Bibliographie de Médecine d'Urgence

Mois de juin 2019


Academic Emergency Medicine

Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria.
Amoako J, Evans S, Brown NV, Khaliqdina S, Caterino JM. | Acad Emerg Med. 2019 Jun;26(6):648-656
DOI: https://doi.org/10.1111/acem.13695
Keywords: Aucun

Original contributions

Introduction : The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center.

Méthode : An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center.

Résultats : Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR] = 0.89), age ≥ 90 (OR = 0.76), and either only a Level 3 (OR = 0.3) or no trauma center (OR = 0.11) in county of residence had decreased odds of transport, while male sex (OR = 1.38), black race (OR = 2.07), Injury Severity Score (ISS) 10-15 (OR = 1.99), ISS > 15 (OR = 2.85), and Glasgow Coma Scale score < 9 (OR = 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR = 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center.

Conclusion : We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport.

Conclusion (proposition de traduction) : Nous avons identifié les facteurs associés indépendamment à l'échec du transport des personnes âgées blessées vers les centres de traumatologie dans les données recueillies à l'échelle de l'État après l'adoption des critères de triage gériatrique. L'absence d'un centre de traumatologie dans le comté de résidence est demeurée un facteur même dans les analyses qui incluaient le transport final.

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis.
Kabrhel C, Rosovsky R, Baugh C, Connors J, White B, Giordano N, Torrey J, Deadmon E, Parry BA, Hagan S, Zheng H. | Acad Emerg Med. 2019 Jun;26(6):657-669
DOI: https://doi.org/10.1111/acem.13640
Keywords: Aucun

Original contributions

Introduction : The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission.

Méthode : We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7- and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests.

Résultats : We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59 years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p < 0.001), PE (18% from 12%, p = 0.002), low-risk PE (28% from 18%, p < 0.001), and DVT (60% from 49%, p = 0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol.

Conclusion : A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.

Conclusion (proposition de traduction) : Un protocole de traitement combinant la stratification du risque, un traitement au rivaroxaban et un suivi défini est associé à une augmentation du nombre de patients atteints d'EP et de TVP traités en consultation externe, sans augmentation des effets indésirables.

Critical Review, Development, and Testing of a Taxonomy for Adverse Events and Near Misses in the Emergency Department.
Griffey RT, Schneider RM, Todorov AA, Yaeger L, Sharp BR, Vrablik MC, Aaronson EL, Sammer C, Nelson A, Manley H, Dalton P, Adler L. | Acad Emerg Med. 2019 Jun;26(6):670-679
DOI: https://doi.org/10.1111/acem.13724
Keywords: Aucun

original articles

Introduction : An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g., hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g., "communication error"). We set out to create a patient-centered, emergency department (ED)-specific framework for describing AEs and near misses to advance quality and safety in the acute care setting.

Méthode : We performed a critical review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified AEs and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our criterion standard.

Résultats : Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems AE taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories, and up to three modifiers to further describe events. On testing, overall reviewer agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55 of 59 scenarios (93%) and all four concurred in 46 of 59 scenarios (78%). At the subcategory level, there was complete agreement in 40 of 59 (68%) scenarios and majority agreement in 55 of 59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level.

Conclusion : We developed a taxonomy of AEs and near misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good inter-rater reliability. This taxonomy can be adapted and modified by EDs seeking to enhance their quality and safety reviews and characterize harm occurring in their EDs for quality improvement purposes.

Conclusion (proposition de traduction) : Nous avons élaboré une classification des événements indésirables et des accidents évités de justesse aux urgences, modifiée à partir d'un cadre existant. La mise en place expérimentale de l'outil avec une formation minimale a permis d'obtenir un rendement élevé et une bonne fiabilité entre les évaluateurs.
Cette classification peut être adaptée et modifiée par les urgences qui cherchent à améliorer leurs analyse de la qualité et de l'innocuité et à caractériser les dommages subis dans leurs urgences à des fins d'amélioration de la qualité.

Corticosteroids for Preventing Postherpetic Neuralgia After Herpes Zoster Infection.
Kowalsky DS, Wolfson AB. | Acad Emerg Med. 2019 Jun;26(6):686-687
DOI: https://doi.org/10.1111/acem.13661
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Introduction : Post-herpetic neuralgia is a painful condition of persistent chronic pain following acute reactivation of varicella zoster virus. The review defines PHN as persisting or recurring pain at the site of shingles at least one month after the onset of the acute rash. The incidence of shingles increases with age, almost doubling in each decade after 50 years of age. Of these cases, roughly 20% go on to develop PHN, with age again being the strongest risk factor. The pain of PHN is frequently debilitating and can significantly affect quality of life. It is thought that the anti-inflammatory effects of corticosteroids might decrease nerve damage and prevent PHN.
This Cochrane review is an update of a previous Cochrane review first published in 2008 and updated in 2010. This update concludes based on moderate quality evidence that steroids do not provide benefit in the prevention of PHN, whereas prior reviews indicated insufficient evidence to draw a conclusion. More up to date data analysis methods were used in this review to provide conclusions It included all RCTs in which corticosteroids were given by oral, intramuscular, or intravenous routes within 7 days after onset of rash and in which steroids were compared to either no treatment or to placebo. Five trials with a total of 787 patients were included. The meta-analysis provides moderate-quality evidence that corticosteroids are not effective in preventing PHN six months after onset of acute herpetic rash (Relative risk (RR) 0.95, 95% confidence interval (CI) 0.45 to 1.99). The review found no statistically significant difference in the secondary outcome of pain severity at 3, 6, or 12 months.

Conclusion : The meta-analysis provides moderate-quality evidence that corticosteroids are not effective in preventing PHN six months after onset of acute herpetic rash (Relative risk (RR) 0.95, 95% confidence interval (CI) 0.45 to 1.99). The review found no statistically significant difference in the secondary outcome of pain severity at 3, 6, or 12 months.
The Cochrane authors suggest that future trials should include measurements of function and quality of life, and furthermore, that there should be longer-term follow- up in order to determine an effect of steroids on the likelihood of transition from acute pain to PHN.

Conclusion (proposition de traduction) : La méta-analyse fournit des preuves de qualité modérée que les corticoïdes ne permettent pas de prévenir efficacement le névralgie post-zostérienne six mois après l'apparition d'une éruption herpétique aiguë (risque relatif (RR) de 0,95, intervalle de confiance à 95 % (IC) de 0,45 à 1,99). L'examen n'a révélé aucune différence statistiquement significative dans le résultat secondaire de l'intensité de la douleur à 3, 6 ou 12 mois.
Les auteurs Cochrane suggèrent que les futurs essais devraient inclure des mesures de la fonction et de la qualité de la vie et qu'un suivi à plus long terme devrait être mis en place afin de déterminer l'effet des corticoïdes sur la probabilité de transition de la douleur aiguë de la névralgie post-zostérienne.

Resolution of Acute Priapism in Two Children With Sickle Cell Disease Who Received Nitrous Oxide.
Greenwald MH, Gutman CK, Morris CR. | Acad Emerg Med. 2019 Jun 22
DOI: https://doi.org/10.1111/acem.13822
Keywords: Aucun

Special Contribution

Introduction : Nitrous oxide (N O) is an inhalational medication that has anxiolytic, amnestic, potent venodilatory and mild-to-moderate analgesic properties commonly used in the emergency department (ED) setting. N2 O has a rapid onset of action (<5 minutes) and recovery (<5 minutes) and can be quickly titrated to effect without the need for IV access. It has few side effects, does not require renal or hepatic metabolism for excretion and has no reports of allergic reaction. Priapism is a serious complication of sickle cell disease (SCD) affecting approximately 35% of males, with an adverse impact on quality of life. Treatment options are limited and not evidence based, including hydration, alkalization, analgesia, oxygenation to prevent further sickling, and exchange transfusion. Patients who do not respond within 4 hours often require a painful invasive procedure that includes aspiration of blood from the corpus cavernosum and phenylephrine injections. Case reports have described a therapeutic benefit from oral pseudoephedrine, sildenafil, and intravenous (IV) arginine, however controlled clinical trials are lacking. Although a 50:50 nitrous oxide/oxygen mix is commonly used in France to enhance analgesia in patients with SCD and vasoocclusive pain events (VOE) not sufficiently responding to IV morphine, there are no reports of its use to treat priapism. We describe the effects of N2 O for the treatment of acute priapism associated with SCD in a pediatric ED.

Méthode : This is a case series of two adolescent boys with Hb-SS who on 3 separate occasions presented to the ED with acute priapism that failed oral therapy (pseudoephedrine and opioids). N2 O gas was utilized to help facilitate IV catheter placement.

Résultats : In each presentation (at ages 8 and 10 years for patient 1; age 15 years for patient 2), the patient experienced complete resolution of the priapism within 4-15 min of receiving N2 O (max 60%). The patients were discharged from the ED following each presentation and had no recurrence during the subsequent week.

Conclusion : Priapism is a challenging complication of SCD associated with long-term morbidity and a paucity of treatment options. Opioids are commonly used. Given the risks and inconsistent results of current recommended therapy, N2 O may represent a potential opioid-sparing treatment option for priapism presenting to the ED that warrants further investigation. Although anecdotal, N2 O inhalation is an intervention to consider during a time when a treating ED physician may have few alternatives.

Conclusion (proposition de traduction) : Le priapisme est une complication complexe de la drépanocytose associée à une morbidité à long terme et à une pénurie d'options thérapeutiques. Les opioïdes sont couramment utilisés. Compte tenu des risques et des résultats incohérents du traitement actuellement recommandé, le protoxyde d'azote peut représenter une option thérapeutique potentielle d'économie d'opioïdes pour le priapisme admis aux urgences qui justifie une étude plus approfondie. Bien qu'anecdotique, l'inhalation de protoxyde d'azote est une intervention à envisager à un moment où le médecin traitant peut avoir peu d'alternatives.

Annals of Emergency Medicine

Derivation and Validation of the SWAP Score for Very Early Prediction of Neurologic Outcome in Patients With Out-of-Hospital Cardiac Arrest.
Shih HM, Chen YC, Chen CY, Huang FW, Chang SS, Yu SH, Wu SY, Chen WK. | Ann Emerg Med. 2019 Jun;73(6):578-588
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.017
Keywords: Aucun

Cardiology

Introduction : For patients with out-of-hospital cardiac arrest who receive cardiopulmonary resuscitation in an emergency department (ED), the early evaluation of their neurologic prognosis is essential for emergency physicians. The aim of this study is to establish a simple and useful assessment tool for rapidly estimating the prognosis of patients with out-of-hospital cardiac arrest after their arrival at an ED.

Méthode : A total of 852 patients admitted from January 1, 2015, to June 30, 2017, were prospectively registered and enrolled in the derivation cohort. Multivariate logistic regression on this cohort identified 4 independent factors associated with unfavorable outcomes: initial nonshockable rhythm (odds ratio [OR] 3.40; 95% confidence interval [CI] 1.58 to 7.32), no witness of collapse (OR 3.19; 95% CI 1.51 to 6.75), older than 60 years (OR 3.65; 95% CI 1.64 to 8.09), and pH less than or equal to 7.00 (OR 3.27; 95% CI 1.42 to 7.54). The shockable rhythm-witness-age-pH (SWAP) score was developed and 1 point was assigned to each predictor.

Résultats : For a SWAP score of 4, the specificity was 97.14% (95% CI 91.62% to 100%) for unfavorable outcomes in the derivation cohort. For validation, we retrospectively collected data for 859 patients with out-of-hospital cardiac arrest from January 1, 2012, to December 31, 2014. A SWAP score of 4 was 100% specific (95% CI 99.9% to 100%) for unfavorable outcomes in the validation cohort.

Conclusion : The SWAP score is a simple and useful predictive model that may provide information for the very early estimation of prognosis for patients with out-of-hospital cardiac arrest. Further research is required to integrate ultrasonographic findings and validate the SWAP score's application in other populations.

Conclusion (proposition de traduction) : Le score SWAP est un modèle prédictif simple et utile qui peut fournir des informations pour une estimation très précoce du pronostic chez les patients en arrêt cardiaque extra-hospitalier. Des recherches supplémentaires sont nécessaires pour intégrer les résultats échographiques et valider l'application du score SWAP dans d'autres populations.

Commentaire : Score SWAP, en résumé :
• Rythme choquable ? : non choquable = 1 point
• Témoin ? : Arrêt cardiaque ou effondrement sans témoin = 1 point
• Âge ? : Plus de 60 ans = 1 point
• pH ? : pH ≤ 7 = 1 point
Les patients qui présenteraient un score de 4 au SWAP auraient une probabilité de résultat neurologique favorable de 0 % (score CPC ≥ 3 ou décès - c'est-à-dire autre chose qu'un rétablissement complet ou une invalidité modérée) avec une spécificité de 100 % (IC à 95 % de 99,9 % à 100 %) et avec une valeur prédictive positive de 100 %.

Voir le résumé de l'article sur le site JournalFeed : SWAP Score - Shockable, Witness, Age, pH for OHCA  . Rédigé par le Dr Clay Smith.

Effect of Barthel Index on the Risk of Thirty-Day Mortality in Patients With Acute Heart Failure Attending the Emergency Department: A Cohort Study of Nine Thousand Ninety-Eight Patients From the Epidemiology of Acute Heart Failure in Emergency Departments Registry..
Rossello X, Rossello X, Miró Ò, Llorens P, Jacob J, Herrero-Puente P, Gil V, Rizzi MA, Pérez-Durá MJ, Espiga FR, Romero R, Sevillano JA, Vidán MT, Bueno H, Pocock SJ, Martín-Sánchez FJ; ICA-SEMES Research Group. | Ann Emerg Med. 2019 Jun;73(6):589-598
DOI: https://doi.org/10.1016/j.annemergmed.2018.12.009
Keywords: Aucun

Cardiology

Introduction : We assess the value of the Barthel Index (BI) in predicting 30-day mortality risk among patients with acute heart failure who are attending the emergency department (ED).

Méthode : We selected 9,098 acute heart failure patients from the Acute Heart Failure in Emergency Departments registry who had BI score available both at baseline and the ED visit. Patients' data were collected from 41 Spanish hospitals during four 1- to 2-month periods between 2009 and 2016. Unadjusted and adjusted logistic regression models were used to assess the association between 30-day mortality and BI score. c Statistics were used to estimate their prognostic value.

Résultats : The mean baseline BI score was 79.4 (SD 24.6) and the mean ED BI score was 65.3 (SD 29.1). Acute functional decline (≥5-point decrease between baseline BI and ED BI score) was observed in 5,771 patients (53.4%). Within 30 days of the ED visit, 905 patients (9.9%) died. There was a steep inverse gradient in 30-day mortality risk for baseline BI and ED BI score. For instance, compared with BI score=100, a BI score of 50 to 55 doubled the mortality risk both at baseline and the ED visit. At the ED visit, a BI score of 0 to 5 carried a 5-fold increase in risk after adjustment for other risk predictors. In comparison with baseline BI score, ED BI score consistently provided greater discrimination. Neither baseline BI score nor the change in BI score from baseline to the ED visit added further prognostic value to the ED BI score.

Conclusion : Functional status assessed by the BI score at the ED visit is a strong predictor of 30-day mortality in acute heart failure patients, with higher predictive value than baseline BI score and acute functional decline. Routine recording of BI score at the ED visit may help in decisionmaking and health care planning.

