evi- dence support current protocols or even modified use of epinephrine, or do we persist in using a treatment option that is based purely on physiological models and expert opinion, without a strong evidence base? Further, from a cost perspective, is epinephrine use providing mean- ingful health improvements for society, or is it a cost without any benefits?

Conclusion : Epinephrine use in cardiac arrest is complicated. The PARAMEDIC2 trial has raised as many important questions as it has answered. The evidence for epinephrine is not yet definitive, one way or another. Based on one trial, if we prematurely stop using epinephrine in cardiac arrest, are we saying that disability is worse than death? Clinicians, researchers, policy-makers, and the general public need to discuss and debate our values and the evidence. If one thing is for certain, it is that with epinephrine, nothing is certain at all.

Conclusion (proposition de traduction) : L'utilisation de l'adrénaline en cas d'arrêt cardiaque est compliquée. L'essai PARAMEDIC2 a suscite autant de questions qu'il n'apporte de réponses.
Les preuves en faveur de l'adrénaline ne sont pas encore définitives, d'une façon ou d'une autre. D'après un essai, si nous arrêtions prématurément d'utiliser l'adrénaline dans l'arrêt cardiaque, affirmons-nous que l'invalidité est pire que la mort ? Les cliniciens, les chercheurs, les décideurs et le grand public doivent discuter et débattre de nos valeurs et des éléments de preuve. Si une chose est sûre, c'est qu'avec l'adrénaline, rien n'est certain.

The prognostic significance of repeated prehospital shocks for out-of-hospital cardiac arrest survival.
Cournoyer A, Notebaert É, Cossette S, Londei-Leduc L, de Montigny L, Ross D, Lamarche Y, Potter BJ, Vadeboncoeur A, Daoust R, Sokoloff C, Albert M, Bernard F, Morris J, Paquet J, Chauny JM, Iseppon M, Marquis M, de Champlain F, Cavayas YA, Denault A. | CJEM. 2019 May;21(3):330-338
DOI: https://doi.org/10.1017/cem.2018.437
Keywords: defibrillation; out-of-hospital cardiac arrest; survival

Original Research

Introduction : Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA.

Méthode : This cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression.

Résultats : A total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001).

Conclusion : Survival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.

Conclusion (proposition de traduction) : La survie reste possible même après un nombre élevé de chocs pour les patients présentant un arrêt cardiaque extra-hospitalier avec un rythme initial choquable. Cependant, le fait d'avoir besoin de plus de chocs est associé de façon indépendante à une survie moins bonne.

Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure.
Scheuermeyer FX, Wong H2, Barrett TW, Christenson J, Grafstein E, Grunau B, Wiens M, Innes G. | CJEM. 2019 May;21(3):352-360
DOI: https://doi.org/10.1017/cem.2018.475
Keywords: Atrial fibrillation; patient safety; renal impairment

Original Research

Introduction : Atrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure.

Méthode : This cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) > 60 mL/min/1.73 m2) or impaired renal function ("low eGFR"). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure.

Résultats : Of 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43)

Conclusion : In this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.

Conclusion (proposition de traduction) : Dans cette cohorte de patients présentant une fibrillation atriale ou un flutter aux urgences bénéficiant d'un contrôle de la fréquence ou du rythme, ceux dont le taux de filtration glomérulaire estimé était bas présentaient un risque excédentaire ajusté significativement plus élevé d'événements indésirables que les patients dont la fonction rénale était normale. Les probabilités d'échec du traitement ont également augmenté de façon significative.

Blood on board: The development of a prehospital blood transfusion program in a Canadian helicopter emergency medical service.
Krook C, O'Dochartaigh D, Martin D, Piggott Z, Deedo R, Painter S, van Werkhoven G, McKay D, Nesdoly D, Armstrong JN. | CJEM. 2019 May;21(3):365-373
DOI: https://doi.org/10.1017/cem.2018.457
Keywords: helicopter emergency medical services; prehospital blood transfusion; quality assurance

Original Research

Introduction : Prehospital blood transfusion has been adopted by many civilian helicopter emergency medical services agencies, and early outcomes are positive. The Shock Trauma Air Rescue Society operates six bases in Western Canada and started a blood on board process in 2013 in Regina that has expanded to all bases. Two units of O negative packed red blood cells are carried on every mission. We describe the processes and standard work ensuring safe storage, administration, and stewardship of this important resource.

Méthode : The packed red blood cells are stored in an inexpensive, reusable temperature controlled cooler at 1°C-6°C. Close collaboration with local transfusion services and adherence to Canadian transfusion standards contributes to safety and sustainability.

Résultats : From October 1, 2013 to October 10, 2017, the Shock Trauma Air Rescue Society administered blood to 431 patients. Of this total, 62.9% received blood carried on our aircraft. A total of 463 blood box units were administered, and the majority of patients (69.0%) received both units. Blood used in Calgary, Alberta was 100% traceable, and only 1.2% of total units dispensed was wasted. The vast majority of unused units were returned to circulation.

Conclusion : We describe the process to set up and monitor a prehospital blood transfusion program. Our standard work and stewardship processes minimize wastage of blood while keeping it readily available for our critically ill and injured patients.

Conclusion (proposition de traduction) : Nous décrivons le processus que nous avons mise en place et le suivi d'un programme de transfusion sanguine préhospitalière. Nos processus de travail et de gestion standard minimisent le gaspillage des poches de sang tout en le maintenant facilement disponible pour les patients gravement malades et blessés.

Self-documentary in the emergency department: Perspectives on patients recording their own procedures.
Oyedokun T, Donauer A, Stempien J, McKay S. | CJEM. 2019 May;21(3):384-390
DOI: https://doi.org/10.1017/cem.2018.423
Keywords: Audiovisual recordings; emergency department; privacy; smart phones; social media

Original Research

Introduction : Patients often bring their smartphones to the emergency department (ED) and want to record their procedures. There was no clear ED recording policy in the Saskatoon Health Region nor is there in the new Saskatchewan Health Authority. With limited literature on the subject, clinicians currently make the decision to allow/deny the request to record independently. The purpose of this study was to examine and compare patient and clinician perspectives concerning patients recording, in general, and recording their own procedures in the ED.

Méthode : Surveys were developed for patients and clinicians with respect to history and opinions about recording/being recorded. ED physicians and nurses, and patients>17 years old who entered the ED with a laceration requiring stitches were recruited to participate; 110 patients and 156 staff responded.

Résultats : There was a significant difference between the proportion of patients (61.7% [66/107]) and clinicians (28.1% [41/146]) who believed that patients should be allowed to video record their procedure. There was also a significant difference between clinicians and patients with regard to audio recording, but not "selfies" (pictures). However, with no current policy, 47.8% (66/138) of clinicians said that they would allow videos if asked, with caveats about staff and patient privacy, prior consent, and procedure/patient care.

Conclusion : Contrary to patients' views, clinicians were not in favour of allowing audio or video recordings in the ED. Concerns around consent, staff and patient privacy, and legal issues warrant the development of a detailed policy if the decision is made in favour of recording.

Conclusion (proposition de traduction) : Contrairement à l'opinion des patients, les cliniciens n'étaient pas favorables à autoriser l'enregistrement audio ou vidéo aux urgences.
Les préoccupations concernant le consentement, la vie privée du personnel et des patients, et, les questions juridiques justifient l'élaboration d'une politique détaillée si la décision est prise en faveur de l'enregistrement.

Commentaire : Quelques lectures sur le sujet (Enregistrement d'une consultation médicale réalisée à l'insu du praticien) :
• Quel regard éthique peut-on porter sur la situation de l’enregistrement, par un patient, de son entretien avec un médecin, et ce à l’insu du médecin  . (Avis rendu le 21 MARS 2016).
• Téléphone portable en consultation  . Conseil départemental de guadeloupe de l'ordre des médecins (12/09/2018)
• De la recevabilité judiciaire des enregistrements sonores subreptices  . Par Nicolas Guerrero, Avocat (27 février 2012)

Evaluation of emergency department ultrasound machines for the presence of occult blood.
Poonja Z, Uppal J, Netherton SJ, Bryce R, Lyon AW, Cload B. | CJEM. 2019 May;21(3):395-398
DOI: https://doi.org/10.1017/cem.2018.447  | Télécharger l'article au format  
Keywords: blood contamination; emergency department; occult contamination; ultrasound

Brief Original Contribution

Introduction : Bedside ultrasound in the emergency department is a common diagnostic tool, especially when evaluating trauma patients. Many trauma patients have blood on their chest and abdomen that may contact the probe during examination. The primary aim of this study was to investigate whether occult blood contamination was present on the emergency department ultrasound machine, both after daily use and after use in trauma.

Méthode : For a period of 31 days, the ultrasound machine at the trauma centre emergency department in Saskatoon, Saskatchewan, was tested once daily and following all Level 1 traumas. The ultrasound machine probes and keyboard were swabbed, and contamination was detected using a commercially available phenolphthalein blood testing kit. Any visible blood contamination was also noted. The machine was then cleaned following each positive test and re-tested to ensure the absence of contamination.

Résultats : Over the study period, the ultrasound machine tested positive for occult blood contamination on 10% of daily tests and on 43% of assessments after its use in trauma. The curvilinear probe was most frequently contaminated (daily, 6%; trauma, 26%), followed by the keyboard (daily, 3%; trauma, 26%), but both lacked visible contamination.

Conclusion : In this single centre study, there was evidence of occult blood on the emergency department ultrasound machine after both routine use and major trauma cases, highlighting the need for a standardized cleaning and disinfection protocol.

Conclusion (proposition de traduction) : Dans cette étude monocentrique, il y avait la mise en évidence de traces de sang microscopique sur l'échographe des urgences après une utilisation de routine et des cas de traumatismes majeurs, ce qui mettait en évidence la nécessité d'un protocole normalisé de nettoyage et de désinfection.

A lung ultrasound score for early triage of elderly patients with acute dyspnea.
Markarian T, Zieleskiewicz L, Perrin G, Claret PG, Loundou A, Michelet P, Bobbia X. | CJEM. 2019 May;21(3):399-405
DOI: https://doi.org/10.1017/cem.2018.483
Keywords: dyspnea; emergency medicine; lung; point-of-care systems; triage; ultrasonography

Original Research

Introduction : L’échographie pulmonaire (EP) a une valeur diagnos- tique dans la dyspnée. L’étude avait pour objectif principal d’évaluer l’exactitude du score d’échographie pulmonaire modifiée (EPM) aux fins de prévision du degré de gravité de la dyspnée aiguë chez les personnes âgées.

