Bibliographie du mois d'août 2019 en Médecine d'urgence

Essai randomisé contre placebo, dans l'utilisation du dropéridol et de l'ondansétron chez des patients adultes présentants des nausées au service des urgences |

Randomized Placebo-controlled Trial of Droperidol and Ondansetron for Adult Emergency Department Patients With Nausea.
Meek R, Mee MJ, Egerton-Warburton D, Graudins A, Meyer A, Pouryahya P, Blecher G, Fahey J, Crow S. | Acad Emerg Med. 2019 Aug;26(8):867-877
DOI: https://doi.org/10.1111/acem.13650
Keywords: Aucun

Original contributions

Introduction : The objective was to separately compare effectiveness of 1.25 mg of intravenous (IV) droperidol and 8 mg of IV ondansetron with 0.9% saline placebo for adult emergency department (ED) patients with nausea. A novel primary outcome measure, expected to aid clinical interpretation of reported results, was employed.

Méthode : A randomized controlled trial was conducted at the three EDs of Monash Health, Melbourne, Australia. The design was to demonstrate superiority of the active drugs over placebo. The primary outcome measure of symptom improvement was defined as a visual analog scale (VAS) rating change of -8 mm or more from baseline at 30 minutes posttreatment. Mean VAS changes per group and percentages experiencing the desired treatment effect were also compared. The study was concluded after recruitment of 215 of the planned 378 patients, as interim analysis confirmed that continuation could not result in a finding of superiority.

Résultats : Of 215 patients, 73 (34%), 71 (33%), and 71 (33%) received droperidol, ondansetron, and placebo. Symptom improvement occurred in 75% (95% confidence interval [CI] = 64% to 85%), 80% (95% CI = 69% to 89%), and 76% (95% CI = 64% to 85%), respectively. Mean VAS changes were -29 mm (95% CI = -36 to -23 mm), -34 mm (95% CI = -41 to -28 mm), and -24 mm (95% CI = -29 to -19 mm), respectively. Desired treatment effects were experienced by 77% (95% CI = 65% to 86%), 73% (95% CI = 61% to 83%), and 59% (95% CI = 47% to 71%), respectively.

Conclusion : For adult ED patients with nausea, superiority was not demonstrated for droperidol or ondansetron over placebo.

Conclusion (proposition de traduction) : Chez les patients adultes atteints de nausée, la supériorité du dropéridol ou de l'ondansétron sur le placebo n'a pas été démontrée.

Commentaire :
Pour rappel :
Indications thérapeutiques du dropéridol : Prévention des nausées et vomissements post-opératoires de l'adulte présentant un risque modéré à sévère de NVPO c'est à dire ayant au moins deux facteurs de risque au score simplifié d'APFEL   , traitement des nausées et vomissements post-opératoires et prévention des nausées et vomissements induits par les morphiniques administrés en analgésie auto-contrôlée, en post-opératoire. Posologie chez l'adulte : 0,625 mg à 1,25 mg (0,25 à 0,5 ml) [http://base-donnees-publique.medicaments.gouv.fr  ].

Indications thérapeutiques de l'ondansétron : Prévention et traitement des nausées et vomissements aigus induits par la chimiothérapie cytotoxique moyennement à hautement émétisante et la radiothérapie hautement émétisante chez l'adulte, prévention des nausées et vomissements aigus induits par la chimiothérapie cytotoxique moyennement à hautement émétisante chez l'enfant à partir de 6 mois. Traitement des nausées et vomissements induits par la chimiothérapie cytotoxique chez l’enfant à partir de 6 mois et traitement des nausées et vomissements post-opératoires chez l’adulte. Posologie chez l'adulte : la dose initiale habituelle est de 8 mg [http://base-donnees-publique.medicaments.gouv.fr  ].

Pour information :
Médicaments antiémétiques dans le traitement symptomatique des nausées et vomissements    - élaboré à partir des données de l’AMM, des études disponibles et de l’ensemble des avis de la transparence. Haute Autorité de Santé (HAS) - Avril 2019 : La prescription de dompéridone, métoclopramide ou métopimazine ne devrait être envisagée que si la prescription d'un antiémétique apparaît indispensable, c’est-à-dire uniquement en cas de vomissements ayant à court terme des complications graves ou très gênantes.

Résultats psychiatriques des patients présentant une agitation sévère après l'administration de kétamine préhospitalière |

Psychiatric Outcomes of Patients With Severe Agitation Following Administration of Prehospital Ketamine.
Lebin JA1, Akhavan AR, Hippe DS, Gittinger MH, Pasic J, McCoy AM, Vrablik MC. | Acad Emerg Med. 2019 Aug;26(8):889-896
DOI: https://doi.org/10.1111/acem.13725
Keywords: Aucun

Original contributions

Introduction : Ketamine is an emerging drug used in the management of undifferentiated, severe agitation in the prehospital setting. However, prior work has indicated that ketamine may exacerbate psychotic symptoms in patients with schizophrenia. The objective of this study was to describe psychiatric outcomes in patients who receive prehospital ketamine for severe agitation.

Méthode : This is a retrospective cohort study, conducted at two tertiary academic medical centers, utilizing chart review of patients requiring prehospital sedation for severe agitation from January 1, 2014, to June 30, 2016. Patients received either intramuscular (IM) versus intravenous (IV) ketamine or IM versus IV benzodiazepine. The primary outcome was psychiatric inpatient admission with secondary outcomes including ED psychiatric evaluation and nonpsychiatric inpatient admission. Generalized estimating equations and Fisher's exact tests were used to compare cohorts.

Résultats : During the study period, 141 patient encounters met inclusion with 59 (42%) receiving prehospital ketamine. There were no statistically significant differences between the ketamine and benzodiazepine cohorts for psychiatric inpatient admission (6.8% vs. 2.4%, difference = 4.3%, 95% CI = -2% to 12%, p = 0.23) or ED psychiatric evaluation (8.6% vs. 15%, difference = -6.8%, 95% CI = -18% to 5%, p = 0.23). Patients with schizophrenia who received ketamine did not require psychiatric inpatient admission (17% vs. 10%, difference = 6.7%, 95% CI = -46% to 79%, p = 0.63) or ED psychiatric evaluation (17% vs. 50%, difference = -33%, 95% CI = -100% to 33%, p = 0.55) significantly more than those who received benzodiazepines, although the subgroup was small (n = 16). While there was no significant difference in the nonpsychiatric admission rate between the ketamine and benzodiazepine cohorts (35% vs. 51%, p = 0.082), nonpsychiatric admissions in the benzodiazepine cohort were largely driven by intubation (63% vs. 3.8%, difference = 59%, 95% CI = 38% to 79%, p < 0.001).

Conclusion : Administration of prehospital ketamine for severe agitation was not associated with an increase in the rate of psychiatric evaluation in the emergency department or psychiatric inpatient admission when compared with benzodiazepine treatment, regardless of the patient's psychiatric history.

Conclusion (proposition de traduction) : L'administration de kétamine préhospitalière pour une agitation grave n'était pas associée à une augmentation du taux d'évaluation psychiatrique au service des urgences ni à l'admission des patients hospitalisés en psychiatrie par rapport au traitement par benzodiazépine, quels que soient les antécédents psychiatriques du patient.

Dépression chez les patients des services d'urgence et association avec l'utilisation des soins de santé |

Depression in Emergency Department Patients and Association With Health Care Utilization.
Beiser DG, Ward CE, Vu M, Laiteerapong N, Gibbons RD. | Acad Emerg Med. 2019 Aug;26(8):878-888
DOI: https://doi.org/10.1111/acem.13726
Keywords: Aucun

Original contribution

Introduction : Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations.

Méthode : This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes.

Résultats : Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates.

Conclusion : Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.

Conclusion (proposition de traduction) : Les taux de dépression étaient élevés dans un échantillon de patients adultes anglophones au service des urgences qui présentaient des troubles non psychiatriques et qui étaient associés indépendamment à un risque accru d'utilisation subséquente des services d'urgence et d'une hospitalisation. Des outils d'évaluation normalisés qui permettent une classification rapide et précise de la gravité des troubles dépressifs majeurs (MDD) peuvent jouer un rôle important dans l'identification des patients aux urgences nécessitant un avis psychiatrique urgent.