Conclusion (proposition de traduction) : L’état fonctionnel évalué par l'indice de Barthel lors de la consultation aux urgences est un puissant facteur prédictif de la mortalité à 30 jours chez les patients insuffisants cardiaques aigus, avec une valeur prédictive plus élevée que le score de base de l'Index de Barthel et une baisse aigüe de la capacité fonctionnelle. L'enregistrement de routine de l'indice de Barthel lors de la visite au service des urgences peut aider à la prise de décision et à la planification des soins de santé.

Commentaire : L’Indice de Barthel mesure l’étendue du fonctionnement indépendant et de la mobilité dans les activités de la vie quotidienne (AVQ) c.-à-d. se nourrir, prendre un bain, soins personnels, s’habiller, continence intestinale, continence vésicale, faire sa toilette, transfert à partir d’une chaise, marcher et monter les marches. L’indice indique aussi le besoin d’assistance en matière de soins.
L’IB est une mesure de l’incapacité fonctionnelle largement utilisée. L’indice a été élaboré dans l’optique d’être utilisé en réadaptation auprès de personnes ayant subi un AVC ou présentant des troubles neuromusculaires ou squelettiques ; il peut aussi être utilisé auprès de patients en oncologie, in: Indice de Barthel  .

Hands-Only Cardiopulmonary Resuscitation Education: A Comparison of On-Screen With Compression Feedback, Classroom, and Video Education.
Heard DG, Andresen KH, Guthmiller KM, Lucas R, Heard KJ, Blewer AL, Abella BS, Gent LM, Sasson C. | Ann Emerg Med. 2019 Jun;73(6):599-609
DOI: https://doi.org/10.1016/j.annemergmed.2018.09.026
Keywords: Aucun

Cardiology

Introduction : We compare 3 methods of hands-only cardiopulmonary resuscitation (CPR) education, using performance scores. A paucity of research exists on the comparative effectiveness of different types of hands-only CPR education. This study also includes a novel kiosk approach that has not previously been studied, to our knowledge.

Méthode : A randomized, controlled study compared participant scores on 4 hands-only CPR outcome measures after education with a 25- to 45-minute practice-while-watching classroom session (classroom), 4-minute on-screen feedback and practice session (kiosk), and 1-minute video viewing (video only). Participants took a 30-second compression test after initial training and again after 3 months.

Résultats : After the initial education session, the video-only group had a lower total score (compressions correct on hand placement, rate, and depth) (-9.7; 95% confidence interval [CI] -16.5 to -3.0) than the classroom group. There were no significant differences on total score between classroom and kiosk participants. Additional outcome scores help explain which components negatively affect total score for each education method. The video-only group had lower compression depth scores (-9.9; 95% CI -14.0 to -5.7) than the classroom group. The kiosk group outperformed the classroom group on hand position score (4.9; 95% CI 1.3 to 8.6) but scored lower on compression depth score (-5.6; 95% CI -9.5 to -1.8). The change in 4 outcome variables was not significantly different across education type at 3-month follow-up.

Conclusion : Participants exposed to the kiosk session and those exposed to classroom education performed hands-only CPR similarly, and both groups showed skill performance superior to that of participants watching only a video. With regular retraining to prevent skills decay, the efficient and free hands-only CPR training kiosk has the potential to increase bystander intervention and improve survival from out-of-hospital cardiac arrest.

Conclusion (proposition de traduction) : Les participants ayant bénéficié de la session sur le stand et ceux ayant bénéficié de la formation en cours effectuaient la RCP pratique uniquement, de la même manière, et les deux groupes ont démontré des performances supérieures à celles des participants qui ont regardé seulement une vidéo. Grâce à un recyclage régulier pour prévenir la dégradation des compétences, le stand efficace et gratuit de formation pratique en RCR a le potentiel d'accroître l'intervention des témoins et d'améliorer la survie après un arrêt cardiaque extrahospitalier.

Do Mechanical Chest Compression Devices Compared With High-Quality Manual Chest Compressions Improve Neurologically Intact Survival of Patients Who Experience Cardiac Arrest?.
Long B, April MD. | Ann Emerg Med. 2019 Jun;73(6):620-623
DOI: https://doi.org/10.1016/j.annemergmed.2018.09.027
Keywords: Aucun

Cardiology

Introduction : Authors searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, Science Citation Index Expanded, Conference Proceedings Citation Index–Science, Science Citation abstracts on the Web of Science, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, Biotechnology and Bioengineering Abstracts, and bibliographies of included articles. Authors also contacted experts in mechanical chest compression devices to identify additional published and unpublished trials. Authors did not limit the search according to language.

Méthode : The review included only randomized controlled trials comparing compressions delivered by powered, automatic mechanical chest compression devices versus manual chest compressions performed by a human being, with a primary outcome of survival to hospital discharge with good neurologic function equivalent to a Cerebral Performance Category score of 1 or 2.1 Authors included patients experiencing out-of- hospital cardiac arrest or inhospital cardiac arrest who underwent resuscitation by trained medical personnel. The meta-analysis excluded trials with patients experiencing cardiac arrest from trauma, drowning, hypothermia, and toxic substances. Two authors used the predefined inclusion criteria to decide which trials to include, with disagreements resolved through consensus or discussion with a third author.

Résultats : Two authors abstracted data independently, with discrepancies resolved through consensus. Authors quantified the primary outcome of survival to hospital discharge with good neurologic function and dichotomous secondary outcomes by calculating risk ratios with 95% confidence intervals. Authors adjusted for clustering in cluster-randomized trials by calculating effective sample sizes. If trials used multiple comparator groups, authors combined data from all mechanical device groups into one comparator group. Authors contacted original trial investigators directly for missing or ambiguous data; if they did not receive a response within 1 month, they designated the data as missing. Two authors independently evaluated risk of bias and quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach and quantified heterogeneity by calculating the I2 statistic.

Conclusion : Mechanical chest compression devices are not superior to conventional, high-quality manual chest compressions in improving survival to hospital discharge with good neurologic function.

Conclusion (proposition de traduction) : Les dispositifs de compression thoracique mécaniques ne sont pas supérieurs aux compressions manuelles conventionnelles de haute qualité pour améliorer la survie à la sortie de l'hôpital avec une bonne fonction neurologique.

Do Colloids Improve Mortality Compared With Crystalloids for Resuscitation of Critical Patients?.
Nikolla DA, McCarthy MT, Carlson JN. | Ann Emerg Med. 2019 Jun;73(6):648-649
DOI: https://doi.org/10.1016/j.annemergmed.2018.09.024  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Introduction : Authors searched the Cochrane Central Register of Controlled Trials, MEDLINE Ovid, EMBASE Ovid, PubMed, Web of Science, the National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform, OpenGrey, and reference lists of relevant systematic reviews identified during their search on February 23, 2018, for randomized controlled trials and quasi- randomized trials including critically ill patients and comparing crystalloids with colloids.

Méthode :  Studies had to compare crystalloids with starches, dextrans, either albumin or fresh frozen plasma, or gelatins individually. Crystalloids could be either isotonic or hypertonic. Subjects in the studies had to be described as critically ill and requiring fluid volume replacement for burns, trauma, or severe medical conditions such as sepsis. Exclusion criteria included elective surgical procedures, neonates, women experiencing cesarean section, colloids administered for a known nutritional deficiency, preoperative hydration, and fluids administered specifically for intracranial pressure control after head injury. Primary outcomes measured were all-cause mortality at the end of follow-up, within 30 days, and within 90 days. Secondary outcomes were transfusion of blood products, renal replacement therapy, and adverse events, including allergic reactions, itching, and rashes.

Résultats : Three authors screened the titles independently in pairs, using Covidence software (Melbourne, Victoria, Australia) and standard data extraction forms to select relevant references from the search results. A fourth author was consulted to resolve disagreements between paired reviewers. Full texts were reviewed for inclusion and exclusion criteria. Dichotomous data were collected for each outcome measure (ie, number of subjects who died in each group at the end of follow-up). Review Manager (version 5; Nordic Cochrane Centre, Copenhagen, Denmark) was used to calculate risk ratios (RRs) with the Mantel- Haenszel model, as well as a random-effects statistical model for variation among subject groups. Risk of bias was assessed for each study with the Cochrane Risk of Bias Tool, including the following domains: sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and baseline characteristics. Selective reporting and publication bias were assessed with clinical trial registers and prospectively published protocols. Heterogeneity was calculated with the I2 statistic and chi2 test.

Conclusion : When used as an intravenous resuscitation fluid in critically ill adult and pediatric patients, colloids, including starches, dextrans, albumin, fresh frozen plasma, and gelatins, do not improve mortality compared with crystalloids.

Conclusion (proposition de traduction) : Lorsqu'ils sont utilisés comme liquide de réanimation intraveineuse chez les adultes et les enfants gravement malades, les colloïdes, y compris les amidons, les dextranes, l'albumine, le plasma frais congelé et les gélatines, n'améliorent pas la mortalité comparativement aux cristalloïdes.

Can Acute Uncomplicated Diverticulitis Be Safely Treated Without Antibiotics?.
Gottlieb M, Shah N, Yu B. | Ann Emerg Med. 2019 Jun;73(6):e75-e76
DOI: https://doi.org/10.1016/j.annemergmed.2018.08.441  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Introduction : The authors searched MEDLINE, EMBASE, Scopus, the Cochrane Library, the Web of Science database, and conference abstracts from 1946 to June 2017 for relevant studies that included terms such as “diverticulitis AND antibiotics.” The search strategy was limited to human studies in English. The authors also manually searched the references of included articles and performed a search of the gray literature with Google.

Méthode : Abstracts were screened independently by 2 reviewers for studies meeting the following inclusion criteria: adult patients (defined as !18 years) who had computed tomography–proven acute uncomplicated diverticulitis and studies with greater than or equal to 5 subjects enrolled. Acute uncomplicated diverticulitis was defined as Ambrosetti’s classification of mild diverticulitis, Hinchey’s 1a (confined pericolic inflammation) classification, or Hinchey’s 1b (confined pericolic abscess) classification.1,2 Primary outcomes included treatment failure, recurrence, abscesses, strictures, perforations, fistulas, and bleeding. Secondary outcomes included hospital length of stay, need for emergency surgery, or elective surgery. Any disagreements were settled by consensus, with the addition of a third reviewer if necessary.

Résultats : Data were extracted by one reviewer, with accuracy assessed by a second one. Outcomes associated with acute uncomplicated diverticulitis treatment with and without antibiotics were evaluated through meta-analyses. Study quality was assessed with the Cochrane Risk of Bias tool for randomized trials and the Methodological Index for Non- Randomized Studies tool for nonrandomized trials. Heterogeneity was assessed with the chi2 test and I2 statistic.

Conclusion : Antibiotic use in patients with acute uncomplicated diverticulitis is associated with an increased length of hospital stay but does not reduce overall or individual complication rates.

Conclusion (proposition de traduction) : L'antibiothérapie chez les patients atteints de diverticulite aiguë non compliquée est associée à une durée d'hospitalisation plus longue, mais ne réduit pas les taux globaux ou individuels de complications.

Evaluation of US Federal Guidelines (Primary Response Incident Scene Management [PRISM]) for Mass Decontamination of Casualties During the Initial Operational Response to a Chemical Incident.
Chilcott RP, Larner J, Durrant A, Hughes P, Mahalingam D, Rivers S, Thomas E, Amer N, Barrett M, Matar H, Pinhal A, Jackson T, McCarthy-Barnett K, Reppucci J. | Ann Emerg Med. 2019 Jun;73(6):671-684
DOI: https://doi.org/10.1016/j.annemergmed.2018.06.042  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : The aim of this study was to evaluate the clinical and operational effectiveness of US federal government guidance (Primary Response Incident Scene Management [PRISM]) for the initial response phase to chemical incidents.

Méthode : The study was performed as a large-scale exercise (Operation DOWNPOUR). Volunteers were dosed with a chemical warfare agent simulant to quantify the efficacy of different iterations of dry, ladder pipe system, or technical decontamination.

Résultats : The most effective process was a triple combination of dry, ladder pipe system, and technical decontamination, which attained an average decontamination efficiency of approximately 100% on exposed hair and skin sites. Both wet decontamination processes (ladder pipe system and technical decontamination, alone or in combination with dry decontamination) were also effective (decontamination efficiency >96%). In compliant individuals, dry decontamination was effective (decontamination efficiency approximately 99%), but noncompliance (tentatively attributed to suboptimal communication) resulted in significantly reduced efficacy (decontamination efficiency approximately 70%). At-risk volunteers (because of chronic illness, disability, or language barrier) were 3 to 8 times slower than ambulatory casualties in undergoing dry and ladder pipe system decontamination, a consequence of which may be a reduction in the overall rate at which casualties can be processed.

Conclusion : The PRISM incident response protocols are fit for purpose for ambulatory casualties. However, a more effective communication strategy is required for first responders (particularly when guiding dry decontamination). There is a clear need to develop more appropriate decontamination procedures for at-risk casualties.

Conclusion (proposition de traduction) : Les protocoles de réponse aux incidents PRISM sont adaptés aux victimes ambulatoires. Cependant, une stratégie de communication plus efficace est nécessaire pour les premiers intervenants (en particulier lors de la décontamination à sec). Il est clairement nécessaire de mettre au point des procédures de décontamination plus appropriées pour les victimes à risque.

BMJ Open

Is high-sensitivity troponin, alone or in combination with copeptin, sensitive enough for ruling out NSTEMI in very early presenters at admission? A post hoc analysis performed in emergency departments.
Chenevier-Gobeaux C, Sebbane M, Meune C, Lefebvre S, Dupuy AM, Lefèvre G, Peschanski N, Ray P. | BMJ Open. 2019 Jun 16;9(6):e023994
DOI: https://doi.org/10.1136/bmjopen-2018-023994  | Télécharger l'article au format  
Keywords: chest pain; chest pain onset; copeptin; high sensitive cardiac troponin; non st-elevation acute myocardial infarction; very early presenters

Emergency medicine Research

Introduction : Copeptin and high-sensitivity cardiac troponin (HS-cTn) assays improve the early detection of non-ST-segment elevation myocardial infarction (NSTEMI). Their sensitivities may, however, be reduced in very early presenters.

Méthode : SETTING: We performed a post hoc analysis of three prospective studies that included patients who presented to the emergency department for chest pain onset (CPO) of less than 6 hours.
PARTICIPANTS: 449 patients were included, in whom 12% had NSTEMI. CPO occurred <2 hours from ED presentation in 160, between 2 and 4 hours in 143 and >4 hours in 146 patients. The prevalence of NSTEMI was similar in all groups (9%, 13% and 12%, respectively, p=0.281).
MEASURES: Diagnostic performances of HS-cTn and copeptin at presentation were examined according to CPO. The discharge diagnosis was adjudicated by two experts, including cardiac troponin I (cTnI). HS-cTn and copeptin were blindly measured.