Méthode : Il s’agit d’une étude d’observation monocentrique, menée chez des patients âgés de plus de 64 ans et admis au service des urgences pour de la dyspnée aiguë, accompagnée d’hypoxie. Les participants ont été soumis à une EP précoce, effectuée par un urgentologue spécialisé en la matière, puis ont reçu les soins usuels donnés par des professionnels tenus dans l’ignorance des résultats de l’EP. Les patients ont été classés, selon les suites à donner, dans le groupe de soins intensifs (SI) (patients admis au service de soins inten- sifs [SSI] ou morts au cours des 48 h suivant leur arrivée) ou dans le groupe de soins usuels (SU).

Résultats : Les dossiers de 137 patients ont été analysés (âge moyen : 79 ± 13 ans; femmes : 74 [54%]) et, sur ce nombre, 43 (31%) ont été classés dans le groupe de SI. Le temps d’at- tente des résultats de l’EPM s’est établi à 30 ± 22 min. La valeur prévisionnelle de la surface sous la courbe de l’EPM pour le classement des patients dans le groupe de SI était de 0,97 (0,92–0,99; p < 0,01), et la valeur-seuil a été établie rigoureuse- ment au-dessus de 17, d’où une sensibilité de 93% (81–99); une spécificité de 99% (94–100); une valeur prévisionnelle positive de 98% (87–100); une valeur prévisionnelle négative de 97% (91–99); un rapport de vraisemblance positif de 86; un rapport de vraisemblance négatif de 0,07 et une exactitude diagnos- tique de 97% (93–99). D’après l’analyse plurifactorielle, le score d’EPM était le seul facteur indépendant associé au groupe de SI.

Conclusion : An early lung ultrasound score can predict the need for ICU admission and/or death within 48 hours in elderly dyspneic patients.

Conclusion (proposition de traduction) : Le score d’échographie pulmonaire précoce offre une valeur prévisionnelle quant à la nécessité d’admettre des personnes âgées dyspnéiques au SSI ou au risque de décès dans les 48 h suivant leur arrivée.

Commentaire : Référence à consulter :
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134(1):117-25  .

The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review and meta-analysis.
Stickles SP, Carpenter CR, Gekle R, Kraus CK, Scoville C, Theodoro D, Tran VH, Ubiñas G, Raio C. | CJEM. 2019 May;21(3):406-417
DOI: https://doi.org/10.1017/cem.2018.498
Keywords: POCUS; RUSH; hypotension; shock; ultrasound

Original Research

Introduction : The aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department.

Méthode : Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock.

Résultats : A total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock.

Conclusion : The rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.

Conclusion (proposition de traduction) : L'échographie rapide dans le choc et l'hypotension (Rapid Ultrasound for Shock and Hypotension - RUSH) est plus efficace lorsqu'elle est utilisée pour déterminer les causes du choc, plutôt que pour exclure définitivement des étiologies spécifiques.
Les rapports de vraisemblance négatifs de l'examen par sous-type suggèrent qu'il exclut avec plus de précision le choc obstructif (ndlr : les quatre principales causes de chocs obstructifs sont la tamponnade cardiaque, le pneumothorax compressif [tamponnade « gazeuse »] et l’embolie pulmonaire massive).

Commentaire : • RUSH protocol : Protocole d’évaluation d’un choc via 5 cibles : HI MAP (Heart, Inferior vena cava, Morison, Aorta, Pulmonary) et 9 sites : parasternal grand axe, apical 4 cavités, veine cave inférieure, poche de Morison et hémothorax D, espace spléno-rénal et hémothorax G, sus-pubien, aorte, pneumothorax D, pneumothorax G (Blog thoracotomie  )
• Voir l'article princeps de Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010 Feb;28(1):29-56, vii  .

illustration: Métrailler-Mermoud J, Fishman D, Frochaux V, Selz Amaudruz F. Apport de l’échographie dans la prise en charge initiale des patients en état de choc. Rev Med Suisse 2014;10:1485-89  .

Pour mémoire, on distingue quatre types de choc :
• cardiogénique (défaillance de la pompe cardiaque) ;
• hypovolémique (diminution du volume intravasculaire : hémorragie, pertes digestives [diarrhées et vomissements importants], brûlures étendues, défaut d’hydratation…) ;
• distributif (choc septique [le plus souvent bactérienne, mais peut être également virale, parasitaire ou fongique] et non septiques [chocs anaphylactiques, états de choc inflammatoires comme les pancréatites ou les grands brûlés par exemple, choc spinal secondaire à une section médullaire…]) ;
• obstructif (tamponnade cardiaque, le pneumothorax compressif [tamponnade « gazeuse »] et l’embolie pulmonaire massive qui est la plus fréquente des causes).

Randomised controlled trial of simulation-based education for mechanical cardiopulmonary resuscitation training .
Coggins AR, Nottingham C, Byth K, Ho KR, Aulia FA, Murphy M, Shetty AL, Todd A, Moore N.. | Emerg Med J. 2019 May;36(5):266-272
DOI: https://doi.org/10.1136/emermed-2017-207431  | Télécharger l'article au format  
Keywords: cardiac arrest; education; education, teaching; resuscitation, training

Original article

Introduction : Mechanical cardiopulmonary resuscitation (M-CPR) is increasingly used in the management of cardiac arrest. There are no previously reported randomised studies investigating M-CPR training. This study of newly trained M-CPR providers hypothesised that a brief simulation-based intervention after 4 months would improve M-CPR performance at 6 months.

Méthode : This study used a simulated 'in situ' cardiac arrest model. The M-CPR device used was a proprietary Lund University Cardiac Assist System 3 machine (Physio Control, Redmond, Washington, USA). Standardised baseline training was provided to all participants. Following training, baseline performance was assessed. The primary outcome measure was the time taken to initiate M-CPR and the secondary outcome was performance against a checklist of errors. Participants were then randomised to intervention group (simulation training) or control group (routine clinical use of M-CPR). After 6 months the outcome measures were reassessed. Comparative statistical tests used an intention-to-treat analysis.

Résultats : 112 participants were enrolled. The intervention group (n=60) and control group (n=52) had similar demographic characteristics. At the 6-month assessment, median time to M-CPR initiation was 27.0 s (IQR 22.0-31.0) in the intervention group and 31.0 s (IQR 25.6-46.0) in the control group (p=0.003). The intervention group demonstrated fewer errors compared with controls at 6 months (p<0.001).

Conclusion : In this randomised study of approaches to M-CPR training, providers receiving additional simulation-based training had higher retention levels of M-CPR skills. Therefore, when resuscitation skills are newly learnt, provision follow-up training should be an important consideration.

Conclusion (proposition de traduction) : Dans cette étude randomisée sur une approche de formation en RCP avec un appareil de massage cardiaque automatisé, les intervenants recevant une formation supplémentaire fondée sur la simulation avaient des niveaux de rétention plus élevés des compétences en RCP avec un appareil de massage cardiaque automatisé.
Par conséquent, lorsque les compétences en réanimation sont nouvellement acquises, la formation de suivi devrait être un facteur important.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments.
Al Jalbout N, Balhara KS, Hamade B, Hsieh YH, Kelen GD, Bayram JD. | Emerg Med J. 2019 May;36(5):293-297
DOI: https://doi.org/10.1136/emermed-2018-208002
Keywords: death/mortality; hospitalisations; triage

ORIGINAL ARTICLES

Introduction : The shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in specific disease states. However, there is scarcity of data about the utility of the SI in the general emergency department (ED)population. Our goal was to use a large national database of EDs in the United States (US) to determine whether the likelihood of inpatient mortality and hospital admission was associated with initial SI at presentation.

Méthode : Data from the National Hospital Ambulatory Medical Care Survey were retrospectively reviewed to obtain a weighted sample of all US ED visits between 2005 and 2010. All adults >18 years old who survived the ED visit were included, regardless of their chief complaint. Likelihood ratios (LR) were calculated for a range of SI values, in order to determine SI thresholds most predictive of hospital admission and inpatient mortality. +LRs >5 were considered to be clinically significant.

Résultats : A total of 526 455 251 adult patient encounters were included in the analysis. 56.9% were women, 73.9% were white and 53.2% were between the ages of 18 and 44 years. 88 326 638 (15.7%) unique ED visits resulted in hospital admission and 1 927 235 (2.6%) visits resulted in inpatient mortality. SI>1.3 was associated with a clinically significant increase in both the likelihood of hospital admission (+LR=6.64) and inpatient mortality (+LR=5.67). SI>0.7 and >0.9, the traditional cited cut-offs, were only associated with marginal increases (+LR= 1.13; 1.54 for SI>0.7 and +LR=1.95; 2.59 for SI>0.9 for hospital admission and inpatient mortality, respectively).

Conclusion : In this largest retrospective study to date on SI in the general ED population, we demonstrated that initial SI at presentation to the ED could potentially be useful in predicting the likelihood of hospital admission and inpatient mortality, which could help guide rapid and accurate acuity designation, resource allocation and disposition.

Conclusion (proposition de traduction) : Dans cette plus vaste étude rétrospective à ce jour sur l'indice de choc dans la population générale de l'urgence, nous avons démontré que l'indice de choc initial présenté à l'urgence pourrait être utile pour prédire la probabilité d'hospitalisation et de mortalité des patients hospitalisés, ce qui pourrait aider à déterminer rapidement et avec précision l'acuité, la répartition des ressources et la disposition.

Outcomes of non-invasive ventilation in 'very old' patients with acute respiratory failure: a retrospective study.
Montoneri G, Noto P, Trovato FM, Mangano G, Malatino L, Carpinteri G. | Emerg Med J. 2019 May;36(5):303-305
DOI: https://doi.org/10.1136/emermed-2018-207563
Keywords: geriatrics; intermediate care; ventilation, non invasive

SHORT REPORTS

Introduction : Non-invasive ventilation (NIV) is increasingly used to support very old (aged ≥85 years) patients with acute respiratory failure (ARF). This retrospective observational study evaluated the impact of NIV on the prognosis of very old patients who have been admitted to the intermediate care unit (IMC) of the Emergency Department of the University Hospital Policlinico-Vittorio Emanuele of Catania for ARF.