Commentaire : En France, la HAS a publié une conférence de consensus en octobre 2000 (mise à jour en juillet 2006) : La crise suicidaire : reconnaître et prendre en charge.
Pour apprécier la dangerosité et l'urgence de la situation, la Conférence de la HAS juge souhaitable d'explorer six éléments : (...)
1. Le niveau de souffrance : désarroi ou désespoir, repli sur soi, isolement relationnel, sentiment de dévalorisation ou d’impuissance, sentiment de culpabilité.
2. Le degré d’intentionnalité : idées envahissantes, rumination, recherche ou non d’aide, attitude par rapport à des propositions de soins, dispositions envisagées ou prises en vue d’un passage à l’acte (plan, scénario).
3. Les éléments d’impulsivité : tension psychique, instabilité comportementale, prise d'alcool ou de drogues, agitation motrice, état de panique, antécédents de passage à l’acte, de fugue ou d’actes violents.
4. Un éventuel élément précipitant : conflit, échec, rupture, perte…
5. La présence de moyens létaux à disposition : armes, médicaments…
6. La qualité du soutien de l’entourage proche : capacité de soutien ou inversement, renforcement du risque dans le cas de familles « à transaction suicidaire ou mortifère (...) ».
L’évaluation du risque suicidaire associera les constatations cliniques et l’utilisation de l’échelle de désespoir de Beck  . À l'issue de cette évaluation, un avis spécialisé ou une hospitalisation brève est recommandé en principe de référence.
Cotation des items de l'échelle de désespoir de Beck (le score total peut varier de 0 à 20) :
- un point aux items 2, 4, 7, 9, 11, 12, 14, 16, 17, 18, 20 s'ils sont cotés vrai ;
- et un point aux items 1, 3, 5, 8, 10, 13, 15, 19 s'ils sont cotés faux.

Revue systématique et méta-analyse sur l'utilisation de la kétamine comme une alternative aux opioïdes pour le traitement de la douleur aiguë au service des urgences |

A Systematic Review And Meta-analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department.
Heitz C, Morgenstern J, Bond C, Milne WK. | Acad Emerg Med. 2019 Aug;26(8):946-948
DOI: https://doi.org/10.1111/acem.13658
Keywords: Aucun

HOT OFF THE PRESS

Editorial : Ketamine has been studied as an alternative to opioids for acute pain in the emergency department setting. This review compares the effectives of intravenous ketamine at a dose of <0.5mg/kg to opioids for acute pain in adult patients. Measurements were taken within 60 minutes of administration. Ketamine was found to have similar effectiveness to opioids. Increased, but short-lived, side effects were seen with ketamine.

Conclusion : Ketamine is a reasonable alternative to opioids for acute pain in the ED. Dosing of <0.5 mg/kg appears to be similarly effective to 0.1 mg/kg morphine equiva- lents. Increased, short-lived side effects have been reported. Longer-term effectives, or analgesic options at discharge, were not assessed.

Conclusion (proposition de traduction) : La kétamine est une alternative raisonnable aux opioïdes pour la douleur aiguë aux urgences. Une dose < 0,5 mg/kg semble avoir une efficacité similaire à 0,1 mg/kg équivalent morphine.
Des effets secondaires accrus et de courte durée ont été rapportés. Les effets à long terme ou les options analgésiques à la sortie n'ont pas été évalués.

L'aspirine dans la prévention primaire de crise cardiaque ou de l'accident vasculaire cérébral |

Aspirin for Preventing a First Heart Attack or Stroke.
Roach K, Ritchie M, Zehtabchi S. | Acad Emerg Med. 2019 Aug;26(8):949-952.
DOI: https://doi.org/10.1111/acem.13808
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Cardiovascular disease (CVD) is a major cause of death worldwide. Aspirin inhibits platelet aggregation, which reduces clot formation. Thus, aspirin can help prevent cardiovascular problems caused by blood clots, but it can also increase risk of bleeding. For persons with known CVD, the beneficial effect of aspirin use for preventing cardiovascular events outweighs the harmful side effects (e.g., bleeding). The efficacy of aspirin in preventing cardiovascular events in patients without previously known CVD (primary prevention) has been unclear. This evidence-based summary examines the benefits and harms of aspirin in patients without known CVD. For this purpose, we summarize the 2015 U.S. Preventive Services Task Force report and two recent systematic reviews of aspirin for primary prevention. The USPSTF report, published in 2016, was the definitive systematic review until three trials were published after its release. The ARRIVE ASCEND and ASPREE clinical trials together included over 47,000 new subjects. Two updated systematic reviews by Mahmoud et al. and Zheng et al. were published in 2019, and both include all the most recent trials. The summary table above of benefits and harms are derived from the two most recent meta-analyses by Mahmoud et al. and Zheng et al. because the USPTF report does not include the most recent trials. For the most part, the reported number-needed-to-treat (NNT) values and number-needed-to-harm (NNH) values were similar between the two reviews. When the NNT and NNH values were different, to be conservative, we reported the higher NNT value and the lower NNH value.

Conclusion : We chose a red color recommendation (no benefit) because of consistent findings of harm outweighing benefit. We considered black (harmful) but recognize that there may be subgroups studies that will identify patients who can benefit.

Conclusion (proposition de traduction) : Nous avons choisi une recommandation de couleur rouge (aucun avantage) en raison du constat de préjudices supérieurs aux avantages (ndlr : balance bénéfices/risques en défaveur de l'utilisation de l'aspirine dans la prévention primaire de l'infarctus et de l'AVC).
Nous avons considéré les Noirs (nocifs) mais reconnaissons qu’il peut exister des études en sous-groupes permettant d’identifier les patients pouvant en bénéficier.

Effet du processus de soins HEART sur la gestion de la douleur thoracique dans un système de santé intégré |

Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System.
Sharp AL, Baecker AS, Shen E, Redberg R, Lee MS, Ferencik M, Natsui S, Zheng C, Kawatkar A, Gould MK, Sun BC. | Ann Emerg Med. 2019 Aug;74(2):171-180
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.007
Keywords: Aucun

Cardiology

Introduction : We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs).

Méthode : We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable.

Résultats : A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08).

Conclusion : Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.

Conclusion (proposition de traduction) : La mise en œuvre du processus HEART dans l'évaluation des patients souffrant de douleurs thoracique au service des urgences a entraîné moins de soins hospitaliers et de bilans cardiaques non invasifs et était sans danger.
L'utilisation de HEART pour stratifier le risque des patients souffrant de douleurs thoraciques peut améliorer l'efficacité et la qualité des soins.

Stratification du risque avec le score HEART chez les patients présentant une douleur thoracique à faible risque au service des urgences : revue systématique et méta-analyse |

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.
Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H. | Ann Emerg Med. 2019 Aug;74(2):187-203
DOI: https://doi.org/10.1016/j.annemergmed.2018.12.010
Keywords: Aucun

Cardiology

Introduction : The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals.

Méthode : We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.

Résultats : There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).

Conclusion : In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

Conclusion (proposition de traduction) : Dans cette méta-analyse, malgré son utilisation dans différentes populations de patients, un type de troponine utilisé différent et une chronologie du suivi également différente, le score HEART à faible risque présentait une sensibilité élevée, une valeur prédictive négative et un rapport de vraisemblance négatif pour prédire les événements cardiaques indésirables majeurs à court terme, malgré un risque élevé de biais et d'hétérogénéité statistique.

Commentaire : HEART Score for Major Cardiac Event

Lidocaïne intraveineuse versus hydromorphone, essai randomisé dans la douleur abdominale aiguë au service des urgences |

Randomized Trial of Intravenous Lidocaine Versus Hydromorphone for Acute Abdominal Pain in the Emergency Department.
Chinn E, Friedman BW, Naeem F, Irizarry E, Afrifa F, Zias E, Jones MP, Pearlman S, Chertoff A, Wollowitz A, Gallagher EJ. | Ann Emerg Med. 2019 Aug;74(2):233-240
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.021
Keywords: Aucun

Pain Management and Sedation

Introduction : We compare the efficacy and safety of intravenous lidocaine with that of hydromorphone for the treatment of acute abdominal pain in the emergency department (ED).

Méthode : This was a randomized, double-blind, clinical trial conducted in 2 EDs in the Bronx, NY. Adults weighing 60 to 120 kg were randomized to receive 120 mg of intravenous lidocaine or 1 mg of intravenous hydromorphone. Thirty minutes after administration of the first dose of the study drug, participants were asked whether they needed a second dose of the investigational medication to which they were randomized. Patients were also stratified according to clinical suspicion of nephrolithiasis. The primary outcome was improvement in pain scores of 0 to 10 between baseline and 90 minutes. An important secondary outcome was need for "off-protocol" parenteral analgesics, including opioids and nonsteroidal anti-inflammatory drugs.