Résultats : Diagnostic accuracies of cTnI, cTnI +copeptin and HS-cardiac troponin T (HS-cTnT) (but not HS-cTnT +copeptin) lower through CPO categories. For patients with CPO <2 hours, the choice of a threshold value of 14 ng/L for HS-cTnT resulted in three false negative (Sensitivity 80%(95% CI 51% to 95%); specificity 85% (95% CI 78% to 90%); 79% of correctly ruled out patients) and that of 5 ng/L in two false negative (sensitivity 87% (95% CI 59% to 98%); specificity 58% (95% CI 50% to 66%); 52% of correctly ruled out patients). The addition of copeptin to HS-cTnT induced a decrease of misclassified patients to 1 in patients with CPO <2 hours (sensitivity 93% (95% CI 66% to 100%); specificity 41% (95% CI 33% to 50%)).

Conclusion : A single measurement of HS-cTn, alone or in combination with copeptin at admission, seems not safe enough for ruling out NSTEMI in very early presenters (with CPO <2 hours).

Conclusion (proposition de traduction) : Une seule mesure de troponine cardiaque à haute sensibilité, seule ou en association avec la copeptine à l'admission, ne semble pas suffisamment sûre pour écarter la possibilité d'un NSTEMI en cas de prise en charge très précoce (avec douleur thoracique < à 2 heures).

Emergency Medicine Journal

Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England.
Allen T, Walshe K, Proudlove N, Sutton M. | Emerg Med J. 2019 Jun;36(6):326-332
DOI: https://doi.org/10.1136/emermed-2018-207941
Keywords: emergency care systems, emergency departments; performance improvement; quality; statistics

ORIGINAL ARTICLES

Introduction : Hospital inspection and the publication of inspection ratings are widely used regulatory interventions that may improve hospital performance by providing feedback, creating incentives to change and promoting choice. However, evidence that these interventions assess performance accurately and lead to improved performance is scarce.

Méthode : We calculated six standard indicators of emergency department (ED) performance for 118 hospitals in England whose EDs were inspected by the Care Quality Commission, the national regulator in England, between 2013 and 2016. We linked these to inspection dates and subsequent rating scores. We used multilevel linear regression models to estimate the relationship between prior performance and subsequent rating score and the relationship between rating score and post-inspection performance.

Résultats : We found no relationship between performance on any of the six indicators prior to inspection and the subsequent rating score. There was no change in performance on any of the six indicators following inspection for any rating score. In each model, CIs were wide indicating no statistically significant relationships.

Conclusion : We found no association between established performance indicators and rating scores. This might be because the inspection and rating process adds little to the external performance management that EDs receive. It could also indicate the limited ability of hospitals to improve ED performance because of extrinsic factors that are beyond their control.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune association entre les indicateurs de performance établis et les scores de notation. Cela pourrait s'expliquer par le fait que le processus d'inspection et d'évaluation n'ajoute pas grand-chose à la gestion du performance externe que reçoivent les services d'urgence. Cela pourrait également indiquer la capacité limitée des hôpitaux d'améliorer le performance des services d'urgence en raison de facteurs extrinsèques qui échappent à leur contrôle.

Commentaire : Ce que cette étude ajoute :
► Les évaluations des services d'urgence de 118 hôpitaux en Angleterre entre 2013 et 2016 n'étaient pas associées à leurs performances pour six indicateurs avant l'inspection. La performance de ces indicateurs n'a pas non plus changé après l'inspection.
► L'inspection et la notation ne semblent pas refléter la performance réelle des services d'urgence ni stimuler une amélioration.

Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest.
Barnard EBG, Sandbach DD, Nicholls TL, Wilson AW, Ercole A. | Emerg Med J. 2019 Jun;36(6):333-339
DOI: https://doi.org/10.1136/emermed-2018-208165  | Télécharger l'article au format  
Keywords: cardiac arrest; doctors in PHC; prehospital care; prehospital care, clinical management; trauma, major trauma management

Original article

Introduction : Out-of-hospital cardiac arrest (OHCA) is prevalent in the UK. Reported survival is lower than in countries with comparable healthcare systems; a better understanding of outcome determinants may identify areas for improvement.

Méthode : An analysis of 9109 OHCA attended in East of England between 1 January 2015 and 31 July 2017. Univariate descriptives and multivariable analysis were used to understand the determinants of survival for non-traumatic cardiac arrest (NTCA) and traumatic cardiac arrest (TCA). Two Utstein outcome variables were used: survival to hospital admission and hospital discharge.

Résultats : The incidence of OHCA was 55.1 per 100 000 population/year. The overall survival to hospital admission was 27.6% (95% CI 26.7% to 28.6%) and the overall survival to discharge was 7.9% (95% CI 7.3% to 8.5%). Survival to hospital admission and survival to hospital discharge were both greater in the NTCA group compared with the TCA group: 27.9% vs 19.3% p=0.001, and 8.0% vs 3.8% p=0.012 respectively.Determinants of NTCA and TCA survival were different, and varied according to the outcome examined. In NTCA, bystander cardiopulmonary resuscitation (CPR) was associated with survival at discharge but not at admission, and the likelihood of bystander CPR was dependent on geographical socioeconomic status. An air ambulance was associated with increased survival to both hospital admission and discharge in NTCA, but only with survival to admission in TCA.

Conclusion : NTCA and TCA are clinically distinct entities with different predictors for outcome-future OHCA reports should aim to separate arrest aetiologies. Determinants of survival to hospital admission and discharge differ in a way that likely reflects the determinants of neurological injury. Bystander CPR public engagement may be best focused in more deprived areas.

Conclusion (proposition de traduction) : Les arrêts cardiaques non traumatique et traumatique sont des entités cliniquement distinctes avec des prédicteurs de résultats différents - les futurs rapports sur les arrêts cardiaques prèshospitaliers devraient viser à séparer les étiologies des arrêts cardiaques. Les déterminants de la survie jusqu'à l'admission à l'hôpital et à la sortie diffèrent d'une manière qui reflète probablement les déterminants des lésions neurologiques. La participation du public à la réanimation cardio-pulmonaire peut être mieux ciblée dans les régions les plus défavorisées.

Ageing population has changed the nature of major thoracic injury.
Ferrah N, Cameron P, Gabbe B, Fitzgerald M, Judson R, Marasco S, Kowalski T, Beck B. | Emerg Med J. 2019 Jun;36(6):340-345
DOI: https://doi.org/10.1136/emermed-2018-207943
Keywords: chest; epidemiology; research; trauma

Original article

Introduction : An increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with implications for trauma system design. The aim of this study was to examine trends in thoracic injuries among major trauma patients in an inclusive trauma system.

Méthode : This was a retrospective review of all adult cases of major trauma with thoracic injuries of Abbreviated Injury Scale score of 3 or more, using data from the Victorian State Trauma Registry from 2007 to 2016. Prevalence and pattern of thoracic injury was compared between patients with multitrauma and patients with isolated thoracic injury. Poisson regression was used to determine whether population-based incidence had changed over the study period.

Résultats : There were 8805 cases of hospitalised major trauma with serious thoracic injuries. Over a 10-year period, the population-adjusted incidence of thoracic injury increased by 8% per year (incidence rate ratio [IRR] 1.08, 95% CI 1.07 to 1.09). This trend was observed across all age groups and mechanisms of injury. The greatest increase in incidence of thoracic injuries, 14% per year, was observed in people aged 85 years and older (IRR 1.14, 95% CI 1.09 to 1.18).

Conclusion : Admissions for thoracic injuries in the major trauma population are increasing. Older patients are contributing to an increase in major thoracic trauma. This is likely to have important implications for trauma system design, as well as morbidity, mortality and use of healthcare resources.

Conclusion (proposition de traduction) : Les admissions pour traumatismes thoraciques dans la population de traumatismes majeurs sont en augmentation. Les patients plus âgés contribuent à une augmentation des traumatismes thoraciques majeurs. Ceci aura probablement des implications importantes pour la conception du système de traumatologie, ainsi que pour la morbidité, la mortalité et l'utilisation des ressources de soins de santé.

Emergency Medicine Journal (EMJ)

Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest.
Barnard EBG, Sandbach DD, Nicholls TL, Wilson AW, Ercole A. | Emerg Med J. 2019 Jun;36(6):333-339
DOI: https://doi.org/10.1136/emermed-2018-208165  | Télécharger l'article au format  
Keywords: cardiac arrest; doctors in PHC; prehospital care; prehospital care, clinical management; trauma, major trauma management

Original article

Introduction : Out-of-hospital cardiac arrest (OHCA) is prevalent in the UK. Reported survival is lower than in countries with comparable healthcare systems; a better understanding of outcome determinants may identify areas for improvement.

Méthode : An analysis of 9109 OHCA attended in East of England between 1 January 2015 and 31 July 2017. Univariate descriptives and multivariable analysis were used to understand the determinants of survival for non- traumatic cardiac arrest (NTCA) and traumatic cardiac arrest (TCA). Two Utstein outcome variables were used: survival to hospital admission and hospital discharge.

Résultats : he incidence of OHCA was 55.1 per 100 000 population/year. The overall survival to hospital admission was 27.6% (95% CI 26.7% to 28.6%) and the overall survival to discharge was 7.9% (95% CI 7.3% to 8.5%). Survival to hospital admission and survival to hospital discharge were both greater in the NTCA group compared with the TCA group: 27.9% vs 19.3% p=0.001, and 8.0% vs 3.8% p=0.012 respectively. Determinants of NTCA and TCA survival were different, and varied according to the outcome examined. In NTCA, bystander cardiopulmonary resuscitation (CPR) was associated with survival at discharge but not at admission, and the likelihood of bystander CPR was dependent on geographical socioeconomic status. An air ambulance was associated with increased survival to both hospital admission and discharge in NTCA, but only with survival to admission in TCA.

Conclusion : NTCA and TCA are clinically distinct entities with different predictors for outcome—future OHCA reports should aim to separate arrest aetiologies. Determinants of survival to hospital admission and discharge differ in a way that likely reflects the determinants of neurological injury. Bystander CPR public engagement may be best focused in more deprived areas.

Conclusion (proposition de traduction) : Les arrêts cardiaques traumatique et non traumatique sont des entités distinctes sur le plan clinique et dont les facteurs prédictifs sont différents.
A l'avenir, les rapports sur les arrêts cardiaques extrahospitaliers devraient viser à séparer les étiologies de l'arrêt. Les déterminants de la survie jusqu'à l'admission à l'hôpital et à la sortie diffèrent d'une manière qui reflète probablement les déterminants des lésions neurologiques. La meilleure façon d'engager le public dans la RCP est peut-être de cibler les zones les plus défavorisées.

Plight of the pelvic exam.
McLean ME, Santiago-Rosado L. | Emerg Med J. 2019 Jun;36(6):383-384
DOI: https://doi.org/10.1136/emermed-2019-208474
Keywords: Aucun

IN PERSPECTIVE

Editorial : In recent years, a series of clinical studies have ques- tioned the utility of the pelvic exam, and have concluded that it may be routinely omitted from patient evaluations in the ED. Tintinalli’s 2016 text states: ‘Vaginal examinations in stable women presenting with first-trimester bleeding may add little to the clin- ical diagnosis; some providers are moving away from routine use of vaginal examinations in initial patient assessment as long as a transvaginal US is obtained.’2 A recent article in Emergency Medicine News was boldly entitled ‘Why Are You Still Performing Pelvic Exams?’ as if it were already an obsolete intervention.3 Yet a closer examination of the literature suggests these conclusions are far too premature.

Conclusion : In the absence of high-quality evidence, it is irrespon- sible to suggest it is safe for EM providers caring for women with low abdominal pain, vaginal discharge or bleeding, or systemic symptoms without a source, to omit a pelvic exam. When medical providers exclude the female reproductive tract from the standard list of examinable body parts, without solid evidence that doing so is safe, the real issue may be provider discomfort or unease, and if that is the case, we are simply not doing our job.

Conclusion (proposition de traduction) : En l'absence de preuves de haute qualité, il est absolument irréfutable de suggérer qu'il est sans danger pour les urgentistes prenant en charge des femmes souffrant de douleurs abdominales basses, de pertes ou de saignements vaginaux, ou de symptômes systémiques sans source, d'omettre l'examen pelvien. Lorsque les praticiens médicaux excluent l'appareil reproducteur féminin de la liste standard des parties du corps pouvant faire l'objet d'un examen, sans preuve solide que le faire est sans danger, le véritable problème peut être la gêne ou le malaise du prestataire et si tel est le cas, nous ne faisons tout simplement pas notre travail.

Emergency Radiology

CCTA in patients with positive troponin and low clinical suspicion for ACS: a useful diagnostic option to exclude obstructive CAD.
Nugent JP, Wang J, Louis LJ, O'Connell TW, Khosa F, Wong GC, Saw JWL, Nicolaou S, McLaughlin PD. | Emerg Radiol. 2019 Jun;26(3):269-275
DOI: https://doi.org/10.1007/s10140-019-01668-1
Keywords: Acute coronary syndrome; Coronary artery disease; Coronary computed tomography angiography; Troponin

Original Article

Introduction : It is uncertain whether patients with elevated troponin and non-classical presentation of acute coronary syndrome (ACS) should receive coronary CT angiography (CCTA). A proportion of these patients will have no coronary artery disease (CAD) and would benefit from non-invasive investigations and expedited discharge. Objectives were to determine most common diagnoses and rate of ACS among patients with positive troponin and low clinical suspicion of ACS who received CCTA.

Méthode : IRB approved retrospective analysis of 491 consecutive patients in a level I trauma center ED referred for CCTA between April 4, 2015 to April 2, 2017. Patients were included if there was an elevated troponin (TnI > 0.045 μg/L) and atypical chest pain within 24 h prior to imaging. One hundred one patients met inclusion criteria; 17 excluded due to technical factors or history. Scans performed on dual-source CT.

Résultats : Eighty-four patients (47 men, 37 women) with median TnI of 0.11 ± 0.21 μg/L underwent CCTA 8.20 ± 6.41 h after first elevated Tn. Mean age was 53.2 ± 14.6 years. CCTA demonstrated absence of CAD in 39 patients (46.4%; 20 M, 19 F). CAD < 25% stenosis was observed in 24 (28.6%; 9 M, 15 F). CAD with 25-50% stenosis was observed in seven (8.3%; six M, one F). CAD > 50% stenosis was observed in 11 (13.1%; 9 M, 2 F), and non-diagnostic in three (3.6%, 3 M, 0 F). Forty-six (56.8%) were discharged directly from ED with median stay 15.82 ± 6.41 h.

Conclusion : Use of CCTA in ED patients with elevated troponin and low clinical suspicion for ACS allowed obstructive CAD to be excluded in 83%.

Conclusion (proposition de traduction) : L’utilisation de l’angiographie coronarienne par tomodensitométrie chez les patients du service des urgences présentant une troponine élevée et une faible suspicion clinique de SCA a permis d’exclure une maladie coronarienne obstructive à 83%.

Beyond appendicitis: ultrasound findings of acute bowel pathology.
Choe J, Wortman JR, Michaels A, Sarma A, Fulwadhva UP, Sodickson AD. | Emerg Radiol. 2019 Jun;26(3):307-317
DOI: https://doi.org/10.1007/s10140-019-01670-7
Keywords: Abdominal pain; Bowel; Emergency; Ultrasound

Review Article

Editorial : Bowel pathology is a common unexpected finding on routine abdominal and pelvic ultrasound. However, radiologists are often unfamiliar with the ultrasound appearance of the gastrointestinal tract due to the underutilization of ultrasound for bowel evaluation in the USA. The purpose of this article is to familiarize radiologists with the characteristic ultrasound features of a variety of bowel pathologies. Basic ultrasound technique for bowel evaluation, ultrasound appearance of normal bowel, and key ultrasound features of common acute bowel abnormalities will be reviewed.