Méthode : All patients admitted to the IMC between January and December 2015 who received NIV as the treatment for respiratory failure were included in this study. Outcomes of patients aged ≥85 years were compared with lower ages. The expected intrahospital mortality was calculated through the Simplified Acute Physiology Score (SAPS) II and compared with the observed mortality.

Résultats : The mean age was 87.9±2.9 years; the M:F ratio was approximately 1:3. The average SAPS II was 50.1±13.7. The NIV failure rate was 21.7%. The mortality in the very old group was not statistically different from the younger group (20% vs 25.6%; d=5.6%; 95% CI -8% to 19%; p=0.404). The observed mortality was significantly lower than the expected mortality in both the group ≥85 (20.0% vs 43.4%, difference=23.4%; 95% CI 5.6% to 41.1%, p=0.006) and the younger group (25.6% vs 38.5%, difference=12.9%; 95% CI -0.03% to 25.8%, p=0.046). In both age groups, patients treated with NIV for chronic obstructive pulmonary disease had lower mortalities than those treated for other illnesses, although this was statistically significant only in the younger group.

Conclusion : In very old patients, when used with correct indications, NIV was associated with mortality similar to younger patients. Patients receiving NIV had lower than expected mortality in all age groups.

Conclusion (proposition de traduction) : Chez les patients très âgés, lorsqu'elle était utilisée avec des indications correctes, la VNI était associée à une mortalité similaire à celle des patients plus jeunes.
Le taux de mortalité des patients recevant la VNI a été plus faible que prévu dans tous les groupes d'âge.

Commentaire : Les patients atteints de bronchopneumopathie chronique obstructive traités par VNI avaient une mortalité inférieure à celle des patients ayant d’autres indications, bien que cette différence ne soit significative que chez les plus jeunes dans le groupe des « vieux ».

Women have lower chances than men to be resuscitated and survive out-of-hospital cardiac arrest.
Blom MT, Oving I, Berdowski J, van Valkengoed IGM, Bardai A, Tan HL. | Eur Heart J. 2019 May 21. pii: ehz297
DOI: https://doi.org/10.1093/eurheartj/ehz297  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; ESCAPE-NET; Epidemiology; Out-of-hospital cardiac arrest; Sex differences

CLINICAL RESEARCH

Introduction : Previous studies on sex differences in out-of-hospital cardiac arrest (OHCA) had limited scope and yielded conflicting results. We aimed to provide a comprehensive overall view on sex differences in care utilization, and outcome of OHCA.

Méthode : We performed a population-based cohort-study, analysing all emergency medical service (EMS) treated resuscitation attempts in one province of the Netherlands (2006–2012). We calculated odds ratios (ORs) for the association of sex and chance of a resuscitation attempt by EMS, shockable initial rhythm (SIR), and in-hospital treatment using logistic regression analysis. Additionally, we provided an overview of sex differences in overall survival and survival at successive stages of care, in the entire study population and in patients with SIR.

Résultats : We identified 5717 EMS-treated OHCAs (28.0% female). Women with OHCA were less likely than men to receive a resuscitation attempt by a bystander (67.9% vs. 72.7%; P < 0.001), even when OHCA was witnessed (69.2% vs. 73.9%; P < 0.001). Women who were resuscitated had lower odds than men for overall survival to hospital discharge [OR 0.57; 95% confidence interval (CI) 0.48-0.67; 12.5% vs. 20.1%; P < 0.001], survival from OHCA to hospital admission (OR 0.88; 95% CI 0.78-0.99; 33.6% vs. 36.6%; P = 0.033), and survival from hospital admission to discharge (OR 0.49, 95% CI 0.40-0.60; 33.1% vs. 51.7%). This was explained by a lower rate of SIR in women (33.7% vs. 52.7%; P < 0.001). After adjustment for resuscitation parameters, female sex remained independently associated with lower SIR rate.

Conclusion : In case of OHCA, women are less often resuscitated by bystanders than men. When resuscitation is attempted, women have lower survival rates at each successive stage of care. These sex gaps are likely explained by lower rate of SIR in women, which can only partly be explained by resuscitation characteristics.

Conclusion (proposition de traduction) : En cas d'arrêt cardiaque extra-hospitalier, les femmes sont moins souvent réanimées par des passants que les hommes. Lorsqu'une tentative de réanimation est tentée, les taux de survie des femmes sont plus faibles à chaque étape successive des soins. Ces écarts entre les sexes s'expliquent probablement par un taux plus faible de rythme initial choquable chez les femmes, ce qui ne peut s'expliquer que partiellement par les caractéristiques de la réanimation.

Commentaire : ERC Newsletter June 2019: Guideline Scope open for Public Comment :
Les auteurs ont identifié des écarts entre les sexes dans la réanimation. Une observation importante est que les tentatives de réanimation sont moins fréquentes chez les femmes. Les auteurs n'ont pas pu en identifier les raisons.
Le taux de survie était plus faible parce que les femmes étaient plus âgées, que l'arrêt cardiaque extra-hospitalier se situait moins souvent dans un lieu public, qu'il y avait moins souvent un témoins de l'arrêt cardiaque extra-hospitalier et qu'elles avaient moins de rythme choquable initial.

Cognitive heterogeneity among community dwelling older adults with cerebral small vessel disease.
Dey AK, Stamenova V, Bacopulos A, Jeyakumar N, Turner G, Black SE, Levine B. | Neurobiol Aging. 2019 May;77:183-193
DOI: https://doi.org/10.1016/j.neurobiolaging.2018.12.011
Keywords: Cerebral small vessel disease; Executive function; Subjective cognitive complaints; White matter hyperintensities; Vascular cognitive impairment; Cognitive resilience

Original articles

Editorial : Some degree of ischemic injury to white matter tracts occurs naturally with age and is visible on magnetic resonance imaging as focal or confluent white matter hyperintensities (WMHs). Its relationship to cognition, however, remains unclear. To explore this, community-dwelling adults between the ages 55-80 years old completed structural imaging, neuropsychological testing, and questionnaires to provide objective measures and subjective experience of executive functioning. Volumetric lesion burden derived from structural MRI identified those with significant WMH burden (∼10cm3). Half of those recruited met this criterion and were designated as the cerebral small vessel disease (CSVD) group. Subjective complaints but not objective test scores differentiated adults with and without CSVD. Hierarchical clustering revealed two CSVD subgroups that differentiated those with impaired versus preserved executive function relative to controls. Overall these results provide some explanation for behavioural heterogeneity often observed in studies of age-related white matter changes. They also support the use of questionnaires to assess subjective complaints that may be able to detect subtle effects of pathology not evident on standardized cognitive scores.

Conclusion (proposition de traduction) : Points forts
1. 50% des adultes plus âgés participant à une étude cas-témoins présentant des facteurs de risque vasculaires avaient une maladies des petites artères cérébrales.
2. Les plaintes subjectives, mais non les mesures basées sur la performance, distinguent la maladies des petites artères cérébrales des témoins.
3. Dans la maladies des petites artères cérébrales, le maintien de la fonction exécutive semblait se faire au prix d’une réduction de la vitesse de traitement.
4. La maladies des petites artères cérébrales est associée à une incidence plus élevée de symptômes dépressifs.

Predicting Thoracic Injury in Children With Multitrauma.
Weerdenburg KD, Wales PW, Stephens D, Beno S, Gantz J, Alsop J, Schuh S. | Pediatr Emerg Care. 2019 May;35(5):330-334
DOI: https://doi.org/10.1097/PEC.0000000000001129
Keywords: Aucun

Original Articles

Introduction : Previous pediatric trauma studies focused on predictors of abnormal chest radiographs or included patients with low injury severity. This study identified predictors of thoracic injury (TI) diagnoses in a high-risk population and determined TI rate without predictors.

Méthode : This study was a retrospective trauma registry analysis of previously healthy children aged 0 to 17 years with multisystem blunt trauma requiring trauma team activation and chest radiography who were divided into those with and without TI. Plausible TI predictors included Glasgow Coma Scale score of 13 or less, abnormal thoracic symptoms/signs, abnormal chest auscultation, respiratory distress/ rate higher than the 95th percentile, oxygen saturation less than 95%, abnormal abdominal signs/symptoms, tachycardia higher than the 95th percentile, blood pressure lower than the 5th percentile, and femur fracture.

Résultats : One hundred forty-one (29%) of 493 eligible patients had TI. Independent TI predictors include thoracic symptoms/signs (odds ratio [OR], 6.0; 95% confidence interval [CI], 3.6-10.1), abnormal chest auscultation (OR, 3.5; 95% CI, 2.0-6.2), saturation less than 95% (OR, 3.1; 95% CI, 1.8-5.5), blood pressure lower than the 5th percentile (OR, 3.7; 95% CI, 1.1-12.2), and femur fracture (OR, 2.5; 95% CI, 1.2-5.4). Six (5%) of 119 children (95% CI, 0.01-0.09) without predictors had TI.

Conclusion : Predictors of TI include thoracic symptoms/signs, abnormal chest auscultation, saturation less than 95%, blood pressure lower than the 5th percentile, and femur fracture. Because an important portion of children without predictors had TI, chest radiography should remain part of pediatric trauma resuscitation.

Conclusion (proposition de traduction) : Les signes évocateurs de lésion thoracique comprennent les symptômes/signes thoraciques, une auscultation thoracique anormale, une saturation inférieure à 95 %, une pression artérielle inférieure au 5ème percentile et une fracture du fémur.
Comme une partie importante des enfants sans signe clinique présentaient une lésion thoracique, la radiographie thoracique devrait continuer à faire partie de la réanimation pédiatrique des traumatisés.

High Concentration of C-Reactive Protein Is Associated With Serious Bacterial Infection in Previously Healthy Children Aged 3 to 36 Months With Fever and Extreme Leukocytosis.
Kim JH, Lee JY, Cho HR, Lee JS, Ryu JM, Lee J. | Pediatr Emerg Care. 2019 May;35(5):347-352
DOI: https://doi.org/10.1097/PEC.0000000000001080
Keywords: Aucun

Original articles

Introduction : The aim of the study was to investigate the diagnostic efficacy of C-reactive protein (CRP) in predicting serious bacterial infection (SBI) in febrile children aged 3 to 36 months with extreme leukocytosis (EL), defined as a peripheral white blood cell count of 25,000 to 49,999/mm.