Résultats : We enrolled 154 patients, of whom 77 received lidocaine and 77 received hydromorphone. By 90 minutes, patients randomized to lidocaine improved by a mean of 3.8 points on the 0-to-10 scale, whereas those randomized to hydromorphone improved by a mean of 5.0 points (mean difference 1.2; 95% confidence interval 0.3 to 2.2). Need for off-protocol "rescue" analgesics occurred for 39 of 77 lidocaine patients (51%) and 20 of 77 hydromorphone patients (26%) (difference 25%; 95% confidence interval 10% to 40%). Adverse events were comparable between groups. Among the subset of 22 patients with nephrolithiasis, lidocaine patients reported a mean improvement of 3.4 points on the pain scale, whereas hydromorphone patients reported a mean improvement of 6.4 points (mean difference 3.0; 95% confidence interval 0.5 to 5.5).

Conclusion : Intravenous hydromorphone was superior to intravenous lidocaine both for general abdominal pain and a subset of patients with nephrolithiasis. A majority of patients randomly allocated to lidocaine required additional analgesics.

Conclusion (proposition de traduction) : L’hydromorphone par voie intraveineuse était supérieure à la lidocaïne par voie intraveineuse pour la douleur abdominale générale et pour un sous-groupe de patients présentant une colique néphrétiquese. Une majorité de patients alloués au hasard à la lidocaïne ont nécessité des antalgiques supplémentaires.

Analgésie préhospitalière par la kétamine intranasale (PAIN-K) : un essai randomisé en double aveugle chez l'adulte | Accès libre

Prehospital Analgesia With Intranasal Ketamine (PAIN-K): A Randomized Double-Blind Trial in Adults.
Andolfatto G, Innes K, Dick W, Jenneson S, Willman E, Stenstrom R, Zed PJ, Benoit G. | Ann Emerg Med. 2019 Aug;74(2):241-250
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.048 | Télécharger l'article au format
Keywords: Aucun

Pain Management and Sedation

Introduction : We compare intranasal ketamine with intranasal placebo in providing pain reduction at 30 minutes when added to usual paramedic care with nitrous oxide.

Méthode : This was a randomized double-blind study of out-of-hospital patients with acute pain who reported a verbal numeric rating scale (VNRS) pain score greater than or equal to 5. Exclusion criteria were younger than 18 years, known ketamine intolerance, nontraumatic chest pain, altered mental status, pregnancy, and nasal occlusion. Patients received usual paramedic care and were randomized to receive either intranasal ketamine or intranasal saline solution at 0.75 mg/kg. The primary outcome was the proportion of patients with VNRS score reduction greater than or equal to 2 at 30 minutes. Secondary outcomes were pain reduction at 15 minutes, patient-reported comfort, satisfaction scores, nitrous oxide consumption, and incidence of adverse events.

Résultats : One hundred twenty subjects were enrolled. Seventy-six percent of intranasal ketamine patients versus 41% of placebo patients reported a greater than or equal to 2-point VNRS reduction at 30 minutes (difference 35%; 95% confidence interval 17% to 51%). Median VNRS reduction at 15 minutes was 2.0 and 1.0 and at 30 minutes was 3.0 and 1.0 for ketamine and placebo, respectively. Improved comfort at 15 and 30 minutes was reported for 75% versus 57% and 61% versus 46% of ketamine and placebo patients, respectively. Sixty-two percent of patients (95% confidence interval 49% to 73%) versus 20% (95% confidence interval 12% to 32%) reported adverse events with ketamine and placebo, respectively. Adverse events were minor, with no patients requiring physical or medical intervention.

Conclusion : Added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events.

Conclusion (proposition de traduction) : Avec du protoxyde d'azote, la kétamine intranasale procure une réduction de la douleur cliniquement significative et un confort amélioré par rapport au placebo intranasal, avec des effets indésirables moins importants.

Le score de Mallampati est-il utile pour la gestion des voies aériennes au service des urgences oou la sédation procédurale ? | Accès libre

Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?.
Green SM, Roback MG. | Ann Emerg Med. 2019 Aug;74(2):251-259
DOI: https://doi.org/10.1016/j.annemergmed.2018.12.021 | Télécharger l'article au format
Keywords: Aucun

Pain Management and Sedation

Editorial : We review the literature in regard to the accuracy, reliability, and feasibility of the Mallampati score as might be pertinent and applicable to emergency department (ED) airway management and procedural sedation. This 4-level pictorial tool was devised to predict difficult preoperative laryngoscopy and intubation, but is now also widely recommended as a routine screening element before procedural sedation. The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction of a difficult airway. The Mallampati score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. The Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation.

Conclusion : The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction. The score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. We conclude that the Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation.

Conclusion (proposition de traduction) : Les données de la littérature montrent que le score de Mallampati n'est pas suffisamment sensible pour permettre l'identification d'une laryngoscopie difficile, d'une intubation difficile et d'une ventilation difficile du masque au BAVU, les ratios de probabilité indiquant un effet faible et cliniquement non significatif sur la prévision des résultats. Bien qu'il soit important de prévoir que les patients peuvent avoir des voies respiratoires difficiles, il n'y a aucune preuve spécifique que le score de Mallampati augmente ou améliore le jugement clinique de base d'une évaluation des voies aériennes standard. Il génère de nombreuses fausses alertes positives pour chaque prédiction correcte. Le score n'est pas évalué de manière fiable car des observateurs indépendants le notent généralement différemment. Il ne peut pas être évalué chez de nombreux jeunes enfants et chez les patients qui ne peuvent pas coopérer en raison de leur état de santé sous-jacent.
Nous concluons que le score de Mallampati manque de précision, de fiabilité et de faisabilité nécessaires pour compléter une évaluation des voies aériennes standard avant la prise en charge des voies aériennes ou la sédation procédurale.

Commentaire : Le Mallampati est un item du score MACOCHA pour classer la difficulté prévisible de l’intubation :
M : Mallampati ≥ 3 = 5 points
A : Apnée obstructive du sommeil = 2 points
C : mobilité Cervicale limitée = 1 point
O : Ouverture de bouche < 3 cm = 1 point
C : Coma avec GCS ≥ 8 = 1 point
H : Hypoxémie sévère avec SpO2 < 80% en péri-intubation = 1 point
A : intubation par des non-Anesthésistes = 1 point

Score = 0 : Intubation facile prévisible.
Score = 12 : Intubation difficile prévisible.
La présence d’un score de MACOCHA supérieur ou égal à 3 devrait faire changer la stratégie d’abord des voies aériennes.

Bénéfice clinique d'une hospitalisation pour les adultes très âgés se présentant pour syncope inexpliquée : par la méthode d’appariement par les scores de propension | Accès libre

Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis.
Probst MA, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Hollander JE, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. | Ann Emerg Med. 2019 Aug;74(2):260-269
DOI: https://doi.org/10.1016/j.annemergmed.2019.03.031 | Télécharger l'article au format
Keywords: Aucun

Geriatrics

Introduction : Many adults with syncope are hospitalized solely for observation and testing. We seek to determine whether hospitalization versus outpatient management for older adults with unexplained syncope is associated with a reduction in postdisposition serious adverse events at 30 days.

Méthode : We performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope or near syncope who presented to 11 emergency departments (EDs) in the United States. We enrolled adults (≥60 years) who presented with syncope or near syncope. We excluded patients with a serious diagnosis identified in the ED. Clinical and laboratory data were collected on all patients. The primary outcome was rate of post-ED serious adverse events at 30 days.

Résultats : We enrolled 2,492 older adults with syncope and no serious ED diagnosis from April 2013 to September 2016. Mean age was 73 years (SD 8.9 years), and 51% were women. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients, representing an unadjusted difference of 4.2% (95% confidence interval 2.38% to 6.02%). After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group (4.89%) and the discharged group (2.82%) (risk difference 2.07%; 95% confidence interval -0.24% to 4.38%).

Conclusion : In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.

Conclusion (proposition de traduction) : Dans notre échantillon d'adultes très âgés, analysé selon la méthode d’appariement par les scores de propension, présentant une syncope inexpliquée, pour ceux présentant des caractéristiques cliniques similaires à celles de la cohorte de patients sortis des urgences, l'hospitalisation n'était pas associée à une amélioration des taux d'effets indésirables graves à 30 jours.

Caractéristiques préhospitalières des patients présentant un sepsis : comparaison entre les patients avec ou sans évolution défavorable | Accès libre

Prehospital characteristics among patients with sepsis: a comparison between patients with or without adverse outcome.
Olander A, Andersson H, Sundler AJ, Bremer A, Ljungström L, Hagiwara MA. | BMC Emerg Med. 2019 December;19:43
DOI: https://doi.org/10.1186/s12873-019-0255-0 | Télécharger l'article au format
Keywords: Emergency medical services, Characteristics, Prehospital, Sepsis, Symptoms, Vital signs

Research article

Introduction : The prehospital care of patients with sepsis are commonly performed by the emergency medical services. These patients may be critically ill and have high in-hospital mortality rates. Unfortunately, few patients with sepsis are identified by the emergency medical services, which can lead to delayed treatment and a worse prognosis. Therefore, early identification of patients with sepsis is important, and more information about the prehospital characteristics that can be used to identify these patients is needed. Based on this lack of information, the objectives of this study were to investigate the prehospital characteristics that are identified while patients with sepsis are being transported to the hospital by the emergency medical services, and to compare these values to those of the patients with and without adverse outcomes during their hospital stays.