Conclusion : Given its lack of ionizing radiation, widespread availability, low cost, and ability to provide real-time information, ultra- sound continues to play an important role in the evaluation of acute abdominal pain. Currently, many radiologists limit the use of abdominal and pelvic ultrasound to solid organs. However, ultrasound can be a valuable tool for assessment of bowel diseases such as appendicitis, diverticulitis, colitis, Meckel’s diverticulitis, small bowel obstruction, neoplasm, and intussusception. Familiarity with normal and pathologic ultrasound features of the bowel along with a good under- standing of ultrasound technique can facilitate early detection of bowel disease.

Conclusion (proposition de traduction) : Compte tenu de l'absence de rayonnements ionisants, de sa disponibilité généralisée, de son faible coût et de sa capacité à fournir des informations en temps réel, l’échographie continue à jouer un rôle important dans l’évaluation des douleurs abdominales aiguës. Actuellement, de nombreux radiologues limitent l'utilisation des ultrasons abdominaux et pelviens aux organes solides. Cependant, l’échographie peut être un outil précieux pour l’évaluation des maladies intestinales telles que l’appendicite, la diverticulite, la colite, la diverticulite de Meckel, l’obstruction de l’intestin grêle, les cancers et les invaginations.
Une bonne connaissance des caractéristiques échographiques normales et pathologiques de l'intestin ainsi qu'une bonne compréhension de la technique échographique peuvent faciliter la détection précoce des maladies de l'intestin.

European Journal of Emergency Medicine

Can epinephrine therapy be detrimental to patients with hypertrophic cardiomyopathy with hypotension or cardiac arrest? A systematic review.
Ilicki J, Bruchfeld S, Djärv T. | Eur J Emerg Med. 2019 Jun;26(3):150-157
DOI: https://doi.org/10.1097/MEJ.0000000000000573
Keywords: Aucun

Review article

Introduction : Approximately 10% of sudden cardiac deaths among patients under 35 years of age is owing to hypertrophic cardiomyopathy (HCM)-related cardiac arrest (CA). CA is often associated with pre-arrest or peri-arrest hypotension and is treated by a set of interventions, including the administration of epinephrine. It is debated whether epinephrine increases or decreases survival to discharge following CA. HCM is associated with septal hypertrophy with a dynamic left ventricular outflow tract obstruction and impaired peripheral vasoconstriction in response to α1-adrenergic stimulation, both of which could cause epinephrine to have a different effect than in the general population.

Méthode : This systematic review of the literature aimed to investigate if patients with HCM in CA have a detrimental hemodynamic response to epinephrine. A literature search was performed in October 2016 using Medline (OVID), Embase (Elsevier), and Cochrane Library (Wiley).

Résultats : The initial search generated 2429 articles, of which 22 articles were found to meet inclusion criteria: four physiology studies, 13 case reports of hypotensive HCM patients, and five case reports of HCM patients in CA. The reviewed studies demonstrate that epinephrine effect varies in patients with HCM: in some cases, the expected hypertensive effect was obtained, but in others, a paradoxical hypotensive effect, or no effect, was observed. The probable mechanism of this effect is an increased left ventricular outflow tract obstruction. Other drugs were considered in several of these cases.

Conclusion : In summary, the retrieved studies jointly suggest that patients with HCM may respond differently to epinephrine than patients without HCM. The suitability of epinephrine in HCM-associated CA is questionable.

Conclusion (proposition de traduction) : Les études extraites conjointement suggèrent que les patients atteints d'cardiomyopathie hypertrophique peuvent répondre différemment à l'adrénaline que les patients sans cardiomyopathie hypertrophique. La pertinence de l'adrénalinee dans l'ACR associée à une cardiomyopathie hypertrophique est discutable.

Stroke severity quantification by critical care physicians in a mobile stroke unit.
Hov MR, Røislien J, Lindner T, Zakariassen E, Bache KCG, Solyga VM, Russell D, Lund CG. | Eur J Emerg Med. 2019 Jun;26(3):194-198
DOI: https://doi.org/10.1097/MEJ.0000000000000529  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Cerebral revascularization in acute stroke requires robust diagnostic tools close to symptom onset. The quantitative National Institute of Health Stroke Scale (NIHSS) is widely used in-hospital, whereas shorter and less specific stroke scales are used in the prehospital field. This study explored the accuracy and potential clinical benefit of using NIHSS prehospitally.

Méthode : Thirteen anesthesiologists trained in prehospital critical care enrolled patients with suspected acute stroke in a mobile stroke unit. NIHSS was completed twice in the acute phase: first prehospitally and then by an on-call resident neurologist at the receiving hospital. The agreement between prehospital and in-hospital NIHSS scores was assessed by a Bland-Altman plot, and inter-rater agreement for predefined clinical categories was tested using Cohen's κ.

Résultats : This Norwegian Acute Stroke Prehospital Project study included 40 patients for analyses. The mean numerical difference between prehospital and in-hospital NIHSS scores was 0.85, with corresponding limits of agreement from - 5.94 to 7.64. Inter-rater agreement (κ) for the corresponding clinical categories was 0.38. A prehospital diagnostic workup (NIHSS and computed tomographic examination) was completed in median (quartiles) 10 min (range: 7-14 min). Time between the prehospital and in-hospital NIHSS scores was median (quartiles) 40 min (32-48 min).

Conclusion : Critical care physicians in a mobile stroke unit may use the NIHSS as a clinical tool in the assessment of patients experiencing acute stroke. The disagreement in NIHSS scores was mainly for very low values and would not have changed the handling of the patients.

Conclusion (proposition de traduction) : Les médecins de soins intensifs dans une unité mobile de traitement de l'AVC peuvent utiliser le NIHSS comme outil clinique dans l'évaluation des patients victimes d'un AVC aigu.
Le désaccord dans les scores NIHSS concernait principalement des valeurs très basses et n'aurait pas changé le traitement des patients.

Rhabdomyolysis: a 10-year retrospective study of patients treated in a medical department.
Vangstad M, Bjornaas MA, Jacobsen D. | Eur J Emerg Med. 2019 Jun;26(3):199-204
DOI: https://doi.org/10.1097/MEJ.0000000000000510
Keywords: Aucun

Original articles

Introduction : Rhabdomyolysis is a common and potentially life-threatening syndrome, and acute kidney injury (AKI) is a serious complication. We performed a 10-year retrospective study that included all patients treated for rhabdomyolysis in a medical clinic. We examined the relationships between the levels of creatine kinase (CK), myoglobin, and creatinine (as a marker of renal function and thereby AKI), and whether the myoglobin/CK ratio could be a valuable tool in the clinical evaluation of this patient group. Clinical characteristics were noted.

Méthode : The study included all patients treated for rhabdomyolysis in the Department of Medicine, Oslo University Hospital Ulleval, from 2003 to 2012. Rhabdomyolysis was defined as a serum CK activity more than five times the upper reference limit.

Résultats : A total of 341 patients were included in the study; 51% developed AKI, and 20% of those required dialysis. Logistic regression showed that myoglobin concentration [P < 0.001, odds ratio (OR) = 6.24] was a better predictor than CK activity (P = 0.001, OR = 3.45) of the development of AKI. The myoglobin/CK ratio was a good predictor of AKI (P < 0.001, OR = 5.97). The risk of developing AKI increased with increasing myoglobin/CK ratio (P < 0.001); a ratio more than 0.2 was associated with an increased likelihood of developing AKI.

Conclusion : Serum myoglobin concentration was a better predictor of AKI than was serum CK activity. The myoglobin/CK ratio may be useful for assessing the likelihood of developing AKI.

Conclusion (proposition de traduction) : Les taux sérique de myoglobine était un meilleur prédicteur d'une insuffisance rénale aiguë que le taux des CPK sériques. Le rapport myoglobine/CPK peut être utile pour évaluer la probabilité de développer une insuffisance rénale aiguë.

Trendelenburg position in the ED: many critically ill patients in the emergency department do not tolerate the Trendelenburg position.
Burghold CM, Hohenstein C, Rueddel H. | Eur J Emerg Med. 2019 Jun;26(3):212-216
DOI: https://doi.org/10.1097/MEJ.0000000000000525
Keywords: Aucun

Original articles

Introduction : Critically ill patients in emergency departments (ED) frequently require catheterization of the internal jugular vein. For jugular insertion, the Trendelenburg position (TP) is recommended. However, many patients in the ED do not tolerate lying in the supine or even the head-down position, or TP is contraindicated for other reasons. The aim of our trial was to investigate to which extent TP is either not tolerated or contraindicated in the target population of patients admitted to the ED.

Méthode : This was a clinical observational trial, carried out in an ED of a Tertiary Healthcare Hospital, including critically ill patients. From October 2015 to January 2016, we enrolled 117 nonintubated patients over 18 years admitted to the ED of Jena University Hospital, a Tertiary Healthcare Facility. Patients were positioned in TP (15° head-down) for a maximum of 10 min. If the position had to be abandoned for any reason, time to abandonment and reason for ending the position were recorded. 38.5% of all enrolled patients could not be positioned in TP because of contraindications (17.9%) or intolerance of the positioning (20.5%).

Conclusion : For central venous catheterization, TP remains the gold standard. Our trial shows the limitations of this positioning for critically ill patients. Almost 40% of the patients could not be tilted 15° head-down. Therefore, guideline recommendations should be reconsidered and alternatives should be sought.

Conclusion (proposition de traduction) : Pour la pose d'un cathr veineux central, la position de Trendelenburg reste la référence. Notre essai montre les limites de cette position chez les patients gravement malades. Près de 40 % des patients ne supportaient pas d'avoir la tête inclinée à 15° vers le bas.
Par conséquent, les recommandations des lignes directrices doivent être réexaminées et des solutions de remplacement recherchées.

Factors associated with the true location of ingested fishbones.
Lu YT, Chen HW, Tseng YY, Chen CH, Lu YC. | Eur J Emerg Med. 2019 Jun;26(3):224-227
DOI: https://doi.org/10.1097/MEJ.0000000000000527
Keywords: Aucun

Original articles

Introduction : Fishbone ingestion is a common problem worldwide, and the first step for managing this condition is to locate the fishbone precisely. However, until now, no study has analysed the true location of fishbone and its associated factors. Thus, this study identified the factors predicting the true location of fishbone and subsequently attempted to provide a management algorithm for fishbone ingestion.

Méthode : This retrospective study was carried out at St Martin De Porres Hospital, Taiwan, between January 2015 and January 2016. All patients were diagnosed as having fishbone ingestion within the pharynx and underwent fishbone removal.

Résultats : This study included 198 consecutive patients with a mean age of 43.1 years (range: 1-84 years). The sensitivity of lateral neck radiography in the diagnosis of fishbone in the pharynx was only 22%. The fishbone locations were as follows: the tonsil in 72 (36.4%) patients, the tongue base / vallecula in 112 (56.6%) and the hypopharynx in 14 (7.0%). Multiple logistic regression analysis showed that patient age and fishbone length were significant independent risk factors associated with the true location of fishbone ingestion. Among all patients, fishbone was removed transorally under direct vision in 73 (36.9%) patients and using flexible nasopharyngoscopy in 125 (63.1%) patients.

Conclusion : Patient age and fishbone length are important independent factors associated with the location of ingested fishbone. Lateral neck radiography is not beneficial for diagnosing fishbone ingestion within the pharynx. Flexible nasopharyngoscopy, by contrast, is an important method for the diagnosis and treatment of fishbone ingestion within this location.

Conclusion (proposition de traduction) : L'âge du patient et la longueur de l'arête de poisson sont des facteurs indépendants importants associés à l'emplacement de l'arête de poisson ingérée. La radiographie latérale du cou ne permet pas de diagnostiquer l'ingestion d'arête de poisson dans le pharynx. La rhinopharyngoscopie flexible, en revanche, est une méthode importante pour le diagnostic et le traitement de l'ingestion d'arête de poisson à cet endroit.

European Journal of Heart Failure

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial..
Pivetta E, Goffi A, Nazerian P, Castagno D, Tozzetti C, Tizzani P, Tizzani M, Porrino G, Ferreri E, Busso V, Morello F, Paglieri C, Masoero M, Cassine E, Bovaro F, Grifoni S, Maule MM, Lupia E; Study Group on Lung Ultrasound from the Molinette and Careggi Hospitals. | Eur J Heart Fail. 2019 Jun;21(6):754-766
DOI: https://doi.org/10.1002/ejhf.1379
Keywords: Acute dyspnoea; Diagnosis; Heart failure; Lung ultrasound

Research Article

Introduction : Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point-of-care diagnostic tool, but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in conjunction with clinical evaluation.

Méthode : This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non-ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT-proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT-proBNP approaches were calculated.

Résultats : A total of 518 patients were randomized. Addition of LUS had higher accuracy [area under the receiver operating characteristic curve (AUC) 0.95] than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT-proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS-integrated approach was higher then that of the CXR/Nt-proBNP-integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt-proBNP group.

Conclusion : Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT-proBNP.

Conclusion (proposition de traduction) : L'intégration de l'échographie pulmonaire avec l'évaluation clinique pour le diagnostic de l'insuffisance cardiaque décompensée aiguë au service des urgences semble être plus précise que l'approche diagnostique actuelle basée sur la radiographie thoracique et le NT-proBNP.

Pediatric Emergency Care

Pelvic Inflammatory Disease in a Pediatric Emergency Department: Epidemiology and Treatment.
Solomon M, Tuchman L, Hayes K1, Badolato G, Goyal MK. | Pediatr Emerg Care. 2019 Jun;35(6):389-390
DOI: https://doi.org/10.1097/PEC.0000000000001148
Keywords: Aucun

Original Articles

Introduction : Most adolescent cases of pelvic inflammatory disease (PID) are diagnosed in the emergency department (ED). An important step to prevent PID-related morbidity among this high-risk population is to quantify prevalence and microbial patterns and identify testing and treatment gaps.

Méthode : We performed a retrospective, cross-sectional study of all visits by adolescents to an urban children's ED with an International Classification of Diseases, Ninth Revision, diagnosis of PID in 2012. We used standard descriptive statistics to quantify PID diagnoses, sexually transmitted infections (STI) testing, and treatment.

Résultats : Pelvic inflammatory disease was diagnosed in more than 9% of women with a chief complaint of abdominal/pelvic pain. Most diagnosed cases underwent some STI testing, and 40% tested positive. Seventy percent of cases received antibiotics recommended by the Centers for Disease Control and Prevention.

Conclusion : There is a high prevalence of PID among adolescents in the pediatric ED. Rates of STI testing and appropriate treatment reveal gaps in diagnosis and management, representing a lost opportunity for identification and treatment of PID/STIs among high-risk adolescents.

Conclusion (proposition de traduction) : La prévalence de la maladie inflammatoire pelvienne chez les adolescents au service des urgences pédiatriques est élevée. Les taux de dépistage des infections sexuellement transmissibles et du traitement approprié révèlent des lacunes dans le diagnostic et la gestion, ce qui représente une occasion manquée d'identification et de traitement de la maladie inflammatoire pelvienne/infections sexuellement transmissibles chez les adolescents à haut risque.