Méthode : The presence of SBI was reviewed in previously healthy children aged 3 to 36 months with a fever of 39°C or higher and EL, who visited a tertiary care hospital emergency department between September 2010 and August 2015. We measured cutoff values of CRP with corresponding likelihood ratios (LRs) and posttest probabilities (PPs).

Résultats : Of 9989 febrile children, 4252 (42.6%) underwent assays for white blood cell and CRP. Of 233 (5.5%) children with EL, 133 (3.1%) were enrolled, of whom 43 (32.3%; 95% confidence interval [CI], 25.0%-40.7%) had SBI, including 33 pyelonephritis, 5 deep abscesses, 3 lobar pneumonia, and 2 soft tissue infections. With the cutoff of 7.8 mg/dL, the sensitivity of CRP in predicting SBI was 81.4% (95% CI, 67.4%-90.3%); the specificity, 80.0% (95% CI, 70.6%-87.0%); the positive predictive value, 66.0% (95% CI, 52.6%-77.3%); the negative predictive value, 90.0% (95% CI, 81.5%-94.9%); the positive LR, 4.1; and the PP, 66.0% (95% CI, 55.6%-75.0%). A CRP concentration of 16.1 mg/dL or higher yielded an LR of 11.2 and a PP of 84.2% (95% CI, 62.1%-94.5%). A CRP concentration of lower than 3.4 mg/dL yielded an LR of 0.05 and a PP of 2.4% (95% CI, 0.3%-14.6%).

Conclusion : High concentration of CRP is strongly associated with the presence of SBI in febrile children with EL.

Conclusion (proposition de traduction) : Une concentration élevée de la CRP est fortement associée à la présence d'une infection bactérienne grave chez les enfants fébriles atteints de leucocytose importante (25 000 à 49 999 GB/mm3).

Association of ventilation with outcomes from out-of-hospital cardiac arrest.
Chang MP, Lu Y, Leroux B, Aramendi Ecenarro E, Owens P, Wang HE, Idris AH. | Resuscitation. 2019 May 18. pii: S0300-9572(19)30174-1
DOI: https://doi.org/10.1016/j.resuscitation.2019.05.006
Keywords: Bioimpedance; Cardiopulmonary resuscitation; Heart arrest; Outcomes; Ventilation detection

Clinical paper

Introduction : To determine the association between bioimpedence-detected ventilation and out-of-hospital cardiac arrest (OHCA) outcomes.

Méthode : This is a retrospective, observational study of 560 OHCA patients from the Dallas-Fort Worth site enrolled in the Resuscitation Outcomes Consortium Trial of Continuous or Interrupted Chest Compressions During CPR from 4/2012 to 7/2015. We measured bioimpedance ventilation (lung inflation) waveforms in the pause between chest compression segments (Physio-Control LIFEPAK 12 and 15, Redmond, WA) recorded through defibrillation pads. We included cases ≥18 years with presumed cardiac cause of arrest assigned to interrupted 30:2 chest compressions with bag-valve-mask ventilation and ≥2 min of recorded cardiopulmonary resuscitation. We compared outcomes in two a priori pre-specified groups: patients with ventilation waveforms in <50% of pauses (Group 1) versus those with waveforms in ≥50% of pauses (Group 2).

Résultats : Mean duration of 30:2 CPR was 13 ± 7 min with a total of 7762 pauses in chest compressions. Group 1 (N = 424) had a median 11 pauses and 3 ventilations per patient vs. Group 2 (N = 136) with a median 12 pauses and 8 ventilations per patient, which was associated with improved return of spontaneous circulation (ROSC) at any time (35% vs. 23%, p < 0.005), prehospital ROSC (19.8% vs. 8.7%, p < 0.0009), emergency department ROSC (33% vs. 21%, p < 0.005), and survival to hospital discharge (10.3% vs. 4.0%, p = 0.008).

Conclusion : This novel study shows that ventilation with lung inflation occurs infrequently during 30:2 CPR. Ventilation in ≥50% of pauses was associated with significantly improved rates of ROSC and survival.

Conclusion (proposition de traduction) : Cette nouvelle étude montre que la ventilation avec insufflation pulmonaire est peu fréquente pendant la RCP 30:2.
La ventilation (ndlr : efficace, c'est-à-dire > à 250 ml) dans ≥ 50 % des pauses (dans les compressions thoraciques) était associée à une amélioration significative des taux de RACS et de la survie.

Commentaire : ERC Newsletter June 2019: Guideline Scope open for Public Comment :
Les conclusions de cette étude pourraient orienter vers un meilleur résultat dans l'arrêt cardiaque extra-hospitalier lorsqu'une ventilation de haute qualité est effectuée pendant la RCP 30:2.
Une étude comparative entre la RCP 30:2 et la RCP seule ne serait pas éthique, mais cette étude pourrait néanmoins confirmer fortement l'idée du Conseil Européen de Réanimation, selon laquelle une ventilation chez l'adulte est nécessaire.

Using a smartwatch with real-time feedback improves the delivery of high-quality cardiopulmonary resuscitation by healthcare professionals.
Lu TC, Chang YT, Ho TW, Chen Y, Lee YT, Wang YS, Chen YP, Tsai CL, Ma MH, Fang CC, Lai F, Meischke HW, Turner AM. | Resuscitation. 2019 May 9;140:16-22
DOI: https://doi.org/10.1016/j.resuscitation.2019.04.050
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Chest compression; Feedback device; Smartwatch; Wearable device

Simulation and Education

Introduction : Cardiopulmonary resuscitation (CPR) quality affects survival after cardiac arrest. We aimed to investigate if a smartwatch with real-time feedback can improve CPR quality by healthcare professionals.

Méthode : An app providing real-time audiovisual feedback was developed for a smartwatch. Emergency Department (ED) professionals were recruited and randomly allocated to either the intervention group wearing a smartwatch with the preinstalled app, or to a control group. All participants were asked to perform a two-minute CPR on a manikin at a 30:2 compression-ventilation ratio. Primary outcomes were the mean CCR and CCD measured on the manikin. A secondary outcome was the percentage of chest compressions meeting both the guideline-recommended rate (100-120 min-1) and depth (50-60 mm) of high-quality CPR during a 2-min period. Differences between groups were evaluated with t-test, Chi-Square test, or Mann-Whitney U test depending on the distribution.

Résultats : Eighty participants were recruited. 40 people were assigned to the intervention and 40 to the control group. The compression rates (mean ± SD, min-1) were significantly faster (but above the guideline recommendation, P < 0.001) in the control (129.1 ± 14.9) than in the intervention group (112.0 ± 3.5). The compression depths (mean ± SD, mm) were significantly deeper (P < 0.001) in the intervention (50.9 ± 6.6) than in the control group (39.0 ± 8.7). The percentage (%) of high-quality CPR was significantly higher (P < 0.001) in the intervention (median 39.4, IQR 27.1-50.1) than in the control group (median 0.0, IQR 0.0-0.0).

Conclusion : Without real-time feedback, chest compressions tend to be too fast and too shallow. CPR quality can be improved with the assistance of a smartwatch providing real-time feedback.

Conclusion (proposition de traduction) : Sans rétroaction en temps réel, les compressions thoraciques ont tendance à être trop rapides et trop superficielles. La qualité de la RCP peut être améliorée à l'aide d'une montre intelligente qui fournit un retour d'information en temps réel.

Commentaire : ERC Newsletter June 2019: Guideline Scope open for Public Comment :
Cette étude fournit un système de rétroaction (une application) qui peut facilement être porté par tout le monde et améliore la qualité de la de la réanimation cardiopulmonaire. Des professionnels de l'urgence ont participé à l'étude : une étude similaire devrait être réalisée avec des non-professionnels dans un groupe avec l'application par rapport à un groupe sans application. Ce système de rétroaction devrait-il aussi améliorer la réanimation cardiopulmonaire chez les témoins non formés ?

Comorbidity burden conditions the prognostic performance of D-dimer in elderly patients with acute pulmonary embolism.
Polo Friz H, Pezzetti V, Orenti A, Caleffi A, Corno V, Crivellari C, Petri F, Polo Friz M, Punzi V, Teruzzi D, d'Oro LC, Giannattasio C, Vighi G, Cimminiello C, Boracchi P. | Am J Emerg Med. 2019 May;37(5):799-804
DOI: https://doi.org/10.1016/j.ajem.2018.07.034
Keywords: Aged; D-dimer; Mortality; Prognosis; Pulmonary embolism

Original Contribution

Introduction : The prognostic accuracy of D-dimer for risk assessment in acute Pulmonary Embolism (APE) patients may be hampered by comorbidities. We investigated the impact of comorbidity burden (CB) by using the Charlson Comorbidity Index (CCI), on the prognostic ability of D-dimer to predict 30 and 90-day mortality in hemodynamically stable elderly patients with APE.

Méthode : All patients aged >65 years with normotensive APE, consecutively evaluated in the Emergency Department since 2010 through 2014 were included in this retrospective cohort study. Area under the curve (AUC) and ½ Net Reclassification Improvement (NRI) were calculated.

Résultats : Study population: 162 patients, median age: 79.2 years. The optimal cut-off value of CCI score for predicting mortality was ≤1 (Low CB) and >1 (High CB), AUC = 0.786. Higher levels of D-dimer were associated with an increased risk death at 30 (HR = 1.039, 95%CI:1.000-1.080, p = 0.049) and 90 days (HR = 1.039, 95%CI:1.009-1.070, p = 0.012). When added to simplified Pulmonary Embolism Severity Index (sPESI) score, D-dimer increased significantly the AUC for predicting 30-day mortality in Low CB (AUC = 0.778, 95%CI:0.620-0.937, ½NRI = 0.535, p = 0.015), but not in High CB patients (AUC = 0.634, 95%CI:0.460-0.807, ½ NRI = 0.248, p = 0.294). Similarly, for 90-day mortality D-dimer increased significantly the AUC in Low CB (AUC = 0.786, 95%CI:0.643-0.929, ½NRI = 0.424, p-value = 0.025), but not in High CB patients (AUC = 0.659, 95%CI:0.541-0.778, ½NRI = 0.354, p-value = 0.165).

Conclusion : In elderly patients with normotensive APE, comorbidities condition the prognostic performance of D-dimer, which was found to be a better predictor of death in subjects with low CB. These results support multimarker strategies for risk assessment in this population.