Méthode : This was a retrospective observational study. The patients’ electronic health records were reviewed and selected consecutively based on the following: retrospectively diagnosed with sepsis and transported to an emergency department by the emergency medical services. Data were collected on demographics, prehospital characteristics and adverse outcomes, defined as the in-hospital mortality or treatment in the intensive care unit, and analysed by independent sample t-test and chi-square. Sensitivity, specificity and likelihood ratio, of prehospital characteristics for predicting or development of adverse outcome were analysed.

Résultats : In total, 327 patients were included. Of these, 50 patients had adverse outcomes. When comparing patients with or without an adverse outcome, decreased oxygen saturation and body temperature, increased serum glucose level and altered mental status during prehospital care were found to be associated with an adverse outcome.

Conclusion : The findings suggests that patients having a decreased oxygen saturation and body temperature, increased serum glucose level and altered mental status during prehospital care are at risk of a poorer patient prognosis and adverse outcome. Recognizing these prehospital characteristics may help to identify patients with sepsis early and improve their long-term outcomes. However further research is required to predict limit values of saturation and serum glucose and to validate the use of prehospital characteristics for adverse outcome in patients with sepsis.

Conclusion (proposition de traduction) : Les résultats suggèrent que les patients ayant une saturation en oxygène et une température corporelles basses, une glycémie élevée et un état mental altéré au cours de la prise en charge préhospitalière courent le risque d'un pronostic et d'un pronostic défavorables pour le patient.
Reconnaître ces caractéristiques préhospitalières pouraait aider à identifier les patients atteints de septicémie à un stade précoce et à améliorer leur évolution à long terme. Cependant, des recherches supplémentaires sont nécessaires pour prédire les valeurs limites de saturation et de glycémie pour valider l'utilisation de caractéristiques préhospitalières pour des résultats défavorables chez les patients présentant un sepsis.

Utilisation de l'échographie pour l'évaluation de la déshydratation chez les patients pédiatriques présentant une déshydratation légère à modérée | Accès libre

Use of ultrasound for the assessment of dehydration in pediatric patients with mild to moderate dehydration.
Ravanshad Y, Azarfar A, Alamdaran SA, Naseri M, Sarvari G, Bagheri S, Sani AV. | Emerg Care J. 2019 Aug;15(2):8151
DOI: https://doi.org/10.4081/ecj.2019.8151 | Télécharger l'article au format
Keywords: Aorta; Dehydration; Gastroenteritis; Inferior vena cava; Pediatric; Ultrasonography

Original Articles

Introduction : Management of children with acute gastroenteritis is based upon dehydration estimation. There is no clinical or paraclinical tool which exactly estimates the dehydration degree. Recently ultrasonographic parameters as inferior vena cava (IVC) diameter and aorta (AO) have been used in some studies for this purpose. This study aims to evaluate the efficacy of ultrasound in detecting mild and moderate degrees of dehydration in children.

Méthode : The study was performed in the emergency department of Dr. Sheikh’s Children Hospital, Mashhad, Iran. Children with mild to moderate degrees of dehydration according to World health Organization (WHO) clinical scale were enrolled. Their inferior vena cava diameters, aorta and IVC/AO ratio were measured before and after fluid therapy using ultrasound. Ultrasound was performed by two pediatric sonographers.

Résultats : 36 patients (mean age of 16.94±11.02 months) entered the study. 11 patients had mild and 25 moderate dehydration according to WHO clinical scale. All 11 patients with mild dehydration received oral rehydration. 13 patients in the moderate dehydration group received intravenous rehydration because of oral intolerance to fluids and recurrent vomiting. IVC diameter and IVC/AO ratio after fluid therapy in children with both mild and moderate dehydration degrees was significantly greater (P<0.001). However, we did not observe any significant difference in aorta diameter before and after fluid therapy. Using Receiver Operating Characteristic (ROC) curve, the proper cut-off point of IVC/AO ratio to differentiate patients with moderate dehydration from mild dehydration is equal to 0.782 with sensitivity and specificity equal to 88% and 45.45% respectively. Further, the area under the ROC curve for this cut-off is equal to 0.569.

Conclusion : In conclusion, ultrasonography cannot differentiate between mild and moderate dehydration degrees, but studies with larger population of patients should be performed.

Conclusion (proposition de traduction) : En conclusion, l'échographie ne peut pas différencier les degrés de déshydratation légère des degrés de déshydratation modérée, mais des études doivent être menées auprès d'une population plus nombreuse de patients.

Homme contre machine : comparaison de l'estimation à l'œil nu et quantifiée, du temps de recoloration cutanée |

Man versus machine: comparison of naked-eye estimation and quantified capillary refill.
Toll John R, Henricson J, Anderson CD, Björk Wilhelms D. | Emerg Med J. 2019 Aug;36(8):465-471
DOI: https://doi.org/10.1136/emermed-2018-207948
Keywords: acute care; clinical assessment; emergency department management; resuscitation; trauma

ORIGINAL ARTICLES

Introduction : Capillary refill (CR) time is traditionally assessed by 'naked-eye' inspection of the return to original colour of a tissue after blanching pressure. Few studies have addressed intra-observer reliability or used objective quantification techniques to assess time to original colour. This study compares naked-eye assessment with quantified CR (qCR) time using polarisation spectroscopy and examines intra-observer and interobserver agreements in using the naked eye.

Méthode : A film of 18 CR tests (shown in a random fixed order) performed in healthy adults was assessed by a convenience sample of 14 doctors, 15 nurses and 19 secretaries (Department of Emergency Medicine, Linköping University, September to November 2017), who were asked to estimate the time to return to colour and characterise it as 'fast', 'normal' or 'slow'. The qCR times and corresponding naked-eye time assessments were compared using the Kruskal-Wallis test. Three videos were shown twice without observers' knowledge to measure intra-observer repeatability. Intra-observer categorical assessments were compared using Cohen's Kappa analysis. Interobserver repeatability was measured and depicted with multiple-observer Bland-Altman plotting. Differences in naked-eye estimation between professions were analysed using ANOVA.

Résultats : Naked-eye assessed CR time and qCR time differ substantially, and agreement for the categorical assessments (naked-eye assessment vs qCR classification) was poor (Cohen's kappa 0.27). Bland-Altman intra-observer repeatability ranged from 6% to 60%. Interobserver agreement was low as shown by the Bland-Altman plotting with a 95% limit of agreement with the mean of ±1.98 s for doctors, ±1.6 s for nurses and ±1.75 s for secretaries. The difference in CR time estimation (in seconds) between professions was not significant.

Conclusion : Our study suggests that naked-eye-assessed CR time shows poor reproducibility, even by the same observers, and differs from an objective measure of CR time.

Conclusion (proposition de traduction) : Notre étude suggère que le temps de recoloration cutanée (TRC) évalué à l'œil nu montre une faible reproductibilité, même par les mêmes observateurs, et diffère d'une mesure objective du temps de recoloration cutanée.

Commentaire : Le temps de recoloration cutanée (TRC) est largement utilisé pour évaluer la perfusion périphérique. La mesure du TRC se fait en décubitus dorsal, sur l’index (ou le majeur ou l’annulaire), le membre supérieur au niveau du cœur. Une pression modérée est appliquée par le pouce et l’index de l’observateur durant cinq secondes avant de mesurer le temps nécessaire à la pulpe pour retrouver sa couleur initiale, trois mesures devant être moyennées.
Pendant très longtemps, on a utilisé le TRC en considérant des valeurs pathologiques au-delà de deux secondes. Ce seuil a, tardivement, été validé, mais uniquement chez l’enfant et l’adulte jeune de sexe masculin. Chez la femme et les individus des deux sexes de plus de 65 ans, la limite du TRC normal est, respectivement, de trois et quatre secondes.
Pour mémoire, le TRC normal est :
• ≤ à 2 sec chez l'homme et l'enfant ;
• ≤ à 3 sec chez la femme ;
• ≤ à 4 sec chez les individus des deux sexes de plus de 65 ans ;
Diverses conditions externes comme la température ou la lumière ambiantes rendent l'interprétation de ce test difficile. Même dans des circonstances contrôlées, la fiabilité inter-observateur des mesures est discutée. C'est ainsi que des appareils de mesure numérique sont apparus pour suivre ce paramètre de façon quantitative et reproductible :
• Digital Capillary Refill Time, DiCaRT   .