Reliability of Smartphone-Based Instant Messaging Application for Diagnosis, Classification, and Decision-making in Pediatric Orthopedic Trauma.
Stahl I, Katsman A, Zaidman M, Keshet D, Sigal A, Eidelman M. | Pediatr Emerg Care. 2019 Jun;35(6):403-406
DOI: https://doi.org/10.1097/PEC.0000000000001211
Keywords: Aucun

Original articles

Introduction : Smartphones have the ability to capture and send images, and their use has become common in the emergency setting for transmitting radiographic images with the intent to consult an off-site specialist. Our objective was to evaluate the reliability of smartphone-based instant messaging applications for the evaluation of various pediatric limb traumas, as compared with the standard method of viewing images of a workstation-based picture archiving and communication system (PACS).

Méthode : X-ray images of 73 representative cases of pediatric limb trauma were captured and transmitted to 5 pediatric orthopedic surgeons by the Whatsapp instant messaging application on an iPhone 6 smartphone. Evaluators were asked to diagnose, classify, and determine the course of treatment for each case over their personal smartphones. Following a 4-week interval, revaluation was conducted using the PACS. Intraobserver agreement was calculated for overall agreement and per fracture site.

Résultats : The overall results indicate "near perfect agreement" between interpretations of the radiographs on smartphones compared with computer-based PACS, with κ of 0.84, 0.82, and 0.89 for diagnosis, classification, and treatment planning, respectively. Looking at the results per fracture site, we also found substantial to near perfect agreement.

Conclusion : Smartphone-based instant messaging applications are reliable for evaluation of a wide range of pediatric limb fractures. This method of obtaining an expert opinion from the off-site specialist is immediately accessible and inexpensive, making smartphones a powerful tool for doctors in the emergency department, primary care clinics, or remote medical centers, enabling timely and appropriate treatment for the injured child. This method is not a substitution for evaluation of the images in the standard method over computer-based PACS, which should be performed before final decision-making.

Conclusion (proposition de traduction) : Les applications de messagerie instantanée sur smartphone sont fiables pour l'évaluation d'un large éventail de fractures pédiatriques des membres. Cette méthode permettant d'obtenir l'avis d'un spécialiste externe est immédiatement accessible et peu coûteuse, faisant des téléphones intelligents un outil puissant pour les médecins des services d'urgence, des cliniques de soins primaires ou des centres médicaux éloignés, permettant un traitement opportun et approprié de l'enfant blessé. Cette méthode ne remplace pas l'évaluation des images dans la méthode standard par rapport à un PACS (système d'archivage et de communication d'images) informatisé, qui devrait être effectué avant la prise de décision finale.

Educational Effectiveness of an Easily Made New Simulator Model for Ultrasound-Guided Vascular Access and Foreign Body Management Procedures on Pediatric Patients.
Chang I, Kwak YH, Kim DK, Lee JH, Jung JY, Kwon H, Jung JH, Lee B, Paek SH. | Pediatr Emerg Care. 2019 Jun;35(6):407-411
DOI: https://doi.org/10.1097/PEC.0000000000001410
Keywords: Aucun

Original articles

Introduction : This study aimed to introduce an easily made chicken breast simulator for ultrasound (US)-guided vascular access, foreign body (FB) detection, and hydrodissection in pediatric patients and to validate the effectiveness for training using this phantom tissue model.

Méthode : The authors made the tissue phantom simulator using a chicken breast and rubber tourniquet for vascular access and fragments of a tongue blade and steel clip for FB detection and hydrodissection using a very simple method. We provided training on US-guided vascular access (following the tip [FTT] method), FB detection, and hydrodissection using this model for novice physicians to learn US-guided procedures for pediatric patients. In addition, we provided a questionnaire to solicit their thoughts on their knowledge and confidence to perform these procedures before and after training and to learn their thoughts on the similarity to actual patients and usefulness of this model on a 10-point Likert scale.

Résultats : A total of 16 emergency residents participated in this study. We obtained US images during vascular access (FTT) and FB detection/ hydrodissection procedures using this phantom tissue model. Residents' knowledge of and confidence to perform US-guided FTT method and FB detection/hydrodissection procedures after training increased to a statistically significant degree (P < 0.001 in all items). The median Likert scores regarding the similarity to actual patients and usefulness of this model were 8.5 (interquartile range, 7.5-9) and 10 (interquartile range, 8-10), respectively.

Conclusion : The model for US-guided procedures used in this study can be constructed by simple and easy methods, presents realistic procedural images, and was useful for training novice physicians to conduct US-guided procedures on pediatric patients.

Conclusion (proposition de traduction) : Le modèle de procédures guidées par échographie utilisé dans cette étude peut être construit à l'aide de méthodes simples et faciles, présente des images procédurales réalistes et s'est avéré utile pour former les médecins débutants à la conduite de procédures guidées par échographie chez les patients pédiatriques.

Effectiveness of a High-Fidelity Simulation-Based Training Program in Managing Cardiac Arrhythmias in Children: A Randomized Pilot Study.
Bragard I, Farhat N, Seghaye MC, Karam O, Neuschwander A, Shayan Y, Schumacher K. | Pediatr Emerg Care. 2019 Jun;35(6):412-418
DOI: https://doi.org/10.1097/PEC.0000000000000931
Keywords: Aucun

Original articles

Introduction : Pediatric cardiac arrest is a rare event. Its management requires technical (TSs) and nontechnical skills (NTSs). We assessed the effectiveness of a simulation-based training to improve these skills in managing life-threatening pediatric cardiac arrhythmias.

Méthode : Four teams, each composed of 1 pediatric resident, 1 emergency medicine resident, and 2 pediatric nurses, were randomly assigned to the experimental group (EG) participating in 5 video-recorded simulation sessions with debriefing or to the control group (CG) assessed 2 times with video-recorded simulation sessions without debriefing at a 2-week interval. Questionnaires assessed self-reported changes in self-efficacy, stress, and satisfaction about skills. Blinded evaluators assessed changes in leaders' TSs and NTSs during the simulations and the time to initiate cardiopulmonary resuscitation.

Résultats : After training, stress decreased and satisfaction about skills increased in the EG, whereas it remained the same in the CG (P = 0.014 and P < 0.001, respectively). There was no significant change in self-efficacy. Analyses of video-recorded skills showed significant improvements in TSs and NTSs of the EG leaders after training, but not of the CG leaders (P = 0.026, P = 0.038, respectively). The comparison of the evolution of the 2 groups concerning time to initiate cardiopulmonary resuscitation was not significantly different between the first and last simulation sessions.

Conclusion : A simulation-based training with debriefing had positive effects on stress and satisfaction about skills of pediatric residents and nurses and on observed TSs and NTSs of the leaders during simulation sessions. A future study should assess the effectiveness of this training in a larger sample and its impact on skills during actual emergencies.

Conclusion (proposition de traduction) : Une formation basée sur la simulation avec débriefing a eu des effets positifs sur le stress et la satisfaction vis-à-vis des compétences des résidents en pédiatrie et des infirmières et infirmiers, ainsi que sur les compétences techniques et non techniques observées des animateurs lors des séances de simulation. Une future étude devrait évaluer l'efficacité de cette formation dans un échantillon plus large et son impact sur les compétences lors d'urgences réelles.

A Vibrating Cold Device to Reduce Pain in the Pediatric Emergency Department: A Randomized Clinical Trial.
Potts DA, Davis KF, Elci OU, Fein JA. | Pediatr Emerg Care. 2019 Jun;35(6):419-425
DOI: https://doi.org/10.1097/PEC.0000000000001041
Keywords: Aucun

Original articles

Introduction : Pain of intravenous (IV) catheter insertion can be mitigated with appropriate analgesia, thereby avoiding unnecessary distress. Our objective was to compare the self-reported pain of IV catheter insertion in children when using a vibrating cold device (VCD) versus standard of care 4% topical lidocaine cream (TL).

Méthode : This was a 2-arm randomized controlled noninferiority trial with a convenience sample of 4- to 18-year-olds requiring nonemergent IV catheter insertion. Self-reported pain was measured with the Faces Pain Scale-Revised, anxiety with the Child's Rating of Anxiety scale, and observed pain with the Face, Legs, Activity, Crying, Consolability scale. Caregivers and nurses completed satisfaction surveys.

Résultats : Two hundred twenty-four children were included in the analysis: 114 (90%) of 127 in the VCD group and 110 (89%) of 124 in the TL group. Faces Pain Scale-Revised scores for both groups were equivalent (median, 2.0 cm; interquartile range, 0-5 cm; linear regression difference, 0 [95% confidence interval, -0.82 to 0.82]), as were median Face, Legs, Activity, Crying, Consolability scale scores (difference, 0.33 [95% confidence interval, -0.01 to 0.68]). The time of completion for the IV procedure was significantly shorter for the VCD group compared with the TL group (median, 3.0 vs 40.5 minutes; P < 0.0001). There were no significant differences between groups for self-reported state or trait anxiety, success of IV catheter insertion on first attempt, or satisfaction of caregivers or staff.

Conclusion : A VCD and TL showed equal effectiveness in reducing pain and distress for children undergoing IV catheter insertion. The VCD has the added benefit of quick onset time and an acceptable alternative for caregivers and nurses.

Conclusion (proposition de traduction) : Un dispositif vibrant refroidissement et une crème topique à la lidocaïne ont montré une efficacité égale dans la réduction de la douleur et de la détresse chez les enfants subissant une insertion de cathéter IV. Le dispositif vibrant refroidissement présente l'avantage supplémentaire d'un délai d'apparition rapide et constitue une alternative acceptable pour les soignants et les infirmières.

Ibuprofen for Pain Control in Children: New Value for an Old Molecule.
Poddighe D, Brambilla I, Licari A, Marseglia GL. | Pediatr Emerg Care. 2019 Jun;35(6):448-453
DOI: https://doi.org/10.1097/PEC.0000000000001505
Keywords: Aucun

Review Article

Introduction : Acute pain is one of the major complaints reported in pediatric emergency departments and general wards. Recently, both the US Food and Drug Administration and European Medicine Agency emitted some warnings regarding the use of opioids, including codeine, in children.
Objectif : The aims of this study were summarizing the main pharmacological aspects of ibuprofen, discussing the current evidence about the use of ibuprofen in different and specific clinical settings, and providing a comparison with acetaminophen and/or codeine, according to available studies.

Méthode : Studies evaluating ibuprofen for the management of acute pain in children were extracted from the PubMed and MEDLINE database within the period ranging from 1985 through 2017. After discussing safety of ibuprofen and its concomitant use with acetaminophen, the specific indications for the clinical practice were considered.

Résultats : Ibuprofen resulted to be more effective than acetaminophen, and comparable to the combination acetaminophen-codeine, for the control of acute pain related to musculoskeletal pain. Moreover, similar results have been reported also in the management of toothache and inflammatory diseases of the oral cavity and pharynx. Ibuprofen resulted to be useful as a first approach to episodic headache. Finally, the role of ibuprofen in the management of postoperative pain and, particularly, after tonsillectomy and/or adenoidectomy has been reconsidered recently.

Conclusion : Ibuprofen resulted to be the most studied nonsteroidal anti-inflammatory drug in the management of acute pain in children; in general, it showed a good safety profile and provided evidence of effectiveness, despite some differences according to the specific clinical context.

Conclusion (proposition de traduction) : L'ibuprofène s'est avéré être le médicament anti-inflammatoire non stéroïdien le plus étudié dans le traitement de la douleur aiguë chez les enfants ; en général, il présentait un bon profil d'innocuité et fournissait des preuves d'efficacité, malgré certaines différences en fonction du contexte clinique spécifique.

Prehospital and Disaster Medicine

High Tourniquet Failure Rates Among Non-Medical Personnel Do Not Improve with Tourniquet Training, Including Combat Stress Inoculation: A Randomized Controlled Trial.
Tsur AM, Binyamin Y, Koren L, Ohayon S, Thompson P, Glassberg E. | Prehosp Disaster Med. 2019 Jun;34(3):282-287
DOI: https://doi.org/10.1017/S1049023X19004266
Keywords: CSI: combat stress inoculation; IDF: Israel Defense Forces; extremities; hemorrhage; hemorrhagic; injuries; shock; tourniquets; wounds

Original Research

Introduction : The rate of failing to apply a tourniquet remains high.
Hypothèse : The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel.

Méthode : This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure ≥ 200mmHg; (2) time to stop bleeding ≤ 60 seconds; and (3) placement up to 7.5cm above the amputation.

Résultats : Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, -17.283 to 23.404, -1.792 to 6.105, and 0.932 to 2.387, respectively). Tourniquet placement was incorrect in most of the applications (62.30%).

Conclusion : This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.

Conclusion (proposition de traduction) : Cette étude a révélé un taux d'échec élevé dans l'application du garrot immédiatement après la réussite de l'entraînement au garrot. Ces taux ne se sont pas améliorés avec l’entraînement au garrot, même avec la gestion contre le stress de combat. Les résultats pourraient indiquer que de meilleures méthodes d’entraînement à la pose du garrot devraient être recherchées.

Safety and Efficacy of Prehospital Diltiazem for Atrial Fibrillation with Rapid Ventricular Response.
Rodriguez A, Hunter CL, Premuroso C, Silvestri S, Stone A, Miller S, Zuver C, Papa L. | Prehosp Disaster Med. 2019 Jun;34(3):297-302
DOI: https://doi.org/10.1017/S1049023X19004278
Keywords: AFIB: atrial fibrillation; ALS: Advanced Life Support; ECG: electrocardiogram; EMS: Emergency Medical Services; OCEMS: Orange County EMS; RVR: rapid ventricular response; SVT: supraventricular tachycardia; WPW: Wolff-Parkinson-White; ePCR: electronic patient care record; atrial fibrillation; diltiazem; prehospital

Original Research

Introduction : Atrial fibrillation (AFIB) with rapid ventricular response (RVR) is a common tachydysrhythmia encountered by Emergency Medical Services (EMS). Current guidelines suggest rate control in stable, symptomatic patients.
Problématique : Little is known about the safety or efficacy of rate-controlling medications given by prehospital providers. This study assessed a protocol for prehospital administration of diltiazem in the setting of AFIB with RVR for provider protocol compliance, patient clinical improvement, and associated adverse events.

Méthode : This was a retrospective, cohort study of patients who were administered diltiazem by providers in the Orange County EMS System (Florida USA) over a two-year period. The protocol directed a 0.25mg/kg dose of diltiazem (maximum of 20mg) for stable, symptomatic patients in AFIB with RVR at a rate of >150 beats per minute (bpm) with a narrow complex. Data collected included patient characteristics, vital signs, electrocardiogram (ECG) rhythm before and after diltiazem, and need for rescue or additional medications. Adverse events were defined as systolic blood pressure <90mmHg or administration of intravenous fluid after diltiazem administration. Clinical improvement was defined as a heart rate decreased by 20% or less than 100bmp. Original prehospital ECG rhythm interpretations were compared to physician interpretations performed retrospectively.