Conclusion (proposition de traduction) : Chez les patients âgés présentant une embolie pulmonaire aiguë sans signe de choc, les comorbidités conditionnent la performance pronostique des D-dimères, qui s'est révélé être un meilleur prédicteur de la mort chez les sujets présentant un faible nombre de comorbidité. Ces résultats appuient des stratégies multimarqueurs d'évaluation des risques dans cette population.

Time to perforation for button batteries lodged in the esophagus.
Soto PH, Reid NE, Litovitz TL. | Am J Emerg Med. 2019 May;37(5):805-809
DOI: https://doi.org/10.1016/j.ajem.2018.07.035
Keywords: Button battery; Esophageal injury; Esophageal perforation; Foreign body ingestion

Original Contribution

Introduction : New strategies recently proposed to mitigate injury caused by lithium coin cell batteries lodged in the esophagus include prehospital administration of honey to coat the battery and prevent local hydroxide generation and in-hospital administration of sucralfate suspension (or honey). This study was undertaken to define the safe interval for administering coating agents by identifying the timing of onset of esophageal perforations.

Méthode : A retrospective study of 290 fatal or severe battery ingestions with esophageal lodgment was undertaken to identify cases with esophageal perforations.

Résultats : Esophageal perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and 92.0% were ≥20 mm diameter. Only 2% of perforations occurred in <24 h following ingestion, including 3 severe cases with perforations evident at 11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident 24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident 48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days.

Conclusion : Esophageal perforation is unlikely in the 12 h after battery ingestion, therefore the administration of honey or sucralfate carries a low risk of extravasation from the esophagus. This first 12 h includes the period of peak electrolysis activity and battery damage, thus the risk of honey or sucralfate is low while the benefit is likely high.

Conclusion (proposition de traduction) : Une perforation œsophagienne est peu probable dans les 12 heures suivant l’ingestion de la batterie; par conséquent, l’administration de miel ou de sucralfate présente un risque faible de diffusion depuis l’oesophage.
Cette première période de 12 heures comprend la période d'activité électrolytique maximale et les dommages subis par la batterie ; le risque occasionné par l'administration de miel ou de sucralfate est donc faible, alors que le bénéfice est probablement élevé.

Serum lactate as a predictor of neurologic outcome in ED patients with acute carbon monoxide poisoning.
Jung JW, Lee JH. | Am J Emerg Med. 2019 May;37(5):823-827
DOI: https://doi.org/10.1016/j.ajem.2018.07.046
Keywords: Carbon monoxide; Neurotoxicity; Poisoning

Original contribution

Introduction : This study was conducted to assess and clarify the predictive risk factor of neurologic outcome in patients with acute carbon monoxide (CO) poisoning.

Méthode : A total of 453 patients with acute CO poisoning were admitted to the emergency department of Samsung Changwon Hospital from January 2010 to June 2017. Patients with acute CO poisoning who were followed for >6 months were studied. Initial Glasgow Coma Score (GCS), serum neuron-specific enolase (NSE), and lactate were measured after emergency department arrival. Patients were divided into two groups (good vs poor neurologic outcome).

Résultats : A total of 432 patients (median age: 55 years, range: 17-91 years) were enrolled. There was a statistical difference between the good neurologic outcome group and the poor neurologic outcome group in terms of Exposure time, WBC, aspartate aminotransferase (AST), CK-MB, Troponin-I, creatinine kinase, NSE, lactate, CO-Hb, and GCS. NSE, lactate, and GCS were the early predictors of development of poor neurologic outcome. The areas under the curve in the ROC curve analysis for the GCS, NSE, and lactate were 0.842, 0.795, and 0.894, respectively.

Conclusion : Initial serum lactate level may correlate with the patient neurologic outcomes and prove to be a useful prognostic factor. Also NSE, and GCS might be a useful additional parameters that could predict the neurologic outcome on acute CO poisoned patients.

Conclusion (proposition de traduction) : Le taux sérique initial de lactate peut être en corrélation avec les résultats neurologiques du patient et se révéler être un facteur pronostique utile. De plus, l'énolase spécifique du neurone (Neuron Specific Enolase - NSE) et le score de Glasgow pourraient constituer un paramètre supplémentaire utile permettant de prédire l'évolution neurologique de patients présentant une intoxication aiguë au CO.

Commentaire : Pour information, l'énolase neurospécifique (NSE) est présente à concentration élevée dans les neurones et les cellules APUD (amine precursor uptake and decarboxylation) du système endocrinien diffus. C'est un marqueur des tumeurs d'origine neuroectodermiques et neuroendocriniennes. La concentration de NSE est mesurée par des techniques immunologiques dans le sérum non hémolysé, le plasma, le liquide céphalorachidien et pleural. Le suivi d'un patient doit être effectué sur le même type d'échantillons, dans le même laboratoire et par la même méthode.
La NSE est un marqueur très spécifique du cancer anaplasique du poumon à petites cellules (SCLC), utilisé pour l'aide au diagnostic histologique différentiel entre SCLC et NSCLC, l'évaluation pronostique, le suivi thérapeutique et le dépistage précoce des récidives. La NSE est aussi un marqueur de choix au cours du neuroblastome, des APUDome, et marqueur de souffrance cérébrale (la plus commune des tumeurs solides de l’enfant).
Voir les articles suivants :
• Yildirim AO, Eroglu M, Kaldirim U and al. Serum neuron-specific enolase and S-100β levels as prognostic follow-up markers for oxygen administered carbon monoxide intoxication cases.Indian J Biochem Biophys. 2015 Feb;52(1):29-33  .
• Nguyen DN1, Spapen H, Su F and al. Elevated serum levels of S-100beta protein and neuron-specific enolase are associated with brain injury in patients with severe sepsis and septic shock. Crit Care Med. 2006 Jul;34(7):1967-74
  .

Risk factors for necrosis of skin flap-like wounds after ED debridement and suture.
Qiu D, Wang X, Wang X, Jiao Y, Li Y, Jiang D. | Am J Emerg Med. 2019 May;37(5):828-831
DOI: https://doi.org/10.1016/j.ajem.2018.07.049
Keywords: Emergency trauma; Flap necrosis; Flap-like wound; Surgical repairs

Original contribution

Introduction : Skin flap-like wounds are common. These wound flaps are prone to avascular necrosis with simple debrided and sutured, and postoperative hyperplastic scarring and contracture of wound surfaces can adversely affect the patient's appearance. Here, we evaluate the data of cases with flap-like wounds to identify the causes of flap necrosis.

Méthode : Six hundred patients with skin flap-like wounds between January 1, 2013 and December 31, 2016 were retrospectively reviewed. Their age, sex, injury reason, size of flap, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods were recorded. The risks for flap necrosis were analyzed with one-factor analysis.

Résultats : A total success rate of 92.5% (555/600) for flap-like wound reconstruction was obtained. Among 67 flaps with vascular crisis, 22 were salvaged by subcutaneous injection of anisodamine, selective suture removal, and pressure dressing with elastic bandages. For the 45 patients with flap necrosis, there was no significant difference from patients without necrosis in terms of sex, age, and size of flap (P > 0.05). The incidence of flap necrosis was significantly different in terms of injury reason, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods (P < 0.05).

Conclusion : Injury reason, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods, rather than age, sex and size of flap, were significant risk factors for necrosis of flap-like wounds.

Conclusion (proposition de traduction) : Le mécanisme de la plaie, le rapport longueur/largeur de la plaie, l'épaisseur du lambeau triangulaire, la durée de suture, le site de la plaie, la direction de la perfusion sanguine dans le lambeau (ndlr : vitalité du lambeau) et les méthodes opératoires, plutôt que l'âge, le sexe et la taille du lambeau, étaient des facteurs de risque significatifs de nécrose des plaies en forme de lambeau.

Commentaire : Pour aller plus loin :
• Plaies aiguës en structure d’urgence   - Référentiel de bonnes pratiques. Société française de médecine d’urgence - 2017
• Prise en charge des plaies aux Urgences
   - Conférence de consensus. Société française de médecine d’urgence - 2015

Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the ED.
Sharif S, Eventov M, Kearon C, Parpia S, Li M, Jiang R, Sneath P, Fuentes CO, Marriott C, de Wit K. | Am J Emerg Med. 2019 May;37(5):845-850
DOI: https://doi.org/10.1016/j.ajem.2018.07.053
Keywords: D-dimer; Diagnostic imaging; Pulmonary embolism

Original contribution

Introduction : Diagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific.
OBJECTIVE: We compared the efficacy and safety of using age-adjusted D-dimer interpretation, clinical probability-adjusted D-dimer interpretation and standard D-dimer approach to exclude PE in ED patients.

Méthode : We performed a health records review at two emergency departments over a two-year period. We reviewed all cases where patients had a D-dimer ordered to test for PE or underwent CT or VQ scanning for PE. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. We applied the three D-dimer approaches to the low and moderate probability patients. The primary outcome was exclusion of PE with each rule. Secondary objective was to estimate the negative predictive value (NPV) for each rule.

Résultats : 1163 emergency patients were tested for PE and 1075 patients were eligible for inclusion in our analysis. PE was excluded in 70.4% (95% CI 67.6-73.0%), 80.3% (95% CI 77.9-82.6%) and 68.9%; (95% CI 65.7-71.3%) with the age-adjusted, clinical probability-adjusted and standard D-dimer approach. The NPVs were 99.7% (95% CI 99.0-99.9%), 99.1% (95% CI 98.3-99.5%) and 100% (95% CI 99.4-100.0%) respectively.

Conclusion : The clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value.

Conclusion (proposition de traduction) : La règle d'ajustement en fonction de la probabilité clinique semble exclure une embolie pulmonaire chez une plus grande proportion de patients, avec une très faible réduction de la valeur prédictive négative.

Comparison of ultrasonography and computed tomography in the determination of traumatic thoracic injuries.
Kozaci N, Avcı M, Ararat E, Pinarbasili T, Ozkaya M, Etli I, Donertas E, Karakoyun OF. | Am J Emerg Med. 2019 May;37(5):864-868
DOI: https://doi.org/10.1016/j.ajem.2018.08.002
Keywords: Computerized tomography; Thoracic trauma; Ultrasonography

Original contribution

Introduction : In this study, the accuracy of bedside thoracic ultrasonography (TUSG) performed by emergency physicians with patients in the supine position was compared with that of thoracic computed tomography (TCT) for the determination of thoracic injuries due to trauma.