Références :
• Yasufumi O, Morimura N, Shirasawa A and al. Quantitative capillary refill time predicts sepsis in patients with suspected infection in the emergency department: an observational study. J Intensive Care. 2019 May 6;7:29   ;
• Shinozaki K, Jacobson LS, Saeki K and al. Does training level affect the accuracy of visual assessment of capillary refill time?. Crit Care. 2019 May 6;23(1):157   ;
• Lakhala K, Ehrmannb S, Boulain T. Couleur et température de la peau dans l’insuffisance circulatoire aiguë. Réanim 2009;18:261—266   .

Méta-analyse sur la justesse des règles d'arrêt des efforts de réanimation en cas d'arrêt cardiaque extra-hospitalier |

Meta-analysis of the accuracy of termination of resuscitation rules for out-of-hospital cardiac arrest.
Ebell MH, Vellinga A, Masterson S, Yun P. | Emerg Med J. 2019 Aug;36(8):479-484
DOI: https://doi.org/10.1136/emermed-2018-207833
Keywords: cardiac arrest; emergency ambulance systems; resuscitation

ORIGINAL ARTICLES

Introduction : Our objective was to perform a systematic review of studies reporting the accuracy of termination of resuscitation rules (TORRs) for out-of-hospital cardiac arrest (OHCA).

Méthode : We performed a comprehensive search of the literature for studies evaluating the accuracy of TORRs, with two investigators abstracting relevant data from each study regarding study design, study quality and the accuracy of the TORRs. Bivariate meta-analysis was performed using the mada procedure in R.

Résultats : We identified 14 studies reporting the performance of 9 separate TORRs. The sensitivity (proportion of eventual survivors for whom the TORR recommends resuscitation and transport) was generally high: 95% for the European Resuscitation Council (ERC) TORR, 97% for the basic life support (BLS) TORR and 99% for the advanced life support (ALS) TORR. The BLS and ERC TORR were more specific, which would lead to fewer futile transports, and all three of these TORRs had a miss rate of ≤0.13% (defined as a case where a patient is recommended for termination but survives). The pooled proportion of patients for whom each rule recommends TOR was much higher for the ERC and BLS TORRs (93.5% and 74.8%, respectively) than for the ALS TORR (29.0%).

Conclusion : The BLS and ERC TORRs identify a large proportion of patients who are candidates for termination of resuscitation following OHCA while having a very low rate of misclassifying eventual survivors (<0.1%). Further prospective validation of the ERC TORR and direct comparison with BLS TORR are needed.

Conclusion (proposition de traduction) : Les règles de base de la pratique des gestes élémentaires de survie (GES) et des règles d'arrêt des efforts de réanimation de l'ERC identifient une grande proportion de patients candidats à un arrêt des efforts de réanimation lors d'un arrêt cardiaque extra-hospitalier, tout en ayant un très faible de survivants éventuels mal classifiés (< 0,1 %).
Une validation prospective supplémentaire de la règle d'arrêt des efforts de réanimation de l'ERC et d'une comparaison directe avec les règles d'arrêt des efforts de réanimation de la pratique des gestes élémentaires (GES) sont nécessaires.

Commentaire : Références sur le sujet :
• Morrison LJ. Prehospital termination of resuscitation rule. Curr Opin Crit Care. 2019 Jun;25(3):199-203   ;
• Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 3: Ethical Issues   ;
• Part 3: Ethical Issues 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S383–S396  .

En préhospitalier, les règles d'arrêt des efforts de réanimation proposées en 2015 sont :
• un rythme initial non choquable ;
• pas de témoin présent au moment de l'arrêt cardiaque ;
• un âge ≥ 73 ans.
Mancini ME, Diekema DS, Hoadley TA, Kadlec KD, Leveille MH, McGowan JE, et al. Part 3: Ethical Issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S383–S396  .

Paracétamol versus autre analgésie chez les patients adultes présentant des lésions musculo-squelettiques mineures : une revue systématique |

Paracetamol versus other analgesia in adult patients with minor musculoskeletal injuries: a systematic review.
Ridderikhof ML, Saanen J, Goddijn H, Van Dieren S, Van Etten-Jamaludin F, Lirk P, Goslings JC, Hollmann MW. | Emerg Med J. 2019 Aug;36(8):493-500
DOI: https://doi.org/10.1136/emermed-2019-208439
Keywords: analgesia/pain control; emergency department; musculo-skeletal, soft tissue injury

SYSTEMATIC REVIEW

Introduction : Pain treatment in acute musculoskeletal injuries usually consists of paracetamol, non-steroidal antiinflammatory drugs (NSAIDs) or opioids. It would be beneficial to determine whether paracetamol is as effective as other analgesics. The objective of this study was to evaluate available evidence regarding efficacy of paracetamol in these patients.

Méthode : Embase, MEDLINE, Cochrane and relevant trial registers were searched from inception to 14 February 2018 by two independent reviewers to detect all randomised studies with adult patients with acute minor musculoskeletal injuries treated with paracetamol as compared with other analgesics. There were no language or date restrictions. Two independent reviewers evaluated risk of bias and quality of evidence. Primary outcome was decrease in pain scores during the first 24 hours, and secondary outcomes included pain decrease beyond 24 hours, need for additional analgesia and occurrence of adverse events.

Résultats : Seven trials were included, evaluating 2100 patients who were treated with paracetamol or NSAIDs or the combination of both as comparisons, of which only four studies addressed the primary outcome. No studies were found comparing paracetamol with opioids. There were no differences in analgesic effectiveness within and beyond 24 hours, nor in need for additional analgesia and occurrence of adverse events. Overall, quality of evidence was low. Because of methodological inconsistencies, a meta-analysis was not possible.

Conclusion : Based on available evidence, paracetamol is as effective as NSAIDs or the combination of both in treating pain in adult patients with minor musculoskeletal injuries in the acute setting. The quality of evidence is low.

Conclusion (proposition de traduction) : Sur la base des preuves disponibles, le paracétamol est aussi efficace que les AINS ou la combinaison des deux pour le traitement de la douleur chez les patients adultes souffrant de lésions musculo-squelettiques mineures dans un contexte aigu. La qualité des preuves est faible.

BET 1 : vert ou bleu pour vous ? Mélange de méthoxyflurane (Penthrox) ou de protoxyde d'azote/oxygène à 50 % (Entonox) pour le traitement de la douleur aiguë au service des urgences |

BET 1: Green or blue for you? Methoxyflurane (Penthrox) or nitrous oxide/oxygen 50% mixture (Entonox) for the management of acute pain in the ED.
Rahman SM, Quinn E. | Emerg Med J. 2019 Aug;36(8):506-508
DOI: https://doi.org/10.1136/emermed-2019-208777.1
Keywords: emergency care systems

BEST EVIDENCE TOPIC REPORTS

Editorial : A short-cut review of the literature was carried out to establish whether inhaled methoxyflurane (Penthrox) is comparable or superior with a standard inhalational analgesia for the management of acute pain. Only two papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that both methods of inhaled analgesia appear to be useful options for acute pain in the ED when compared with placebo. No evidence was found to suggest superiority of methoxypenflurane. International studies directly comparing the use of both drugs for in acute trauma are ongoing and will develop the evidence base.

Conclusion : -

Spectre des erreurs de diagnostic dans l'imagerie des traumatismes de la colonne cervicale et leur signification clinique |

Spectrum of diagnostic errors in cervical spine trauma imaging and their clinical significance.
Alessandrino F, Bono CM, Potter CA, Harris MB, Sodickson AD, Khurana B. | Emerg Radiol. 2019 Aug;26(4):409-416
DOI: https://doi.org/10.1007/s10140-019-01685-0
Keywords: Cervical vertebrae; Computed tomography; Diagnostic errors; Spinal fractures; Spinal injuries

Original Article

Introduction : To describe and categorize diagnostic errors in cervical spine CT (CsCT) interpretation performed for trauma and to assess their clinical significance.

Méthode : All CsCTs performed for trauma with diagnostic errors that came to our attention based on clinical or imaging follow-up or quality assurance peer review from 2004 to 2017 were included. The number of CsCTs performed at our institution during the same time interval was calculated. Errors were categorized as spinal/extraspinal, involving osseous/soft tissue structures, by anatomical site and level. Images were reviewed by a radiologist and two spine surgeons. For each error, the need for surgery, immobilization, CT angiogram of the neck, and MRI was assessed; if any of these were needed, the error was considered clinically significant.

Résultats : Of an approximate total 59,000 CsCTs, 56 reports containing diagnostic errors were included. Twelve were extraspinal, and 44 were spinal (26 fractures, 15 intervertebral disc protrusions, two subluxations, one lytic bone lesion). The most common sites of spinal fractures were vertebral body (n = 10) and transverse process (n = 8); the most common levels were C5 (n = 8) and C7 (n = 6). All (n = 26) fractures and two atlantooccipital subluxations were considered clinically significant, including three patients who would have required urgent surgical stabilization (two subluxations and one facet fracture). Two transverse processes fractures did not alter the need for surgical intervention/surgical approach, immobilization, or MRI.