Résultats : Over the study period, 197 patients received diltiazem, with 131 adhering to the protocol. The initial rhythm was AFIB with RVR in 93% of the patients (five percent atrial flutter, two percent supraventricular tachycardia, and one percent sinus tachycardia). The agreement between prehospital and physician rhythm interpretation was 92%, with a Kappa value of 0.454 (P <.001). Overall, there were 22 (11%) adverse events, and 112 (57%) patients showed clinical improvement. When diltiazem was given outside of the existing protocol, the patients had higher rates of adverse events (18% versus eight percent; P = .033). Patients who received diltiazem in adherence with protocols were more likely to show clinical improvement (63% versus 46%; P = .031).

Conclusion : This study suggests that prehospital diltiazem administration for AFIB with RVR is safe and effective when strict protocols are followed.

Conclusion (proposition de traduction) : Cette étude suggère que l'administration préhospitalière de diltiazem pour la fibrillation atriale à réponse ventriculaire rapide est sûre et efficace lorsque des protocoles stricts sont suivis.

Predictors of Prehospital On-Scene Time in an Australian Emergency Retrieval Service.
Fok PT, Teubner D, Purdell-Lewis J, Pearce A. | Prehosp Disaster Med. 2019 Jun;34(3):317-321
DOI: https://doi.org/10.1017/S1049023X19004394
Keywords: CGD: clinical governance day; CPG: clinical practice guideline; EMS: Emergency Medical Services; IFT: inter-facility transfer; KPI: key performance indicator; PHI: prehospital intubation; SAAS: South Australian Ambulance Service; TBI: traumatic brain injury; prehospital care; prehospital time; retrieval medicine; scene time; transport medicine

Original Research

Introduction : Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.Hypothesis/Problem:The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time.

Méthode : A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time.

Résultats : A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively.

Conclusion : This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study's results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.

Conclusion (proposition de traduction) : Cette étude identifie deux caractéristiques de la mission, l’âge du patient et le transport héliporté, ainsi que deux interventions, l’intubation préhospitalière et la mise en place d'un cathéter artériel, qui augmentent considérablement la durée de l'intervention sur place.
Les patients âgés sont complexes sur le plan médical et sont plus gravement blessés que les patients plus jeunes. Par conséquent, il faudra peut-être plus de temps pour les stabiliser sur place. Le temps de préparation au vol, plus court pendant le transport terrestre, est inhérent aux opérations en hélicoptère. Le temps nécessaire pour exécuter une intubation préhospitalière en toute sécurité est similaire à celui de la littérature et est resté constant au cours des deux dernières années ; la mise en place d'un cathéter artériel a pris plus de temps que prévu.
Le South Australian Ambulance Service MedSTAR a modifié ses recommandations de pratique clinique pour les interventions préhospitalières en fonction des résultats de cette étude. Les services de secours devraient également évaluer la nécessité et l'efficacité des interventions visant à optimiser le temps passé sur intervention, sachant que le temps nécessaire pour exécuter une intervention en toute sécurité peut atteindre une durée minimale.
Fixer le temps sur intervention permet la planification de la mission, la formation de l'équipe et la révision des audits dans le but d'améliorer les soins aux patients.

Effect of Fluctuating Extreme Temperatures on Tranexamic Acid.
Loner C, Estephan M, Davis H, Cushman JT, Acquisto NM. | Prehosp Disaster Med. 2019 Jun;34(3):340-342
DOI: https://doi.org/10.1017/S1049023X19004308
Keywords: FTMS: Fourier Transform Mass Spectrometry; TXA: tranexamic acid; USP: United States Pharmacopeia; extreme temperatures; prehospital medicine; tranexamic acid

Brief Report

Introduction : Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce morbidity and mortality in hemorrhagic shock. It has potential use in prehospital and wilderness medicine; however, in these environments, TXA is likely to be exposed to fluctuating and extreme temperatures. If TXA degrades under these conditions, this may reduce antifibrinolytic effects.
Problématique : This study sought to determine if repetitive temperature derangement causes degradation of TXA.

Méthode : Experimental samples underwent either seven days of freeze/thaw or heating cycles and then were analyzed via mass spectrometry for degradation of TXA. An internal standard was used for comparison between experimental samples and controls. These samples were compared to room temperature controls to determine if fluctuating extreme temperatures cause degradation of TXA.

Résultats : The coefficient of variability of ratios of TXA to internal standard within each group (room temperature, freeze, and heated) was less than five percent. An independent t-test was performed on freeze/thaw versus control samples (t = 2.77; P = .17) and heated versus control samples (t = 2.77; P = .722) demonstrating no difference between the groups.

Conclusion : These results suggest that TXA remains stable despite repeated exposure to extreme temperatures and does not significantly degrade. These findings support the stability of TXA and its use in extreme environments.

Conclusion (proposition de traduction) : Ces résultats suggèrent que l'acide tranexamique reste stable malgré une exposition répétée à des températures extrêmes et ne se dégrade pas de manière significative. Ces résultats confirment la stabilité de l'acide tranexamique et son utilisation dans des environnements extrêmes.

Prehospital Emergency Care

Classification versus Prediction of Mortality Risk using the SIRS and qSOFA Scores in Patients with Infection Transported by Paramedics.
Lane DJ, Lin S, Scales DC. | Prehosp Emerg Care. 2019 Jun 19:1-8
DOI: https://doi.org/10.1080/10903127.2019.1624901
Keywords: emergency medical services; infection; prediction; sepsis; systemic inflammatory response syndrome

Article

Introduction : Identifying patients with sepsis in the prehospital setting is an important opportunity to increase timely care. When assessing clinical tools designed for paramedic sepsis identification, predicted risk may provide more useful information to support decision-making, compared to traditional estimates of classification accuracy (i.e., sensitivity and specificity). We sought to contrast classification accuracy versus predicted risk of a modified version of the Systemic Inflammatory Response Syndrome score (i.e., excluding white blood cell measure which is often unavailable to paramedics; mSIRS) and quick Sepsis Related Organ Failure Assessment (qSOFA) for determining mortality risk among patients with infection transported by paramedics.

Méthode : A one-year cohort of patients with infections transported to the Emergency Department (ED) by paramedics was linked to in-hospital administrative databases. Scores were calculated using the first reported vital sign measure for each patient. We calculated sensitivity and specificity of mSIRS and qSOFA for classifying hospital mortality at different score thresholds, and estimated discrimination (using the C-statistic) and calibration (using calibration curves). Regression models for predicting hospital mortality were constructed using the mSIRS or qSOFA scores for each patient as the predictor.

Résultats : A total of 10,409 patients with infection who were transported by paramedics were successfully linked, with an overall mortality rate of 9.2%. The mSIRS score had higher sensitivity estimates than qSOFA for classifying hospital mortality at all thresholds (mSIRS ≥ 1: 0.83 vs. qSOFA≥ 1: 0.80, mSIRS ≥ 3: 0.11 vs. qSOFA ≥ 3: 0.08), but the qSOFA score had better discrimination (C-statistic qSOFA: 0.72 vs. mSIRS: 0.63) and calibration. The risk of hospital mortality predicted by the mSIRS score ranged from 8.0 to 19% across score values, whereas the risk predicted by the qSOFA score ranged from 10 to 51%.

Conclusion : Assessing the predicted risk for the mSIRS and qSOFA scores instead of classification accuracy reveals that the qSOFA score provides more information to clinicians about a patient's mortality risk, supporting its use in clinical decision-making.

Conclusion (proposition de traduction) : L'évaluation du risque prédit par les scores mSIRS et qSOFA, au lieu de la précision d'une classification, révèle que le score qSOFA fournit davantage d'informations aux cliniciens sur le risque de mortalité d'un patient, soutenant ainsi son utilisation dans la prise de décision clinique.

Simulating Public Buses as a Mobile Platform for Deployment of Publicly Accessible Automated External Defibrillators.
Hajari H, Salerno J, Weiss LS, Menegazzi JJ, Karimi H, Salcido DD. | Prehosp Emerg Care. 2019 Jun 18:1-7
DOI: https://doi.org/10.1080/10903127.2019.1623353
Keywords: cardiac arrest; public access defibrillation; simulation

Article

Introduction : Public access defibrillation (PAD) programs seek to optimize locations of automated external defibrillators (AEDs) to minimize the time from out-of-hospital cardiac arrest (OHCA) recognition to defibrillation. Most PAD programs have focused on static AED (S-AED) locations in high traffic areas; pervasive electronic data infrastructure incorporating real-time geospatial data opens the possibility for AED deployment on mobile infrastructure for retrieval by nearby non-passengers. Performance characteristics of such systems are not known.
Hypothèses : We hypothesized that publicly accessible AEDs located on buses would increase publicly accessible AED coverage and reduce AED retrieval time relative to statically located AEDs.

Méthode : S-AED sites in Pittsburgh, PA were identified and consolidated to 1 AED per building for analysis (n = 582). Public bus routes and schedules were obtained from the Port Authority of Allegheny County. OHCA locations and times were obtained from the Pittsburgh site of the Resuscitation Outcomes Consortium. Two simulations were conducted to assess the characteristics and impact of AEDs located on buses. In Simulation #1, geographic coverage area of AEDs located on buses (B-AEDs) was estimated using a 1/8th mile (201 m) retrieval radius during weekday, Saturday and Sunday periods. Cumulative geographic coverage across each period of the week was compared to S-AED coverage and the added coverage provided by B-AEDs was calculated. In Simulation #2, spatiotemporal event coverage was estimated for historical OHCA events, assuming constraints designed to reflect real world AED retrieval scenarios. Event coverage and AED retrieval time were compared between B-AEDs and S-AEDs across periods of the week and residential/nonresidential spatial areas.

Résultats : Cumulative geographic coverage by S-AEDs was 23% across all periods, assuming uniform access hours. B-AEDs alone versus B-AEDs + S-AEDs covered 20% vs. 34% (weekday), 14% + 30% (Saturday), and 10% + 28% (Sunday). There was no statistically significant difference in 3-minute historical AED accessibility between only B-AEDs and only S-AEDs in standalone deployments (12% vs. 14%). However, when allowing for retrieval of either type of AED in the same scenario, event coverage was improved to 22% (p < 0.001).

Conclusion : Deployment of B-AEDs may improve AED coverage but not as a standalone deployment strategy.

Conclusion (proposition de traduction) : Le déploiement des DEA dans les bus peut améliorer la couverture des DEA, mais il ne s'agit pas d'une stratégie de déploiement distincte.

Dual Defibrillation is Highly Variable: An Analysis of Pulse Interval Delivered in Dual Defibrillation.
Hamilton RJ, Ramzy M, Teufel J, Laub G, Kresh JY. | Prehosp Emerg Care. 2019 Jun 14:1-6
DOI: https://doi.org/10.1080/10903127.2019.1621411
Keywords: defibrillation; double; dual; sequential

Article

Introduction : Dual defibrillation (DD) is a technique where two external defibrillators are applied with two different pad configurations and discharged to treat refractory ventricular fibrillation (RVF). Although commonly called dual sequential defibrillation (DSD), if the delivered electrical pulses overlap with no pulse interval, the shocks are actually dual simultaneous defibrillation (DSiD). Manual DD technique is not standardized and the effect that the method of activation has on the delivered pulse interval has never been studied.
Objectifs :This study measured the timing of four methods of DD and the resulting inter-shock intervals, frequency with which they were either DSiD or DSD, and frequency which the true DSDs delivered any previously reported optimum pulse interval.

Méthode : This was a single-blinded prospective evaluation of a convenience sample of volunteer physicians, nurses, and paramedics each performing DD in our simulation center on two types of defibrillators using four techniques: single operator-simultaneous with 2 hands (SOSI), two operators-simultaneous (TOSI), single operator-sequential with 1 hand (SOSE1), and single operator-sequential with 2 hands (SOSE2).

Résultats : The four DD methods generated a variable set of pulse intervals depending on the technique and defibrillator employed. The pulse intervals ranged from 0 msec (i.e., overlapping waveforms or DSiD) to 1800 msec. Of all DD attempts, 85.9% met the definition of DSD, 14.1% were DSiD, and 49.4% delivered any one of the optimum pulse intervals previously described in the literature. SOSI and TOSI techniques resulted in DSD between 47.2 and 87.6% of the time, depending on the technique and defibrillator. Shocks delivered sequentially on purpose (SOSE2 and SOSE1) were always DSD but with widely variable pulse intervals. SOSI resulted in the shortest pulse intervals, SOSE1 resulted in the longest, and TOSI and SOSE2 were the least skewed.

Conclusion : Dual Defibrillation using the various methods currently employed produces a highly variable set of pulse intervals even within a single method. It is difficult to reach a conclusion about the efficacy of dual Defibrillation unless the delivered pulse interval is measured or the method of activation reproducibly produces a precise pulse interval.

Conclusion (proposition de traduction) : La double défibrillation, utilisant les différentes méthodes actuellement utilisées, produit un ensemble extrêmement variable d'intervalles d'impulsions, même au sein d'une seule et même méthode. Il est difficile de tirer des conclusions sur l'efficacité de la double défibrillation à moins que l'intervalle d'impulsion délivré ne soit mesuré ou que la méthode d'activation ne produise, de manière reproductible, un intervalle d'impulsion précis.

Commentaire : Pour aller plus loin :
• Hajjar K, Berbari I, El Tawil C, Bou Chebl R, Abou Dagher G. Dual defibrillation in patients with refractory ventricular fibrillation. Am J Emerg Med. 2018 Aug;36(8):1474-1479  .
• Ross EM, Redman TT, Harper SA, Mapp JG, Wampler DA, Miramontes DA. Dual defibrillation in out-of-hospital cardiac arrest: A retrospective cohort analysis. Resuscitation. 2016 Sep;106:14-7  .
• Deakin CD, Kerber RE. Dual sequential defibrillation: Does one plus one equal two? Resuscitation. 2016 Nov;108:A1-A2  .

The American Journal of Emergency Medicine

Desmopressin/indomethacin combination efficacy and safety in renal colic pain management: A randomized placebo controlled trial.
Jalili M, Shirani F, Entezari P, Hedayatshodeh M, Baigi V, Mirfazaelian H. | Am J Emerg Med. 2019 Jun;37(6):1009-1012
DOI: https://doi.org/10.1016/j.ajem.2018.08.033
Keywords: Desmopressin; Indomethacin; Pain; Renal colic

Original Contribution

Introduction : Renal colic is a prevalent cause of abdominal pain in the emergency department. Although non-steroidal anti-inflammatory drugs and opioids are used for the treatment of renal colic, some adverse effects have been reported. Therefore, desmopressin -a synthetic analogue of vasopressin- has been proposed as another treatment choice. In the present study, indomethacin in combination with nasal desmopressin was compared with indomethacin alone in the management of renal colic.

Méthode : Included in the study were 124 patients with initial diagnosis of renal colic and randomized to receive indomethacin suppository (100 mg) with either desmopressin intranasal spray (4 puffs, total dose of 40 micrograms) and or placebo intranasal spray.

Résultats : All the included patients were finally diagnosed with renal colic. There was no difference between the two groups in pain at the baseline (p = 0.4) and both treatments reduced pain successfully (p < 0.001). There was no significant difference between the two groups in pain reduction (p = 0.35).

Conclusion : While there was significant pain reduction in both patients groups, pain reduction of NSAIDs (e.g. indomethacin) in renal colic, does not significantly improve when given in combination with desmopressin.

Conclusion (proposition de traduction) : Bien qu'il y ait eu une réduction significative de la douleur dans les deux groupes de patients, la réduction de la douleur par les AINS (p. ex. indométhacine [INDOCID®]) dans la colique néphrétique n'est pas significativement plus importante lorsqu'elle est administrée à la desmopressine.