Méthode : Patients who suffered the multiple traumas, whose thoracic trauma was identified on physical examination or TCT imaging were included in the study. TUSG was performed following a physical examination by the emergency physician who managed the trauma patient. Subcutaneous emphysema, pneumothorax, pulmonary contusions (PCs), hemothorax, pericardial effusion and tamponade, sternal and clavicular fractures and rib fractures were identified by TUSG. TCT imaging was performed after the ultrasonography examination was completed.

Résultats : Eighty-one patients were included in the study. TCT scans showed subcutaneous emphysema in 16 (19.8%) patients, pneumothorax in 21 (25.9%), PCs in 27 (33.3%), hemothorax in 20 (24.7%), sternum and clavicular fractures in 6 (7.4%) and rib fractures in 21 (25.9%). The sensitivity and specificity of ultrasonography varied for detecting the following pathologies: subcutaneous emphysema (56% and 95%), pneumothorax (86% and 97%), hemothorax (45% and 98%), PCs (63% and 91%), sternal fractures (83% and 97%), clavicular fractures (83% and 100%) and rib fractures (67% and 98%), respectively.

Conclusion : In conclusion, ultrasound was found to be highly specific but only moderately sensitive for the identification of thoracic injuries.

Conclusion (proposition de traduction) : En conclusion, l'échographie s'est avérée hautement spécifique mais modérément sensible pour l'identification des lésions thoraciques.

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix.
Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. | Am J Emerg Med. 2019 May;37(5):879-883
DOI: https://doi.org/10.1016/j.ajem.2018.08.014
Keywords: Aucun

Original contribution

Introduction : Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US.
Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized.

Méthode : A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology.

Résultats : 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%.

Conclusion : When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.

Conclusion (proposition de traduction) : Lorsque l'appendice n'est pas visualisé à l'échographie, les facteurs prédictifs d'appendicite incluent la présence de modifications inflammatoires dans la fosse iliaque droite, une élévation du nombre des globules blancs/CRP et des douleurs abdominales <3 jours.

The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism.
Glober N, Tainter CR, Brennan J, Darocki M, Klingfus M, Choi M, Derksen B, Rudolf F, Wardi G, Castillo E, Chan T. | Am J Emerg Med. 2019 May;37(5):895-901
DOI: https://doi.org/10.1016/j.ajem.2018.08.018
Keywords: Aucun

Original contribution

Introduction : We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli).

Méthode : Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer.

Résultats : Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE.
In our cohort, a DAGMAR Score < 2 equated to overall PE risk < 1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results.

Conclusion : By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.

Conclusion (proposition de traduction) : En prenant en compte les facteurs qui affectent les D-dimères ainsi que l'embolie pulmonaire, nous avons amélioré la spécificité sans compromettre la sensibilité.

Intravenous paracetamol versus dexketoprofen in acute musculoskeletal trauma in the emergency department: A randomised clinical trial.
Yilmaz A, Sabirli R, Ozen M, Turkcuer I, Erdur B, Arikan C, Demirozogul E, Sarohan A, Seyit M, Ok N. | Am J Emerg Med. 2019 May;37(5):902-908
DOI: https://doi.org/10.1016/j.ajem.2018.08.023
Keywords: Aucun

Original contribution

Introduction : Musculoskeletal system traumas are among the most common presentations in the emergency departments. In the treatment of traumatic musculoskeletal pain, paracetamol and non-steroidal anti-inflammatory analgesics (NSAID) are frequently used. Our aim in this study is to compare the efficacy of intravenous dexketoprofen and paracetamol in the treatment of traumatic musculoskeletal pain.

Méthode : This prospective, randomised, double blind, controlled study was conducted in a tertiary care emergency unit. The participating patients were randomised into two groups to receive either 50 mg of dexketoprofen or 1000 mg of paracetamol intravenously by rapid infusion in 150 mL of normal saline. Visual analogue scale (VAS), Numeric Rating Scala (NRS) and Verbal Rating Scale (VRS) was employed for pain measurement at baseline, after 15, after 30 and after 60 mins.

Résultats : 200 patients were included in the final analysis. The median age of the paracetamol group was 34 (24-48), while that of the dexketoprofen group was 35 (23-50), and 63% (n = 126) of them consisted of men. Paracetamol and dexketoprofen administration reduced VAS pain scores over time (p = 0.0001). Median reduction in VAS score at 60 min was 55 (IQR 30-65) for the paracetamol group and 50(IQR 30.25-60) for the dexketoprofen group. There was no statistically significant difference between the paracetamol and dexketoprofen groups in terms of VAS reductions (p = 0.613).

Conclusion : Intravenous paracetamol and dexketoprofen seem to produce equivalent pain relief for acute musculoskeletal trauma in the emergency department.

Conclusion (proposition de traduction) : Le paracétamol et le dexketoprofen intraveineux semblent produire un soulagement équivalent de la douleur en cas de traumatisme musculo-squelettique aigu au service des urgences.

Out-of-hospital cardiac arrest outcomes with "pit crew" resuscitation and scripted initiation of mechanical CPR.
Gonzales L, Oyler BK, Hayes JL, Escott ME, Cabanas JG, Hinchey PR, Brown LH. | Am J Emerg Med. 2019 May;37(5):913-920
DOI: https://doi.org/10.1016/j.ajem.2018.08.031
Keywords: Aucun

Original contribution

Introduction : To compare OHCA outcomes in patients managed with mechanical versus manual CPR in an EMS system with a "pit crew" approach to resuscitation and a scripted sequence for the initiation of mechanical CPR.

Méthode : Through a year-long quality improvement effort we standardized the initial resuscitative efforts for OHCA, prioritizing a "pit crew" approach to high quality manual CPR, early defibrillation and basic airway management ahead of a scripted sequence for initiating mechanical CPR. We then analyzed outcomes for adult, non-traumatic OHCA attended in the following year (2016). We used a propensity score matched analysis to compare ROSC, survival to discharge, and neurologic status among patients managed with manual versus mechanical CPR while controlling for patient demographics and arrest characteristics.

Résultats : Of 444 eligible OHCAs, 217 received manual and 227 received mechanical CPR. Crude ROSC (39.2% vs. 29.1%) and survival to discharge (13.8% vs. 5.7%) were higher with manual CPR. In the propensity matched analysis (n = 176 manual CPR; 176 mechanical CPR), both ROSC (38.6% vs. 28.4%; difference: 10.2%; CI: 0.4% to 20.0%) and survival to discharge (13.6% vs. 6.8%; difference: 6.8%; CI: 0.5% to 13.3%) remained significantly higher for patients receiving manual CPR.

Conclusion : In this EMS system with a standardized, "pit crew" approach to OHCA that prioritized initial high-quality initial resuscitative efforts and scripted the sequence for initiating mechanical CPR, use of mechanical CPR was associated with decreased ROSC and decreased survival to discharge.

Conclusion (proposition de traduction) : Dans ce système EMS avec une approche normalisée d’intervention en équipe de l’arrêt cardiaque extra-hospitalier qui privilégiait les efforts initiaux de réanimation initiale de haute qualité et qui établissait la séquence d'initiation acec la RCP mécanique, l'utilisation de la RCP mécanique était associée à une diminution des RACS (ndlr : Récupération d'activité cardiaque spontanée) et de la survie à la sortie.

Descriptive study of drug-drug interactions attributed to prescriptions written upon discharge from the emergency department.
Jawaro T, Bridgeman PJ, Mele J, Wei G. | Am J Emerg Med. 2019 May;37(5):924-927
DOI: https://doi.org/10.1016/j.ajem.2019.01.049
Keywords: Discharged emergency department patients; Drug interactions; Patient Safety; Pharmacist

Brief reports

Introduction : The primary purpose of this study was to identify the most common drug-drug interactions (DDI'S) in patients prescribed medications upon discharge from the emergency department.

Méthode : We conducted a respective chart review of patients discharged home with a prescription from an academic emergency department. The study period was from August 1, 2015 to August 31, 2015. Patients will be excluded if they meet the following criteria: age under 20 years; discharge home without a prescription; inpatient hospital admission; transfer to another inpatient facility; or sign out against medical advice. The primary endpoint is the identification and characterization of drug-drug interactions caused by discharge prescriptions written by the treating physician.

Résultats : A total of 500 patient charts were included, with 38% having at least one DDI. Overall, there were 429 DDIs among 858 prescriptions written. 15.6% (n = 67) of the DDI's were classified as B, no modification of therapy needed. 60% (n = 260) of the DDIs were risk-rating category C, requiring monitoring of therapy. 22% (n = 95) of the DDI's identified were category D, which are consider modification of therapy. Lastly, we identified 1.6% (n = 7) category X DDI's. The top 3 most commonly associated drugs were oxycodone/acetaminophen, ibuprofen, and ciprofloxacin.

Conclusion : DDIs are occurring upon discharge from a large, urban, tertiary care, academic medical center. Many of the DDI's identified do not require any modification to therapy. However, 23.6% of identified DDI's required modification or were contraindicated. A majority of the category X drug interactions involved QT prolongation.

Conclusion (proposition de traduction) : Des interactions médicamenteuses se retrouvent à la sortie d'un grand centre médical universitaire de soins tertiaires en milieu urbain. Bon nombre des interactions médicamenteuses identifiées ne nécessitent aucune modification du traitement. Toutefois, 23,6 % des interactions médicamenteuses identifiées nécessitaient une modification ou étaient contre-indiquées.
La majorité des interactions médicamenteuses de catégorie X (association à éviter) impliquaient un allongement de l'intervalle QT.