Conclusion : In our study, 66% of spinal diagnostic errors on CsCT were considered clinically significant, potentially altering clinical management. Transverse process and vertebral body fractures were commonly missed.

Conclusion (proposition de traduction) : Dans notre étude, 66 % des erreurs de diagnostic de la colonne vertébrale sur le scanner du rachis cervical ont été considérées comme cliniquement significatives, ce qui pourrait modifier la gestion clinique. Les fractures de l'apophyse transverse et du corps vertébral ont souvent été oubliées.

Fractures du processus coracoïde : anatomie, types de blessures, imagerie multimodale et approche de la gestion |

Coracoid process fractures: anatomy, injury patterns, multimodality imaging, and approach to management.
Li CH, Skalski MR, Matcuk GR Jr, Patel DB, Gross JS, Tomasian A, White EA. | Emerg Radiol. 2019 Aug;26(4):449-458
DOI: https://doi.org/10.1007/s10140-019-01683-2
Keywords: Avulsion fracture; Coracoid fractures; Imaging evaluation

Review Article

Editorial : The coracoid process of the scapula is in close proximity to major neurovascular structures, including the brachial plexus and the axillary artery and vein. In addition, it serves as a major site of attachment for multiple tendons and ligaments about the shoulder. Isolated coracoid fractures are rare; however, they can be easily overlooked on routine shoulder radiographs. Importantly, when these fractures go undiagnosed, they are at high risk for nonunion. In this paper, we will review the relevant anatomy of the coracoid process, classification schemes for coracoid fractures, mechanisms of injury how these fractures typically present, multimodality imaging findings, and associated injuries. Finally, we will briefly discuss the clinical management of these fractures.

Conclusion : Close attention should be paid to identify coracoid process fractures on radiographs as they may be subtle or not apparent. Subtle fractures may only be apparent on view of the shoulder series. The Zanca and Stryker notch views may improve de- tection of coracoid fractures. Coracoid fractures have been reported in association with acromioclavicular separation or following shoulder arthroplasty, and there should be increased suspicion for coracoid fractures in these settings. CT is recommended if clinical suspicion persists or the radiographic findings are equivocal. Fractures that are not diagnosed may go on to a painful nonunion. Classification schemes of coracoid fractures include the Ogawa and Eyres classifications, which can be utilized to determine whether surgical management is indicated.
The normal physis should not be misinterpreted as a fracture. The physis at the tip of the coracoid normally fuses at age of 18–25 years. The physis at the base of the coracoid normal- ly fuses by age 14–15 years.

Conclusion (proposition de traduction) : Il faut porter une attention particulière à l'identification des fractures du processus coracoïdien sur les radiographies, car elles peuvent être ténue ou non apparentes. Des fractures ténues ne peuvent être visibles que sur une série de clichés radiographique d'épaule. Les marques d'encoche de Zanca et de Stryker peuvent améliorer la détection des fractures coracoïdes. Des fractures coracoïdes ont été signalées en association avec une disjonction acromio-claviculaire ou à la suite d'une arthroplastie de l'épaule, et il faut se méfier davantage des fractures coracoïdes dans ces contextes. La tomodensitométrie est recommandée si la suspicion clinique persiste ou si les résultats radiographiques sont équivoques. Les fractures qui ne sont pas diagnostiquées peuvent se traduire par une absence de soudure douloureuse. Les systèmes de classification des fractures coracoïdes comprennent les classifications Ogawa et Eyres, qui peuvent être utilisées pour déterminer si une prise en charge chirurgicale est indiquée.
Un cartilage de conjugaison normal ne doit pas être interprétée à tort comme une fracture. La suture à l'extrémité de la coracoïde fusionne normalement à l'âge de 18-25 ans. La suture à la base de la coracoïde fusionne normalement à l'âge de 14-15 ans.

L'épaule flottante |

The floating shoulder.
Kani KK, Porrino JA, Mulcahy H, Chew FS. | Emerg Radiol. 2019 Aug;26(4):459-464
DOI: https://doi.org/10.1007/s10140-019-01682-3
Keywords: Complex shoulder girdle injuries; Floating shoulder; Scapular neck fracture; Superior shoulder suspensory complex

Pictorial Essay

Editorial : The floating shoulder refers to a subset of complex shoulder injuries that typically occur in the setting of high-energy trauma. Identification of the full extent of complex shoulder injuries with computed tomography may have critical implications in patient management. The goals of this article are to review the anatomy, definition, imaging evaluation, and treatment of floating shoulder injuries.

Conclusion : Floating shoulder is a variably defined term used to describe complex disruptions of the SSSC. When reporting injuries of the SSSC, replacing the term Bfloating shoulder^ with a description of the pattern and number of disrupted SSSC elements as well as the degree and direction of displacement of the main fracture fragments and presence or absence of an isolated glenoid fragment may result in a clearer communication with the orthopedic team.

Conclusion (proposition de traduction) : L'épaule flottante est un terme défini de façon variable utilisé pour décrire les perturbations complexes du complexe suspenseur supérieur de l'épaule. Lors de l'identification d'atteinte du complexe suspenseur supérieur de l'épaule, le remplacement du terme « épaule flottante raquo;; par une description de la configuration et du nombre d'éléments perturbés du complexe suspenseur supérieur de l'épaule ainsi que du degré et de la direction du déplacement des principaux fragments de fracture et la présence ou non d'un fragment glénoïde isolé peut constituer une communication plus claire avec l'équipe orthopédique.

Critères prédictifs d'insuffisance cardiaque aiguë chez les patients présentant une dyspnée aiguë au service des urgences : étude PREDICA |

Predictive criteria for acute heart failure in emergency department patients with acute dyspnoea: the PREDICA study.
Roncalli J, Picard F, Delarche N, Faure I, Pradeau C, Thicoipe M, Galinier M, Charpentier S. | Eur J Emerg Med. 2019 Aug 23
DOI: https://doi.org/10.1097/MEJ.0000000000000622
Keywords: Aucun

Original Articles

Introduction : The early identification of patients with Acute Heart Failure Syndrome (AHFS) among patients admitted to the Emergency Department (ED) with dyspnoea can facilitate the introduction of appropriate treatments. The objectives are to identify the predictive factors for AHFS diagnosis in patients with acute dyspnoea (primary objective) and the clinical 'gestalt' (secondary objective) in ED.

Méthode : PREDICA is an observational, prospective, multicentre study. The enrolment of patients admitted to the ED for nontraumatic acute dyspnoea and data collection on admission were recorded by the patient's emergency physician. The AHFS endpoints were assessed following a duplicate expert evaluation by pairs of cardiologists and emergency physicians. Step-by-step logistic regression was used to retain predictive criteria, and the area under the receiver operating characteristic (ROC) curve of the model was constructed to assess the ability of the selected factors to identify real cases. The probability of AHFS was estimated on a scale from 1 to 10 based on the emergency physician's perception and understanding (gestalt).

Résultats : Among 341 patients consecutively enrolled in three centres, 149 (44%) presented AHFS. Eight predictive factors of AHFS were detected with a performance test showing an area under the model ROC curve of 0.86. Gestalt greater than or equal to five showed sensitivity of 78% and specificity of 90% (AUC 0.91) and diagnosed 88% of AHF in our population.

Conclusion : We identified several independant predictors of final AHFS diagnosis. They should contribute to the development of diagnostic strategies in ED. However, unstructured gestalts seem to perform very well alone.

Conclusion (proposition de traduction) : Nous avons identifié plusieurs facteurs prédictifs indépendants du diagnostic final d'insuffisance cardiaque aiguë. Ils devraient contribuer à l’élaboration de stratégies de diagnostic aux urgences. Cependant, la Gestalt non structuré semblent très bien fonctionner seule.

Variation précoce du qSOFA pour prédire la mortalité intra-hospitalière chez les patients suspects d'être septiques aux services des urgences |

Early variation of quick sequential organ failure assessment score to predict in-hospital mortality in emergency department patients with suspected infection.
Lemachatti N, Ortega M, Penaloza A, Le Borgne P, Claret PG, Occelli C, Truchot J, Dumas F, Feral-Pierssens AL, Andrianjafy H, Beaune S, Yordanov Y, Hausfater P, Riou B, Bloom, Krastinova E, Freund; French Society of Emergency Medicine Collaborators Group and the INFURGSEMES Group. | Eur J Emerg Med. 2019 Aug;26(4):234-241
DOI: https://doi.org/10.1097/MEJ.0000000000000551
Keywords: Aucun

Original articles

Introduction : The quick sequential organ failure assessment (qSOFA) score showed good prognostic performance in patients with suspicion of infection in the emergency department (ED). However, previous studies only assessed the performance of individual values of qSOFA during the ED stay. As this score may vary over short timeframes, the optimal time of measurement, and the prognostic value of its variation are unclear. The objective of the present study was to prospectively assess the prognostic value of the change in qSOFA over the first 3 h (ΔqSOFA = qSOFA at 3 h-qSOFA at inclusion).