Prognostic performance of disease severity scores in patients with septic shock presenting to the emergency department.
Choi A, Park YS, Shin TG, Han KS, Kim WY, Kang GH, Kim K, Choi SH, Lim TH, Suh GJ; Korean Shock Society (KoSS) Investigators. | Am J Emerg Med. 2019 Jun;37(6):1054-1059
DOI: https://doi.org/10.1016/j.ajem.2018.08.046
Keywords: Mortality; Prognosis; Sepsis; Shock

Original contribution

Introduction : An accurate disease severity score that can quickly predict the prognosis of patients with sepsis in the emergency department (ED) can aid clinicians in distributing resources appropriately or making decisions for active resuscitation measures. This study aimed to compare the prognostic performance of quick sequential organ failure assessment (qSOFA) with that of other disease severity scores in patients with septic shock presenting to an ED.

Méthode : We performed a prospective, observational, registry-based study. The discriminative ability of each disease severity score to predict 28-day mortality was evaluated in the overall cohort (which included patients who fulfilled previously defined criteria for septic shock), the newly defined sepsis subgroup, and the newly defined septic shock subgroup.

Résultats : A total of 991 patients were included. All disease severity scores had poor discriminative ability for 28-day mortality. The sequential organ failure assessment and acute physiology and chronic health evaluation II scores had the highest area under the receiver-operating characteristic curve (AUC) values, which were significantly higher than the AUC values of other disease severity scores in the overall cohort and the sepsis and septic shock subgroups. The discriminative ability of each disease severity score decreased as the mortality rate of each subgroup increased.

Conclusion : All disease severity scores, including qSOFA, did not display good discrimination for 28-day mortality in patients with serious infection and refractory hypotension or hypoperfusion; additionally, none of the included scoring tools in this study could consistently predict 28-day mortality in the newly defined sepsis and septic shock subgroups.

Conclusion (proposition de traduction) : Tous les scores de gravité, y compris le qSOFA, n'ont pas fait preuve d'une bonne discrimination pour la mortalité à 28 jours chez les patients présentant une infection grave et une hypotension ou une hypoperfusion réfractaire ; en outre, aucun des outils de cotation inclus dans cette étude ne permettait de prédire systématiquement une mortalité à 28 jours dans les nouveaux sous-groupes septique et choc septique définis.

Osborn wave in hypothermia and relation to mortality.
Eroglu O, Serbest S, Kufeciler T, Kalkan A. | Am J Emerg Med. 2019 Jun;37(6):1065-1068
DOI: https://doi.org/10.1016/j.ajem.2018.08.049
Keywords: Aucun

Original contribution

Introduction : The aim of this study was to compare hypothermia patients with and without an Osborn wave (OW) in terms of physical examination findings, laboratory results, and clinical survival.

Méthode : The study was carried out retrospectively on hypothermic patients. The hypothermic patients were divided into two groups. Group 1 comprised patients with OW on electrocardiogram (ECG), and Group 2 comprised patients without OW on ECG. The Mann-Whitney U test was used to compare the two groups, and the relationships between the variables and the presence of OW and mortality were analyzed with ANOVA. A value of p < 0.05 was considered statistically significant.

Résultats : OW was detected on ECG of 41.9% of the patients (Group 1). The mean body temperature was 30.8 ± 4.1 °C in Group 1 and 33.3 ± 1.6 °C in Group 2 (p = 0.106). The mean creatinine level was 1.01 ± 0.6 mg/dl in Group 1 and 0.73 ± 0.5 mg/dl in Group 2 (p = 0.046). The mean bicarbonate level was 15.9 ± 3.8 mmol/l in Group 1 and 18.6 ± 3.5 mmol/l in Group 2 (p = 0.038). A relationship was determined between the presence of OW and pH, bicarbonate, and creatinine levels (p = 0.026; 0.013; 0.042, respectively). The mortality rate was 69.2% in Group 1 and 77.8% in Group 2 (p = 0.689).

Conclusion : Although there is a relationship between the decrease in bicarbonate levels, changes in kidney functions that cause acidosis, and the presence of OW, it has no effect on mortality. The presence of OW in hypothermic patients is insufficient to make a decision regarding mortality.

Conclusion (proposition de traduction) : Bien qu'il existe un lien entre la diminution des niveaux de bicarbonate, les changements au niveau de la fonction rénale qui enyraînent une acidose et la présence de l'Onde J d'Osborn, elle n'a aucun effet sur la mortalité. La présence de l'Onde J d'Osborn chez les patients en hypothermie est insuffisante pour prendre une décision concernant la mortalité.

Cerebrovascular risks with rapid blood pressure lowering in the absence of hypertensive emergency.
Miller JB, Calo S, Reed B, Thompson R, Nahab B, Wu E, Chaudhry K, Levy P. | Am J Emerg Med. 2019 Jun;37(6):1073-1077
DOI: https://doi.org/10.1016/j.ajem.2018.08.052
Keywords: Aucun

Original contribution

Introduction : In the Emergency Department (ED) setting, clinicians commonly treat severely elevated blood pressure (BP) despite the absence of evidence supporting this practice. We sought to determine if this rapid reduction of severely elevated BP in the ED has negative cerebrovascular effects.

Méthode : This was a prospective quasi-experimental study occurring in an academic emergency department. The study was inclusive of patients with a systolic BP (SBP) > 180 mm Hg for whom the treating clinicians ordered intensive BP lowering with intravenous or short-acting oral agents. We excluded patients with clinical evidence of hypertensive emergency. We assessed cerebrovascular effects with measurements of middle cerebral artery flow velocities and any clinical neurological deterioration.

Résultats : There were 39 patients, predominantly African American (90%) and male (67%) and with a mean age of 50 years. The mean pre-treatment SBP was 210 ± 26 mm Hg. The mean change in SBP was -38 mm Hg (95% CI -49 to -27) mm Hg. The average change in cerebral mean flow velocity was -5 (95% CI -7 to -2) cm/s, representing a -9% (95% CI -14% to -4%) change. Two patients (5.1%, 95% CI 0.52-16.9%) had an adverse neurological event.

Conclusion : While this small cohort did not find an overall substantial change in cerebral blood flow, it demonstrated adverse cerebrovascular effects from rapid BP reduction in the emergency setting.

Conclusion (proposition de traduction) : Bien que cette petite cohorte n'ait pas constaté de changement global substantiel dans le débit sanguin cérébral, elle a démontré des effets cérébrovasculaires indésirables découlant d'une réduction rapide de la TA en situation d'urgence.

Commentaire : Il faut garder en mémoire l'alerte suivante :
• Nicardipine par voie intraveineuse : modifications des indications, des modalités d’utilisation et des conditions de prescription et de délivrance  . Avril 2015. Information destinée aux médecins urgentistes, médecins SAMU, anesthésistes-réanimateurs, cardiologues, gynécologues-obstétriciens et pharmaciens hospitaliers.

ED treatment of migraine patients has changed.
Ruzek M, Richman P, Eskin B, Allegra JR. | Am J Emerg Med. 2019 Jun;37(6):1069-1072
DOI: https://doi.org/10.1016/j.ajem.2018.08.051
Keywords: Emergency department; Migraine; Return visits

Original contribution

Introduction : STUDY OBJECTIVES: Numerous studies have shown benefits of nonnarcotic treatments for emergency department (ED) migraine patients. Our goal was to determine if ED treatment of migraine patients and the rate of return within 72 h have changed.
METHODS: Design: Multi-hospital retrospective cohort.
POPULATION: Consecutive ED patients from 1-1-1999 to 9-31-2014.

Méthode : For determining treatments, we examined charts at the beginning (1999-2000) and end (2014) of the time period. We combined similar medications into the following groups: parenteral narcotics, oral narcotics, antihistamines and dopamine receptor antagonists prochlorperazine/metoclopramide (DRA). We calculated the percent of migraine patients given each treatment in each time period. We identified those who returned to the same ED within 72 h, and calculated the difference in annual return rates between 1999-2000 and 2014.

Résultats : Of the 2,824,710 total visits, 8046 (0.28%) were for migraine. We reviewed 290 charts (147 in 1999-2000 and 143 in 2014) to determine migraine treatments. The use of IV fluids, DRA, ketorolac and dexamethasone increased from 1999-2000 to 2014, whereas narcotic use and discharge prescriptions for narcotics decreased. Of the 8046 migraine patients, 624 (8%) returned within 72 h. The return rate decreased from 1999-2000 to 2014 from 12% to 4% (difference = 8%, 95% CI 5%-11%).

Conclusion : For ED migraine patients, the use of IV fluids, DRA, ketorolac and dexamethasone increased whereas the use of narcotics and discharge prescriptions for narcotics decreased. The return rates for migraines decreased. We speculate that the increased use of non-narcotic medications contributed to this decrease.

Conclusion (proposition de traduction) : Pour les patients migraineux au services des urgences, l’utilisation du remplissage intraveineux, d’antagonistes des récepteurs de la dopamine, prochlorpérazine/métoclopramide, du kétorolac et de la dexaméthasone a augmenté, tandis que l’utilisation des narcotiques et des ordonnances de sortie pour les narcotiques ont diminué. Les taux de reconsultation pour les migraines ont diminué.
Nous supposons que l'utilisation accrue de médicaments non narcotiques a contribué à cette diminution.

Clinical characteristics of elderly drowning patients.
Lee DH, Park JH, Choi SP, Oh JH, Wee JH. | Am J Emerg Med. 2019 Jun;37(6):1091-1095
DOI: https://doi.org/10.1016/j.ajem.2018.08.066
Keywords: Drowning; Emergency medicine; Geriatric

Original contribution

Introduction : Drowning is one of the major causes of traumatic death. The impact of drowning in the elderly and patients who were not elderly will be different because of physiological differences. We wanted to analyze the clinical differences such as mortality, incidence rate of complications, degree of hypothermia and rate of cardiac arrest between elderly and adult drowning patients.

Méthode : This study included drowning patients over 18 years old who came to an emergency department (ED) located on a riverside from September 1997 to July 2016. Patients over the age of 65 years were classified as elderly, while those under the age of 65 years were classified as adults. Demographic data and clinical outcomes were surveyed.

Résultats : A total of 611 patients were included in this study. Sixty-one patients (9.9%) were elderly, and 550 patients (90.1%) were adults. There were 17 elderly patients (15.8%) and 87 adult patients (27.9%) who had cardiac arrest at the time of ED arrival (p = 0.017). The rate of body temperatures < 34 °C was higher in elderly patients than that in adult patients (27.9% vs 17.5%, respectively, p = 0.025). The rates of hospitalization in the intensive care unit (ICU) and mortality were higher in elderly group (23% vs. 15.1%, respectively, p = 0.01; 37.7% vs 21.8%, respectively, p = 0.01). There was no significant difference in suicidal intent between the elderly and adult patient groups (82.0% vs 78.9%, respectively, p = 0.421).

Conclusion : Elderly drowning patients accounted for approximately 1/10 of all drowning cases and were more likely to experience a cardiac arrest, hypothermia, mortality, and ICU admission.

Conclusion (proposition de traduction) : Les patients âgés se noyant représentaient environ 1/10 de tous les cas de noyade et étaient plus susceptibles de subir un arrêt cardiaque, une hypothermie, une mortalité et une admission en USI.

Incorporation of Transcranial Doppler into the ED for the neurocritical care patient.
Montrief T, Alerhand S, Jewell C, Scott J. | Am J Emerg Med. 2019 Jun;37(6):1144-1152
DOI: https://doi.org/10.1016/j.ajem.2019.03.003
Keywords: Aucun

Diagnostics

Introduction : In the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD).

Méthode : This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided.

Résultats : Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided.

Conclusion : With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.

Conclusion (proposition de traduction) : Grâce à la large diffusion de l'échographie au chevet du patient au sein du service des urgences, le médecin urgentiste dispose d'une occasion unique d'utiliser le doppler transcrânien dans diverses situations. Bien que des obstacles à la formation existent, la performance des médecins urgentistes pour un nombre limité de doppler transcrânien au point d'intervention est réalisable et peut fournir des informations cliniques rapides et fiables avec une résolution temporelle élevée.

Principles of safety for ultrasound-guided single injection blocks in the emergency department.
Nagdev A, Dreyfuss A, Martin D, Mantuani D. | Am J Emerg Med. 2019 Jun;37(6):1160-1164
DOI: https://doi.org/10.1016/j.ajem.2019.03.045
Keywords: Aucun

Clinical Note

Editorial : Ultrasound-guided nerve blocks (UGNBs) allow emergency physicians an opportunity to provide optimal pain management for acute traumatic conditions. Over the past decade, a growing body of literature has detailed the novel ways clinicians have incorporated UGNBs for analgesia and an alternative to procedural sedation. UGNBs are considered a relatively safe procedure, and have been shown to increase rates of success and reduce complications (as compared to older techniques). Ultrasound allows the operator needle visualization and a clear anatomic overview. Even with the presumed level of increased safety, we recommend that any clinician who performs ultrasound-guided nerve blocks be aware of complications that could arise during and after the procedure. Peripheral nerve injury (PNI) post block, local anesthetic systemic toxicity (LAST) and the role of single peripheral nerve blocks in patients with a risk for compartment syndrome are common safety issues discussed when performing ultrasound-guided nerve blocks.

Conclusion : UGNBs have become a standard aspect of modern emergency care. POCUS fellowship requirements outline the need for training in UGNBs, and there more than a decade of published literature detailing the use of UGNBs for acute injuries. Even though there is very little data on complication rate from UGNBs in the ED setting, clinicians should be aware to both inform their patients as well as develop methods to reduce risk. As a multimodal strategy for pain management evolves, we hope to safely incorporate UGNBs into emergency care to provide optimal care to all patients with acute traumatic injuries.

Conclusion (proposition de traduction) : Les blocs périnerveux échoguidés sont devenus un aspect standard des soins d'urgence modernes. La formation à l'échographie au point d'intervention sur les blocs périnerveux et plus de dix années de littérature décrivant l'utilisation des blocs périnerveux échoguidés pour les lésions aiguës. Même s'il existe très peu de données sur le taux de complication des blocs nerveux échoguidés au service des urgences, les cliniciens doivent être conscients d'informer leurs patients et de développer des méthodes pour réduire les risques. Alors que la stratégie multimodale de gestion de la douleur évolue, nous espérons intégrer en toute sécurité les blocs périnerveux échoguidés aux soins d'urgence afin de fournir des soins optimaux à tous les patients présentant des lésions traumatiques aiguës.

Mechanical, inflammatory, and embolic complications of myocardial infarction: An emergency medicine review.
Montrief T, Davis WT, Koyfman A, Long B. | Am J Emerg Med. 2019 Jun;37(6):1175-1183
DOI: https://doi.org/10.1016/j.ajem.2019.04.003
Keywords: Acute coronary syndrome; Complications; Mechanical complications; Myocardial infarction

Reviews

Introduction : Despite the declining incidence of coronary heart disease (CHD) in the United States, acute myocardial infarction (AMI) remains an important clinical entity, with many patients requiring emergency department (ED) management for mechanical, inflammatory, and embolic complications.

Méthode : This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post myocardial infarction mechanical, inflammatory, and embolic complications.