Commentaire : Pour information, voir le lien vers l'article Interactions   qui attribue, à chaque interaction médicamenteuse, un indice de risque de A, B, C, D ou X.
•  A - Aucune interaction connue. Les études n'ont pas démontré d'interactions pharmacodynamiques ou pharmacocinétiques entre les médicaments spécifiés.
B - Pas d'action requise. Les études démontrent que les agents spécifiés peuvent interagir les uns avec les autres, mais leur utilisation concomitante ne suscite que peu, voire aucune préoccupation clinique.
•  C - Surveiller le traitement. Les données démontrent que les médicaments spécifiés peuvent interagir les uns avec les autres de manière cliniquement significative. Les avantages de l’utilisation concomitante de ces deux médicaments l'emportent généralement sur les risques. Un plan de surveillance approprié devrait être mis en place pour identifier les effets négatifs potentiels. Un ajustement de la posologie d'un ou des deux médicaments peut être nécessaire chez une minorité de patients.
•  D - Envisager une modification du traitement. Les études démontrent que les deux médicaments peuvent interagir de manière cliniquement significative. Une évaluation spécifique du patient doit être réalisée pour déterminer si les avantages d'un traitement concomitant dépassent les risques. Des actions spécifiques doivent être entreprises afin de concrétiser les avantages et/ou de minimiser la toxicité résultant de l'utilisation concomitante des médicaments. Ces actions peuvent inclure une surveillance active, des changements de dosage empiriques ou le choix d’agents alternatifs.
•  X - Évitez l'association. Les données démontrent que les agents spécifiés peuvent interagir les uns avec les autres de manière cliniquement significative. Les risques associés à l'utilisation concomitante de ces agents l'emportent généralement sur les avantages. Ces agents sont généralement considérés comme contre-indiqués.

Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations.
Murphy DL, Rea TD, McCoy AM, Sayre MR, Fahrenbruch CE, Yin L, Tonelli BA, Joffe AM, Mitchell SH. | Am J Emerg Med. 2019 May;37(5):937-941
DOI: https://doi.org/10.1016/j.ajem.2019.02.038
Keywords: Emergency medical services; Endotracheal intubation; First pass success; Patient positioning; Rapid sequence intubation

Brief reports

Introduction : In hospital-based studies, patients intubated by physicians while in an inclined position compared to supine position had a higher rate of first pass success and lower rate of peri-intubation complications. We evaluated the impact of patient positioning on prehospital endotracheal intubation in an EMS system with rapid sequence induction capability. We hypothesized that patients in the inclined position would have a higher first-pass success rate.

Méthode : Prehospital endotracheal intubation cases performed by paramedics between 2012 and 2017 were prospectively collected in airway registries maintained by a metropolitan EMS system. We included all adult (age ≥ 18 years) non-traumatic, non-arrest patients who received any attempt at intubation. Patients were categorized according to initial positioning: supine or inclined. The primary outcome measure was first pass success with secondary outcomes of laryngoscopic view and challenges to intubation.

Résultats : Of the 13,353 patients with endotracheal intubation attempted by paramedics during the study period, 4879 were included for analysis. Of these, 1924 (39.4%) were intubated in the inclined position. First pass success was 86.3% among the inclined group versus 82.5% for the supine group (difference 3.8%, 95% CI: 1.5%-6.1%). First attempt laryngeal grade I view was 62.9% in the inclined group versus 57.1% for the supine group (difference 5.8%, 2.0-9.6). Challenges to intubation were more frequent in the supine group (42.3% versus 38.8%, difference 3.5%, 0.6-6.3).

Conclusion : Inclined positioning was associated with a better grade view and higher rate of first pass success. The technique should be considered as a viable approach for prehospital airway management.

Conclusion (proposition de traduction) : Le positionnement incliné était associé à une meilleure qualité de vision et à un taux de réussite à la première tentative plus élevé. La technique doit être considérée comme une solution réaliste pour la gestion des voies aériennes supérieures en préhospitalier.

Commentaire : Position inclinée :
La position C est correcte, avec éventuellement un coussin sous la tête.
La position D, avec la tête pendante hors du dossier du brancard, n'est pas correcte.



Voir l'article de Adnet F, Lapostolle F, Borron SW and al. Optimization of glottic exposure during intubation of a patient lying supine on the ground. Am J Emerg Med. 1997 Oct;15(6):555-7  .

Emergency physician care of family members, friends, colleagues and self.
Geiderman JM, Marco CA, Iserson KV. | Am J Emerg Med. 2019 May;37(5):942-946
DOI: https://doi.org/10.1016/j.ajem.2019.01.046
Keywords: Aucun

Controversies

Editorial : Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or "curbside" consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.

Conclusion : Not every source agrees that there should be strict prohibitions on treating family, friends or colleagues or in some situations, for treating minor ailments or prescription refills of non- controlled substances for physicians themselves. Half of state medical Boards address some or all of these issues and half do not. Potential positive and negative aspects of caring for family and friends are listed in this article.
In the emergency setting it is even more difficult because of the lack of clarity on exceptions for “emergencies” and “short term” treatment. Clearly, geographic location should be considered because of the lack of other resources in rural areas and states with large geographic spreads of populations. The authors of this paper encourage organizations and societies to address this issue and provide guidance to members.

Conclusion (proposition de traduction) : Toutes les sources ne s'accordent pour dire qu'il devrait exister des interdictions strictes concernant le traitement des membres de la famille, des amis ou des collègues ou, dans certains cas, le traitement d'affections mineures ou le renouvellement de prescriptions de substances non contrôlées par le médecin lui-même. La moitié des conseils médicaux des États traitent de tout ou partie de ces problèmes et la moitié ne le fait pas. Les aspects positifs et négatifs potentiels des soins à apporter à la famille et aux amis sont énumérés dans cet article.
Dans les situations d'urgence, cela est encore plus difficile en raison du manque de clarté sur les exceptions pour les traitements « en urgences » et « à court terme ». De toute évidence, la localisation géographique devrait être prise en compte en raison du manque d'autres ressources dans les zones rurales et les États à forte étendue géographique. Les auteurs de cet article encouragent les organisations et les sociétés à s’attaquer à ce problème et à donner des conseils à leurs membres.

Impact of a qSOFA-based Triage Procedure on Antibiotic Timing in ED Patients With Sepsis: A Prospective Interventional Study.
Petit J, Passerieux J, Maître O, Guérin C, Rozelle C, Cordeau O, Cassonnet A, Malet A, Boulain T, Barbier F; qSOFAST study group. | Am J Emerg Med. 2019 May
DOI: https://doi.org/10.1016/j.ajem.2019.05.022
Keywords: Antimicrobial agents; Quick sepsis-related organ failure assessment (qSOFA); Sepsis; Sepsis-related organ failure assessment (SOFA); Septic shock

ARTICLES IN PRESS

Introduction :  It has not been investigated whether the quick sepsis-related organ failure assessment score (qSOFA), a new bedside tool for early sepsis detection, may help accelerating antibiotic initiation in ED patients with sepsis.

Méthode : In this prospective pre/post quasi-experimental single-ED study, patients admitted with a suspected bacterial infection were managed using standard triage procedures only (baseline) or in association with qSOFA (intervention, with prioritization of patients with a qSOFA ≥ 2).

Résultats : A total of 151/328 (46.0%) and 185/350 (52.8%) patients with definite bacterial infection met the criteria for sepsis in the baseline and intervention periods, respectively. The sensitivity and specificity of a qSOFA ≥ 2 for sepsis prediction were 17.3% (95% confidence interval [CI], 13.6%-21.7%) and 98.8% (95% CI, 97.0%-99.5%). Eleven (7.3%) and 28 (13.5%) patients with sepsis in the baseline and intervention periods received a first antibiotic dose within one hour following triage (primary endpoint, absolute difference 6.2%, 95% CI [-0.5%, 12.7%], P = 0.08). The proportions of patients with sepsis receiving a first antibiotic dose within three hours following triage (39.7% [50/151] versus 36.8% [68/185], absolute difference - 2.9%, 95% CI [-13.3%, 7.3%], P = 0.65), requiring ICU admission, or dying in the hospital were similar in both periods. The median ED occupation rate at triage was 104.3% (interquartile range [IQR], 80.4%-128.3%), with a median number of 157 ED visits per day (IQR, 147-169).

Conclusion : A qSOFA-based triage procedure does not improve antibiotic timing and outcomes in patients with sepsis admitted to a high-volume ED. The qSOFA value at triage was poorly sensitive for early sepsis detection.

Conclusion (proposition de traduction) : Une procédure de triage basée sur le score qSOFA n'améliore pas le délai d'administration des antibiotiques et les résultats chez les patients présentant un sepsis admis dans un service urgence à volume d'activité élevé. La valeur du qSOFA au triage était peu sensible pour la détection précoce des sepsis.

Diagnostic Accuracy and Financial Implications of Age-Adjusted D-Dimer Strategies for the Diagnosis of Deep Venous Thrombosis in the Emergency Department.
Reardon PM, Patrick S, Taljaard M, Thavorn K, Nemnom MJ, Mukarram M, Kim SM, Le Gal G, Huang L, Thiruganasambandamoorthy V. | J Emerg Med. 2019 May;56(5):469-477
DOI: https://doi.org/10.1016/j.jemermed.2019.01.027
Keywords: D-dimer; deep venous thrombosis

Original Contributions

Introduction : Multiple D-dimer cutoffs have been suggested for older patients to improve diagnostic specificity for venous thromboembolism. These approaches are better established for pulmonary embolism.
OBJECTIVES: We evaluated the diagnostic performance and compared the health system cost for previously suggested cutoffs and a new D-dimer cutoff for low-risk emergency department (ED) deep venous thrombosis (DVT) patients.

Méthode : We conducted a retrospective cohort study in two large EDs involving patients aged > 50 years who had low pretest probability for DVT and had a D-dimer performed. The outcome was a diagnosis of DVT at 30 days. We evaluated the diagnostic accuracy and estimated the difference in cost for cutoffs of 500 ng/mL and the age-adjusted (age × 10) rule. A derived cutoff of 1000 ng/mL was also assessed.

Résultats : Nine hundred and seventy-two patients were included (median age 66 years; 59.5% female); 63 (6.5%) patients were diagnosed with DVT. The conventional cutoff of < 500 ng/mL demonstrated a sensitivity of 100% (95% confidence interval [CI] 94.3-100%) and a specificity of 35.6% (95% CI 32.5-38.8%). The age-adjusted approach increased specificity while maintaining high sensitivity. A new cutoff of 1000 ng/mL demonstrated improved performance: sensitivity 100% (95% CI 94.3-00%) and specificity 66.3% (95% CI 63.2-69.4%). Compared to the conventional approach, both the 1000 ng/mL cutoff and the age-adjusted cutoffs could save healthcare dollars. A cutoff of 1000 ng/mL could have saved 310 ED length of stay hours and $166,909 (Canadian dollars) in our cohort, or an average savings of 0.32 h and $172 per patient.