Méthode : This is an international prospective cohort study conducted in 17 EDs in France, Belgium, and Spain. From November 2016 to March 2017, patients with a suspected infection and a qSOFA score of 2 or higher were included and followed up until death or hospital discharge. qSOFA was measured at inclusion, 1 h and 3 h. Primary end point was in-hospital mortality, truncated at 28 days.

Résultats : Of 534 recruited patients, 512 were included in the analysis. The qSOFA was improved at 3 h (ΔqSOFA < 0) in 287 (55%) patients. Overall in-hospital mortality was 27%: 44% when ΔqSOFA greater than 0, 36% when ΔqSOFA = 0, and 18% when ΔqSOFA less than 0. A positive ΔqSOFA was independently associated with reduced in-hospital mortality (adjusted hazard ratio of 0.48, 95% confidence interval: 0.34-0.68). After modeling qSOFA kinetics in the first 3 h, there was a significant difference in adjusted slopes between patients who died and those who survived (0.15, 95% confidence interval: 0.09-0.22, P < 0.001).

Conclusion : In patients with suspected infection presenting to the ED with a qSOFA of 2 or higher, the early change in qSOFA is a strong independent predictor of mortality.

Conclusion (proposition de traduction) : Chez les patients qui se présentent aux urgences pour une suspicion de sepsis avec un qSOFA égal ou supérieur à 2, l'évolution précoce du qSOFA est un important facteur indépendant de prédiction de la mortalité.

Symptômes cliniques médicalement inexpliqués chez les patients se prensentant au service des urgences : une étude rétrospective multicentrique internationale |

Medically unexplained physical symptoms in patients visiting the emergency department: an international multicentre retrospective study.
Alsma J, Wouw JV, Jellema K, Coffeng SM, Tobback E, Delesie L, Brand CLVD, Vogelaers D, Mariman A, Paepe P, van Saase JL, Weiland A. | Eur J Emerg Med. 2019 Aug;26(4):249-254
DOI: https://doi.org/10.1097/MEJ.0000000000000536
Keywords: Aucun

Original articles

Introduction : The objective of this study was to assess the incidence and characteristics of patients presenting with physical symptoms that remain medically unexplained at the emergency department (ED).

Méthode : A retrospective chart study was carried out in three hospitals in The Netherlands and Belgium. All patients (age > 18 years) visiting the ED in 4 selected weeks in 2013 at the Erasmus University Medical Center (Erasmus MC) in Rotterdam, The Netherlands, and 1 selected week in 2013 at the Haaglanden Medical Center, Westeinde HMC in The Hague, The Netherlands, and the University Hospital Ghent (UZG), Belgium, were included. Descriptive statistics were used for data analysis.

Résultats : A total of 2869 patients (Erasmus MC 1674, HMC 691, UZG 504) were included. Medically unexplained physical symptoms in the emergency department (EDMUPS) were present in 13.4% of all ED visits (Erasmus MC 12.5%, HMC 18.7%, UZG 9.1%). No EDMUPS were identified in trauma patients. When excluding trauma patients, EDMUPS were present in 18.5% (Erasmus MC 16.8%, HMC 26.5%, UZG 13.3%) of the visits. The characteristics of patients with and without EDMUPS differed significantly; patients with EDMUPS were more often younger, female, self-referred, frequent visitors, were prescribed less medication and more often had a psychiatric disease. Dutch and Belgian Hospital differed in the distribution of patients in triage categories and in the incidence of psychiatric illnesses.

Conclusion : Physical symptoms remain unexplained in a significant number of patients at the time of ED assessment.

Conclusion (proposition de traduction) : Les symptômes physiques restent inexpliqués chez un nombre significatif de patients (18.5 %) au moment de la prise en charge aux urgences.

Commentaire : Les caractéristiques des patients avec et sans symptômes cliniques médicalement inexpliqués différaient de manière significative. Les patients chez qui l'ont retrouvait un symptôme clinique médicalement inexpliqué :
• étaient plus souvent, de jeunes femmes ;
• consultaient plus fréquement ;
• se voyaient prescrire moins de médicaments ;
• avaient plus souvent une maladie psychiatrique.
Les hôpitaux néerlandais et belges différaient dans la répartition des patients dans les catégories de triage et dans l'incidence des maladies psychiatriques.

Technique de compression thoracique avec un « doigts de frappe » chez les enfants en arrêt cardiaque : étude sur un mannequin avec un seul secouriste |

'Knocking-fingers' chest compression technique in infant cardiac arrest: single-rescuer manikin study.
Jung WJ, Hwang SO, Kim HI, Cha YS, Kim OH, Kim H, Lee KH, Cha KC. | Eur J Emerg Med. 2019 Aug;26(4):261-265
DOI: https://doi.org/10.1097/MEJ.0000000000000539
Keywords: Aucun

Original articles

Introduction : We designed a new chest compression technique, the 'knocking-fingers' chest compression (KF) technique, for a single rescuer in infant cardiac arrest. We compared the effectiveness and feasibility between the KF technique and the two-finger (TF) and two-thumb encircling hands (TT) techniques.

Méthode : A prospective, randomized, crossover study was carried out to compare the quality of chest compression and ventilation between the KF, TF, and TT techniques using a 30: 2 compression-to-ventilation ratio and mouth-to-mouth ventilation. The area of chest compression, finger(s) pain, and fatigability were measured to compare safety and feasibility.

Résultats : The total frequency of chest compression for 5 min was the highest with the KF technique, followed by the TF and TT techniques. The total frequency of ventilation for 5 min was higher with the KF and TF techniques compared with the TT technique. The total hands-off time was the shortest with the KF technique, followed by the TF and TT techniques. The area of chest compression was the smallest in KF technique. Participants complained of severe finger pain and high fatigability in TF technique.

Conclusion : The single-rescuer KF chest compression technique is an effective alternative to the TF or TT techniques for infant cardiac arrest.

Conclusion (proposition de traduction) : La technique de compression thoracique à un seul sauveteur, appelée « doigts de frappe », constitue une alternative efficace aux techniques de réanimation de l'arrêt cardiaque du nourrisson avec la technique à deux doigts ou à deux pouces, le thorax entouré par les deux mains.

Commentaire :

Dispositif de rétroaction par montre connectée pour les compressions thoraciques de haute qualité par un seul secouriste lors d'un arrêt cardiaque du nourrisson : une étude de simulation contrôlée randomisée | Accès libre

Smartwatch feedback device for high-quality chest compressions by a single rescuer during infant cardiac arrest: a randomized, controlled simulation study.
Lee J, Song Y, Oh J, Chee Y, Ahn C, Shin H, Kang H, Lim TH. | Eur J Emerg Med. 2019 Aug;26(4):266-271
DOI: https://doi.org/10.1097/MEJ.0000000000000537 | Télécharger l'article au format
Keywords: Aucun

Original articles

Introduction : According to the guidelines, rescuers should provide chest compressions (CC) ~1.5 inches (40 mm) for infants. Feedback devices could help rescuers perform CC with adequate rates (CCR) and depths (CCD). However, there is no CC feedback device for infant cardiopulmonary resuscitation (CPR). We suggest a smartwatch-based CC feedback application for infant CPR.

Méthode : We created a smartwatch-based CC feedback application. This application provides feedback on CCD and CCR by colour and text for infant CPR. To evaluate the application, 30 participants were divided randomly into two groups on the basis of whether CC was performed with or without the assistance of the smartwatch application. Both groups performed continuous CC-only CPR for 2 min on an infant mannequin placed on a firm table. We collected CC parameters from the mannequin, including the proportion of correct depth, CCR, CCD and the proportion of correct decompression depth.

Résultats : Demographics between the two groups were not significantly different. The median (interquartile range) proportion of correct depth was 99 (97-100) with feedback compared with 83 (58-97) without feedback (P = 0.002). The CCR and proportion of correct decompression depth were not significantly different between the two groups (P = 0.482 and 0.089). The CCD of the feedback group was significantly deeper than that of the control group [feedback vs. control: 41.2 (39.8-41.7) mm vs. 38.6 (36.1-39.6) mm; P=0.004].

Conclusion : Rescuers who receive feedback of CC parameters from a smartwatch could perform adequate CC during infant CPR.