Résultats : While 30-day mortality rate after AMI has decreased in the past two decades, it remains significantly elevated at 7.8%, owing to a wide variety of subacute complications evolving over weeks. Mechanical complications such as ventricular free wall rupture, ventricular septal rupture, mitral valve regurgitation, and formation of left ventricular aneurysms carry significant morbidity. Additional complications include ischemic stroke, heart failure, renal failure, and cardiac dysrhythmias. This review provides several guiding principles for management of these complications. Understanding these complications and an approach to the management of various complications is essential to optimizing patient care.

Conclusion : Mechanical, inflammatory, and embolic complications of AMI can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. In addition to understanding the natural progression of disease and performing a focused physical examination, an electrocardiogram and bedside echocardiogram provide quick, noninvasive determinations of the underlying pathophysiology. Management varies by presentation and etiology, but close consultation with cardiology and cardiac surgery is recommended.

Conclusion (proposition de traduction) : Les complications mécaniques, inflammatoires et emboliques de l'IDM peuvent entraîner une morbidité et une mortalité importantes. Les médecins doivent rapidement diagnostiquer ces situations tout en évaluant d’autres hypothèses diagnostiques. Outre la compréhension de la progression naturelle de la maladie et la réalisation d'un examen physique ciblé, un électrocardiogramme et un échocardiogramme au lit du patient permettent une détermination rapide et non invasive de la physiopathologie sous-jacente. La prise en charge varie en fonction de la présentation et de l'étiologie, mais une consultation étroite en cardiologie et en chirurgie cardiaque est recommandée.

The Journal of Emergency Medicine

Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider.
Perim D, Mazer-Amirshahi M, Trvalik A, Pourmand A. | J Emerg Med. 2019 Jun;56(6):611-623
DOI: https://doi.org/10.1016/j.jemermed.2019.03.012
Keywords: VAD; complications; heart failure; ventricular assist devices

Clinical Reviews

Introduction : Heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted ventricular assist devices (VADs).

Méthode : This review provides an evidence-based summary of the current data for the evaluation and management of implanted VAD complications in an emergency department context.

Discussion : With a prevalence of >5.8 million individuals and >550,000 new cases diagnosed each year, heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted VADs. As the prevalence of patients with VADs continues to grow, they will sporadically present to the emergency department, regardless of whether the facility is a designated VAD center. As a result, all emergency physicians must be familiar with the basic principles of VAD function, as well as the diagnosis and initial management of VAD-related complications. In this review, we address these topics, with a focus on contemporary third-generation continuous flow VADs. This review will help supplement the critical care skills of emergency physicians in managing this complex patient population.

Conclusion : The cornerstone of managing the unstable VAD patient is rapid initiation of high-quality supportive care and recognition of device-related complications, as well as the identification and use of specialist VAD teams and other resources for support. Emergency physicians must understand VADs so that they may optimally manage these complex patients.

Conclusion (proposition de traduction) : La pierre angulaire de la prise en charge d'un patient présentant des dispositifs d'assistance ventriculaire instables est l'instauration rapide de soins de soutien de haute qualité et la reconnaissance des complications liées aux dispositifs, ainsi que l'identification et l'utilisation d'équipes spécialisées et d'autres ressources pour le soutien.
Les urgentistes doivent comprendre le dispositif d'assistance ventriculaire afin de pouvoir prendre en charge ces patients complexes de façon optimale.

The Thunderclap Headache: Approach and Management in the Emergency Department.
Long D, Koyfman A, Long B. | J Emerg Med. 2019 Jun;56(6):633-641
DOI: https://doi.org/10.1016/j.jemermed.2019.01.026
Keywords: head CT; headache; lumbar puncture; subarachnoid hemorrhage; thunderclap

Clinical Reviews

Introduction : A thunderclap headache (TCH) is a severe headache reaching at least 7 (out of 10) in intensity within 1 min of onset, and can be the presenting symptom of several conditions with potential for significant morbidity and mortality.

Méthode : This narrative review evaluates the various conditions that may present with TCH and proposes a diagnostic algorithm for patients with TCH.

Discussion : TCH is a symptom associated with several significant diseases. The most common diagnosed condition is subarachnoid hemorrhage (SAH). Other diagnoses include reversible cerebral vasoconstriction syndrome, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, spontaneous intracranial hypotension, and several others. Patients with TCH require history and physical examination, with a focus on the neurologic system, evaluating for these conditions, including SAH. Further testing often includes head computed tomography (CT) without contrast, CT angiography of the head and neck, and lumbar puncture. Evaluation must take into account history, examination, and the presence of any red flags or signs suggestive of a specific etiology. An algorithm is provided for guidance within this review incorporating these modalities. Management focuses on the specific diagnosis. If testing is negative for a serious condition and the patient improves, discharge home may be appropriate with follow-up.

Conclusion : Patients presenting with TCH require diagnostic evaluation. History and examination are vital in assessing for risk factors for various conditions. Focused testing can assist with diagnosis, with management tailored to the specific diagnosis.

Conclusion (proposition de traduction) : Les patients présentant une céphalée en coup de tonnerre nécessitent une évaluation diagnostique. Les antécédents et l'examen clinique sont essentiels pour évaluer les facteurs de risque de diverses étiologies. Des examens ciblés peuvent aider au diagnostic, avec une gestion adaptée au diagnostic spécifique.

Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?.
Gamberini L, Giugni A, Ranieri S, Meconi T, Coniglio C, Gordini G, Bardi T. | J Emerg Med. 2019 Jun;56(6):657-665
DOI: https://doi.org/10.1016/j.jemermed.2019.02.005
Keywords: emergency medical services; prehospital emergency care; risk factors; traumatic brain injury; ventilator-associated pneumonia

Selected Topics: Prehospital Care

Introduction : Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome.

Méthode : OBJECTIVES: In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome.
METHODS: The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management.

Résultats : A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP.

Conclusion : Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.

Conclusion (proposition de traduction) : La prise en charge des voies respiratoires préhospitalières n’a pas d’impact significatif sur la survenue d’une pneumopathie acquise sous ventilation mécanique précoce, chez des patients présentant une lésion cérébrale traumatique grave. De même, il n’a pas d’impact significatif sur la mortalité ou les résultats neurologiques à long terme malgré la durée croissante de la ventilation mécanique, des soins intensifs et des séjours en hôpital.

Emergency Physician-Initiated Resuscitative Extracorporeal Membrane Oxygenation.
Shinar Z, Plantmason L, Reynolds J, Dembitsky W, Bellezzo J, Ho C, Glaser D, Adamson R. | J Emerg Med. 2019 Jun;56(6):666-673
DOI: https://doi.org/10.1016/j.jemermed.2019.02.004
Keywords: ECMO; ECPR; cardiac arrest; resuscitation

Selected Topics: Critical Care

Introduction : ACKGROUND: Extracorporeal membrane oxygenation (ECMO) has several applications as a resuscitative intervention, including extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is rarely initiated in the emergency department (ED) by emergency physicians outside regional academic institutions.
OBJECTIVES: To evaluate whether ECPR improves clinical outcomes after cardiac arrest when initiated by emergency physicians (EPs) in a nonacademic hospital.

Méthode : We performed a retrospective analysis of prospectively identified consecutive EP-initiated ECMO subjects from a single community hospital over a 7-year period. Logistic regression and propensity models tested the association between ECPR and survival to hospital discharge compared with concurrent ECPR-eligible control subjects.

Résultats : Over 7 years (2010-2017), EPs initiated ECMO on 58 subjects; 44 (76%) were venoarterial cases (43 ECPR) initiated in the ED. Of those, 11 (25%) survived to discharge (n = 9 with cerebral performance category score 1) and most were still alive after 5 years (66%). Adjusting for known covariates, ECPR subjects were more likely than concurrent controls to survive to discharge (odds ratio 8.4; 95% confidence interval 1.2-60.4). Propensity analysis revealed a favorable trend toward survival to discharge after ECPR (odds ratio 2.0; 95% confidence interval 0.51-7.8).

Conclusion : Emergency physicians initiated ECMO with promising clinical outcomes. Prospective trials are needed to define the efficacy, safety, and cost-effectiveness of EP-initiated ECMO.

Conclusion (proposition de traduction) : Les urgentistes ont débuté une E-CRP avec des résultats cliniques prometteurs.
Des essais prospectifs sont nécessaires pour définir l'efficacité, l'innocuité et la rentabilité de l'ECMO à l'initiative des médecins urgentistes.

The POCUS Pulse Check: A Case Series on a Novel Method for Determining the Presence of a Pulse Using Point-of-Care Ultrasound.
Simard RD, Unger AG, Betz M, Wu A, Chenkin J. | J Emerg Med. 2019 Jun;56(6):674-679
DOI: https://doi.org/10.1016/j.jemermed.2019.02.013
Keywords: cardiac arrest; pulse check; ultrasonography

Ultrasound in Emergency Medicine

Introduction : During cardiopulmonary resuscitation, pulse checks must be rapid and accurate. Despite the importance placed on the detection of a pulse, several studies have shown that health care providers have poor accuracy for detection of central pulses by palpation. To date, the use of point-of-care ultrasound (POCUS) in cardiac arrest has focused on the presence of cardiac standstill and diagnosing reversible causes of the arrest.

Méthode : This case series highlights a simple, novel approach to determine whether pulses are present or absent by using POCUS compression of the central arteries.

Résultats : Using this technique, we found that a POCUS pulse check can be consistently performed in < 5 s and is clearly determinate, even when palpation yields indeterminate results.

Conclusion : In this case series, the POCUS pulse check was a valuable adjunct that helped to change management for critically ill patients. Future prospective studies are required to determine the accuracy of this technique and the impact on patient outcomes in a larger cohort.

Conclusion (proposition de traduction) : Dans cette série de cas, la vérification du pouls par l'échographie au point d'intervention était un complément précieux qui a permis de modifier la gestion des patients gravement malades.
Des études prospectives futures sont nécessaires pour déterminer la précision de cette technique et son impact sur les résultats pour les patients dans une cohorte plus large.

Examiner Position in Ocular Point-of-Care Ultrasound: A Proposed Technique.
Khattab E, Hoffmann B, Schafer J, Naraghi L, Hardin J, Balk D, Beals T. | J Emerg Med. 2019 Jun;56(6):684-686
DOI: https://doi.org/10.1016/j.jemermed.2019.03.027
Keywords: POCUS techniques; ocular ultrasound; point-of-care ultrasound

Ultrasound in Emergency Medicine

Introduction : Ocular point-of-care ultrasound (POCUS) is a fast and safe non-invasive procedure used to evaluate the structural integrity and pathology of the eye. Ocular POCUS can be used for evaluation of posterior chamber and orbital pathology, including retinal detachment, vitreous detachment or hemorrhage, foreign body, lens dislocation, and increased intracranial pressure.

Discussion : The purpose of this brief communication is to describe a technique for conducting an ocular POCUS that may in some cases be easier and more comfortable by adjusting the position of the sonographer relative to the patient.

Conclusion : o our knowledge, this proposed technique has not been described in previous literature and may result in greater comfort for both sonographer and patient.

Conclusion (proposition de traduction) : À notre connaissance, cette technique proposée n'a pas été décrite dans la littérature précédente et peut améliorer le confort de l'opérateur et du patient.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians.
Long B, Hafen L, Koyfman A, Gottlieb M. | J Emerg Med. 2019 Jun;56(6):687-697
DOI: https://doi.org/10.1016/j.jemermed.2019.03.030
Keywords: REBOA; aortic occlusion; balloon; catheter; complication; hemorrhage; junctional hemorrhage; resuscitative endovascular balloon occlusion of the aorta

Techniques and Procedures

Introduction : Non-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians.

Discussion : Traumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA.

Conclusion : REBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.

Conclusion (proposition de traduction) : REBOA peut fournir un contrôle des hémorragies proximales et peut être mis en oeuvre par des urgentistes. Cet article évalue les preuves, les indications, la procédure et les complications pour les urgentistes.

The Journal of Pediatrics

Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials.
Chan E, Hovenden M, Ramage E, Ling N, Pham JH, Rahim A, Lam C, Liu L, Foster S, Sambell R, Jeyachanthiran K, Crock C, Stock A, Hopper SM, Cohen S, Davidson A, Plummer K, Mills E, Craig SS, Deng G, Leong P. | J Pediatr. 2019 Jun;209:160-167.e4
DOI: https://doi.org/10.1016/j.jpeds.2019.02.034
Keywords: anxiety; cannulation; distraction; pain; venipuncture

Original Articles

Introduction : To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice.

Méthode : In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised.

Résultats : In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy.

Conclusion : In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe.

Conclusion (proposition de traduction) : Chez les enfants âgés de 4 à 11 ans qui nécessitaient la pose d'une voie intraveineuse ou une prise de sang pour analyse, la distraction à base de réalité virtuelle (masque de réalité virtuel low cost avec une image fabriquée) était efficace pour diminuer la douleur et était sécuritaire.

The New England Journal of Medicine

Heatstroke.
Epstein Y, Yanovich R. | N Engl J Med. 2019 Jun 20;380(25):2449-2459
DOI: https://doi.org/10.1056/NEJMra1810762
Keywords: Aucun

Review Article

Editorial : Exertional heatstroke, brought on by strenuous activity, is usually seen in young, active people; classic heatstroke, associated with heat waves, is more common in the elderly and may be epidemic. Cooling and fluids are keys to management; sometimes, intensive care is needed.

Conclusion : Heatstroke is a life-threatening condition if it is not promptly recognized and effectively treated. Certain simple preventive measures, such as avoid- ing strenuous activity in hot environments and reducing exposure to heat stress, as well as changing attitudes in sports and addressing socio- economic issues that augment risk, can reduce the prevalence of both classic and exertional heatstroke. Our understanding of the patho- physiology of heatstroke and mechanism-based treatment approaches is still incomplete. Future research is likely to focus on three areas: identi- fying genetic traits that might reduce a person’s ability to cope with heat stress, searching for new biomarkers that can better predict short- and long-term outcomes of heatstroke, and de- veloping new adjuvant treatments that can effec- tively control the inflammatory reaction and counteract multiorgan complications.

Conclusion (proposition de traduction) : Le coup de chaleur est une maladie potentiellement mortelle s'il n'est pas rapidement reconnu et traité efficacement. Certaines mesures préventives simples, telles que la prévention des activités pénibles dans des environnements chauds et la réduction de l'exposition au stress thermique, ainsi que le changement d'attitude dans le sport et la résolution de problèmes socio-économiques augmentant les risques, peuvent réduire la prévalence des coups de chaleur classiques et à l'effort. Notre compréhension de la physiopathologie des approches de traitement par coup de chaleur et par mécanisme est encore incomplète. Les recherches futures porteront probablement sur trois domaines : identifier les caractéristiques génétiques susceptibles de réduire la capacité d'une personne à faire face au stress thermique, rechercher de nouveaux biomarqueurs permettant de mieux prédire les résultats à court et à long terme du coup de chaleur et développer de nouveaux biomarqueurs. des traitements adjuvants capables de contrôler efficacement la réaction inflammatoire et de lutter contre les complications multiorganes.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Coup de chaleur : une urgence diagnostique et thérapeutique  . Rédigé par le Dr Jean-Pierre Usdin le 26 juin 2019.


Mois de juin 2019