Conclusion : Among patients aged > 50 years with suspected DVT, the age-adjusted D-dimer and a cutoff of 1000 ng/mL improved specificity without compromising sensitivity, and lowered the health care system cost compared to that for the conventional approach.

Conclusion (proposition de traduction) : Parmi les patients âgés de plus de 50 ans chez qui on soupçonnait une TVP, les D-dimères ajustés à l'âge et une valeur seuil de 1 000 ng/ml amélioraient la spécificité sans compromettre la sensibilité et réduisaient le coût du système de santé par rapport à l'approche classique.

Factors Associated With Influenza in an Emergency Department Setting.
Pedersen CJ, Quinn JV, Rogan DT, Yang S. | J Emerg Med. 2019 May;56(5):478-483
DOI: https://doi.org/10.1016/j.jemermed.2018.12.012
Keywords: acute respiratory illness; influenza; nosocomial infections; predictors

Original contribution

Introduction : Emergency departments (EDs) become more overcrowded during peak respiratory virus season. Distinguishing influenza from other viruses is crucial to implement social distancing practices, early treatment, and prompt disposition.
/ OBJECTIVES: We sought to determine factors associated with influenza among a prospective cohort of consecutive ED patients with acute respiratory illness (ARI).

Méthode : Between December 2016 and March 2017, trained research assistants screened consecutive ED patients with ARI symptoms. ARI criteria included measured fever at home or in the ED >38°C and a cough, sore throat, or rhinorrhea with a duration of symptoms >12 hours and <1 week. After consent, research assistants collected demographics and clinical history using a standardized data form, and patients had a polymerase chain reaction-based assay that is nearly 100% sensitive for influenza. Univariate analysis was conducted on all predictor variables. Significant variables were entered into a multivariate logistic regression model to find factors that were independently associated with influenza.

Résultats : One hundred nineteen patients consented to enrollment and 31% were found to be positive for influenza. Myalgia, the absence of gastrointestinal symptoms (no diarrhea or vomiting), sore throat, chills, headache, and oxygen saturation ≥97% were significant on univariate analysis and were entered into the multivariate model. Myalgia (adjusted odds ratio [AOR] 3.9), the absence of gastrointestinal symptoms (AOR 4.7), and oxygen saturation ≥97% (AOR 2.8) were significant independent factors of influenza.

Conclusion : The presence of myalgia, the absence of gastrointestinal symptoms, and oxygen saturation ≥97% are factors that can help distinguish influenza from other acute respiratory illnesses in the ambulatory ED population.

Conclusion (proposition de traduction) : La présence de myalgie, l'absence de symptômes gastro-intestinaux et une saturation en oxygène ≥ 97 % sont des signes cliniques qui peuvent aider à identifier la grippe d'autres pathologies respiratoires aiguës dans une population ambulatoire.

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics.
Klein LR, Driver BE, Horton G, Scharber S, Martel ML, Cole JB. | J Emerg Med. 2019 May;56(5):484-490
DOI: https://doi.org/10.1016/j.jemermed.2018.12.036
Keywords: agitation; sedation

Original contributions

Introduction : Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available.
OBJECTIVE: The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED.

Méthode : This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1 h. Secondary outcomes included rescue sedation for the entire encounter and adverse events.

Résultats : There were 15,918 patients included (median age 37 years, 75% male). Rescue rates at 1 h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs.

Conclusion : Olanzapine and droperidol lead to lower rates of rescue sedation at 1 h and overall, compared with haloperidol. There were no significant differences in major adverse events.

Conclusion (proposition de traduction) : L'olanzapine et le dropéridol entraînent une diminution du taux de sédation d'urgence à 1 heure et moins, par rapport à l'halopéridol. Il n'y avait pas de différences significatives dans les événements indésirables majeurs.

Commentaire : En France, on utilise préférentiellement la loxapine (Loxapac).

Whole Blood in Trauma: A Review for Emergency Clinicians.
Weymouth W, Long B, Koyfman A, Winckler C. | J Emerg Med. 2019 May;56(5):491-498
DOI: https://doi.org/10.1016/j.jemermed.2019.01.024
Keywords: blood products; protocol; transfusion; whole blood

Clinical Reviews in Emergency Medicine

Introduction : Blood products are a cornerstone of trauma resuscitation. From the historically distant battlefields of World War II through present-day conflict around the globe, whole blood (WB) has been a potent tool in the treatment of massive hemorrhagic shock. Component therapy with a targeted ratio of packed red blood cells, platelets, and plasma has previously been utilized.

Méthode : This narrative review describes modern-day WB transfusion, its benefits, potential drawbacks, and implementation.

Discussion : The current form of stored low-titer O WB seems to be the safest and most effective solution. There are many advantages to WB, including the maintenance of coagulation factors, the lack of subsequent thrombocytopenia, and the reduction of infused anticoagulant. Several studies suggest its utility in trauma. Most of the disadvantages of WB stem from a lack of prospective data on the topic, which are likely forthcoming. Logistical issues likely present the greatest barrier to this therapy, but an advanced prehospital protocol developed in San Antonio, Texas, has successfully overcome several of these challenges.

Conclusion : Although stored WB holds promise, it is not without its distinct challenges, including logistical issues, which this article addresses. There are programs underway currently that demonstrate its feasibility in metropolitan areas. As demonstrated in military settings, WB is likely the ideal resuscitation fluid for civilian trauma in the prehospital and emergency department settings.

Conclusion (proposition de traduction) : Bien que le stockage de sang total soit porteur d'espoir, cet article ne manque pas de défis particuliers, notamment de problèmes logistiques. Il existe actuellement des programmes démontrant sa faisabilité dans les zones métropolitaines. Comme démontré dans les contextes militaires, le sang total est probablement le fluide de réanimation idéal pour les traumatismes civils dans les contextes préhospitaliers et des services d'urgence.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review.
Long B, Koyfman A, Gottlieb M. | J Emerg Med. 2019 May;56(5):499-511
DOI: https://doi.org/10.1016/j.jemermed.2019.01.025
Keywords: complete obstruction; endoscopy; esophageal foreign body; food bolus impaction

Clinical Reviews in Emergency Medicine

Introduction : Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

Méthode : This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

Discussion : Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

Conclusion : This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.

Conclusion (proposition de traduction) : Cet revue fournit des recommandations fondées sur des preuves concernant ces conditions, axées sur l'évaluation et la gestion.

Bedside Use of Speckle Tracking Echocardiography in the Emergency Department to Identify Acute Myocardial Infarction.
Colla J, Martin J, Eilbert W, Wishnoff M. | J Emerg Med. 2019 May;56(5):530-535
DOI: https://doi.org/10.1016/j.jemermed.2019.01.014
Keywords: bedside echocardiography; emergency echocardiography; emergency ultrasound; myocardial infarction; speckle tracking echocardiography

Ultrasound in Emergency Medicine

Editorial : Rapid diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) is often hindered by the limitations of the electrocardiogram (ECG). Speckle tracking echocardiography (STEch) is a semiautomated, computer-assisted process that provides accurate detection of regional ventricular wall motion abnormalities and can be performed at the bedside by operators with limited experience.

Conclusion : Two separate patients, each with history and ECG findings concerning for AMI, were evaluated using STEch performed by an emergency physician. Ventricular wall motion abnormalities found on STEch accurately reflected the findings of emergent cardiac catheterization, with one patient requiring urgent coronary artery revascularization and the other with no coronary artery occlusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: STEch is a novel, easy-to-use form of echocardiography that can be used in the ED to identify patients with AMI who would benefit from emergent revascularization.

Conclusion (proposition de traduction) : Deux patients distincts, chacun ayant des antécédents et des résultats d'ECG concernant un infarctus aigu du myocarde, ont été évalués à l'aide d'une échocardiographie de débrouillage effectuée par un urgentiste. Les anomalies du mouvement de la paroi ventriculaire trouvées sur l'échocardiographie de débrouillage reflétaient fidèlement les résultats du cathétérisme cardiaque, un patient nécessitant une revascularisation urgente des artères coronaires et l'autre sans occlusion des artères coronariennes.
POURQUOI UN MÉDECIN URGENTISTE DEVRAIT-IL ÊTRE AU COURANT ?
L'échocardiographie de débrouillage est une nouvelle forme d'échocardiographie facile à utiliser qui peut être utilisée aux urgences pour identifier les patients présentant un syndrome coronarien aigu qui pourraient bénéficier d'une revascularisation.

Analyzing the Effectiveness of Different Forms of Cardiopulmonary Resuscitation.
Holcomb SJ | J Emerg Med. 2019 May;56(5):540-543
DOI: https://doi.org/10.1016/j.jemermed.2018.12.041
Keywords: CPR; Emergency Medicine training; cardiopulmonary resuscitation; education; instruction; resuscitation

Techniques and Procedures

Introduction : In order to simulate a heartbeat in a cardiac arrest patient, cardiopulmonary resuscitation (CPR) requires that chest compressions be delivered with a force of at least 560 N at a rate >100 compressions/min. Many new learners initially use CPR forms that may not meet these parameters sufficiently. We examined three forms of CPR: the form recommended by the American Heart Association (AHA) and two forms that are common among new learners but that are considered incorrect, using a CPR manikin placed on a force plate. Four trained CPR users tested the different methods.

Discussion : AHA-recommended CPR is the most effective, delivering a force of 737.2 ± 5.3 N at a rate of 103.2 ± 1.2 compressions/min. Compressions using a bent arms method delivered compressions with a force of 511.8 ± 4.1 N at a rate of 112.8 ± 3.0 compressions/min. Compressions using a different hand position from that recommended by the AHA delivered compressions with a force of 433.3 ± 3.2 N at a rate of 115.2 ± 1.2 compressions/min.

Conclusion : AHA-recommended CPR more effectively compresses a patient's heart than the bent-arms method or the alternate hand-position method, and, of the three methods, only the AHA-recommended form can reliably simulate a patient's heartbeat.

Conclusion (proposition de traduction) : La RCP recommandée par l'AHA comprime plus efficacement le cœur d'un patient que la méthode des bras fléchis ou la méthode alternative de la position de la main et, parmi les trois méthodes, seule la forme recommandée par l'AHA peut reproduire de manière fiable le rythme cardiaque du patient.