Conclusion (proposition de traduction) : Les sauveteurs qui reçoivent des informations sur les paramètres de compression thoracique par une montre connectée peuvent effectuer leurs tâches de manière adéquate pendant la RCP du nourrisson.

Exactitude de l'examen échographique effectué par les résidents en médecine d'urgence par rapport aux résidents en radiologie dans le diagnostic de l'appendicite aiguë |

Accuracy of ultrasound exam performed by emergency medicine versus radiology residents in the diagnosis of acute appendicitis.
Shahbazipar M, Seyedhosseini J, Vahidi E, Motahar Vahedi HS, Jahanshir A. | Eur J Emerg Med. 2019 Aug;26(4):272-276
DOI: https://doi.org/10.1097/MEJ.0000000000000547
Keywords: Aucun

Original articles

Introduction : BACKGROUND: Although the traditional approach to the diagnosis of acute appendicitis (AA) is using clinical methods, experience has shown that strict reliance on clinical data can lead to mismanagement or unnecessary surgery.
OBJECTIVE: The objective of this study was to determine the total agreement of ultrasound (US) results in AA performed by emergency medicine (EM) versus radiology residents in emergency department.

Méthode : In this cross-sectional study, 121 patients with AA suspicion underwent an US exam by both trained EM and radiology residents in emergency department. The training course for EM residents consisted of attending an 8-h-workshop and then practicing an US exam on real patients within a 2-month period. The gold standards were either histopathologic or follow-up results. Total agreement of the results in both specialties was compared.

Résultats : There were 67 men and 54 women, with a mean age of 33.6 ± 16.1 years (18.2-88.7 years). Fifty-four (44.6%) patients underwent surgery with the initial diagnosis of AA and the rest were evaluated by follow-ups. On the basis of our gold standards, the diagnosis was finally confirmed in 46 (38%) cases. There was a high total agreement in AA diagnosis [96% agreement, κ = 0.90; 95% confidence interval (CI) = 0.81-0.99] between the two groups. The specificity and sensitivity of EM and radiology groups were 99% (95% CI = 93-100), 63% (95% CI = 48-77), 97% (95% CI = 91-100), and 72% (95% CI = 57-84), respectively.

Conclusion : US has a high diagnostic specificity in patients suspected of having AA and EM residents can perform this modality as accurately as radiologists after training in the emergency setting.

Conclusion (proposition de traduction) : L'échographie a une haute spécificité diagnostique chez les patients suspects d'appendicite aiguë et les résidents en médecine d'urgence peuvent exécuter cette modalité avec autant de précision que les radiologues après une formation en situation d'urgence.

Un meilleur respect des critères de triage en cas de traumatisme réduirait les coûts tout en maintenant la sécurité des patients | Accès libre

Better compliance with triage criteria in trauma would reduce costs with maintained patient safety.
Linder F, Holmberg L, Eklöf H, Björck M, Juhlin C, Mani K. | Eur J Emerg Med. 2019 Aug;26(4):283-288
DOI: https://doi.org/10.1097/MEJ.0000000000000544 | Télécharger l'article au format
Keywords: Aucun

Original articles

Introduction : o evaluate trauma triage criteria in terms of compliance, undertriage, and overtriage and identify risk factors for mistriage.

Méthode : In a retrospective cohort study, all consecutive trauma patients at a University Hospital in Sweden in 2012 were included. Patients were stratified into three groups on the basis of trauma team activation (full trauma team, limited trauma team, and no trauma team). Case records were reviewed for mechanism of injury, vital signs, and injuries. Compliance with alert criteria was evaluated and injury severity score combined with the Matrix method was used for assessment of overtriage and undertriage.

Résultats : A total of 1424 trauma patients were included in the study. Seventy-three (5.1%) patients activated a full trauma team, 732 (51.4%) a limited trauma team, and 619 (43.5%) did not activate any trauma team. Undertriage was 2.7% [95% confidence interval (CI): 1.9-3.8%] and overtriage was 34.2% (95% CI: 23.5-46.3%) in the complete cohort. Compliance with 'trauma triage criteria' was assessed by comparing actual alerts with what was estimated to be the correct alert levels on the basis of prehospital case records. Compliance with full trauma team criteria was 80% (68-88%), limited trauma team was 54% (51-58%), and no trauma team was 79% (76-82%). Assuming full compliance with trauma criteria, the Matrix method resulted in an undertriage of 2.3% (95% CI: 1.6-3.3%) and an overtriage of 42.6% (95% CI: 32.4-53.2%).

Conclusion : The overtriage and undertriage in this study is in line with the recommendations of the American College of Surgeons Committee on Trauma. However, better compliance with trauma alert criteria would result in fewer trauma team activations without affecting patient safety.

Conclusion (proposition de traduction) : Le sur et soustriage dans cette étude sont conformes aux recommandations de l'American College of Surgeons Committee on Trauma. Cependant, une meilleure conformité aux critères d'alerte de traumatisme réduirait le nombre d'activations d'équipes de traumatologie sans affecter la sécurité des patients.

Attentats terroristes à Paris : gestion d'un grand nombre de blessés dans un centre de traumatologie distant |

Terrorist attacks in Paris: managing mass casualties in a remote trauma center.
Femy F, Follin A, Juvin P, Feral-Pierssens AL. | Eur J Emerg Med. 2019 Aug;26(4):289-294
DOI: https://doi.org/10.1097/MEJ.0000000000000555
Keywords: Aucun

Original articles

Introduction : On 13 November 2015, Paris was the target of multiple terrorist attacks responsible for a massive influx of casualties in emergency departments (EDs). Because of the activation of a local crisis plan and the arrival of extra staff, our capacities increased markedly. Our aim was to analyze whether our center, in this challenging context, efficiently managed this massive influx of patients.

Méthode : We carried out a monocentric retrospective study. All patients received in the first 24 h were included (isolated psychological trauma with no physical injury excluded). Our main endpoint was to assess patient diversion through early secondary transfers ( ≤ 24 h) because of an overrun of our capacities.

Résultats : A total of 53 victims were sent to our center in a 4 h timeframe; 12 patients were excluded (no physical injury). We analyzed 41 victims. Their median injury severity score was 4 (1;9). Three (7%) patients were transferred after ED management to a nearby hospital within the first 24 h for minor orthopedic surgery. There was a significant increase in medical/surgical staff (eight ED physicians instead of two; six intensivists vs. two; three orthopedic surgeons vs. one). Among the victims, 71% had firearms wounds and 30% had open fractures. Twenty surgeries were performed in the first 24 h. There were no in-hospital deaths.

Conclusion : Faced with an unusual event and thanks to the increase in staff, our operating capacities increased. Our center took charge of almost all victims. Patient diversion concerned only three patients transferred to a nearby hospital for minor orthopedic surgery.

Conclusion (proposition de traduction) : Face à un événement inhabituel et grâce à l'augmentation des effectifs, nos capacités opérationnelles se sont accrues. Notre centre s'est occupé de presque toutes les victimes. Le transfert de patients n'a concerné que trois patients dirigés vers un hôpital voisin pour une chirurgie orthopédique mineure.

Optimisation de l'estimation du poids aux urgence chez les enfants présentant une insuffisance pondérale ou une obésité : précision des estimations du poids total (PT) et du poids idéal (PI) |

Optimising emergency weight estimation in underweight and obese children: the accuracy of estimations of total body weight and ideal body weight.
Wells M, Goldstein LN. | Eur J Emerg Med. 2019 Aug;26(4):301-307
DOI: https://doi.org/10.1097/MEJ.0000000000000561
Keywords: Aucun

Original articles

Introduction : During medical emergencies, underweight and obese children are at a higher risk of weight-estimation errors than 'average' children, which may lead to poorer outcomes. In obese children, optimum drug dosing requires a measure of both total body weight (TBW) and ideal body weight (IBW) for appropriate scaling. We evaluated the ability of the Broselow tape, the Mercy method and the PAWPER XL tape to estimate TBW and IBW in obese and underweight children.

Méthode : Data for children aged 0-18 years were extracted and pooled from three previous weight-estimation studies. The accuracy of estimation of TBW and IBW by each method was evaluated using percentage of estimations within 10% of target weight (PW10) as the primary outcome measure.

Résultats : The Broselow tape estimated TBW poorly in obese and underweight children (PW10: 3.9 and 41.4%), but estimated IBW extremely accurately (PW10: 90.6%). The Mercy method estimated TBW accurately in both obese and underweight children (PW10: 74.3 and 76.3%) but did not predict IBW accurately (PW10: 14.3%). The PAWPER XL tape predicted TBW well (PW10: 73.0% in obese children and 74.9% in underweight children) and predicted IBW extremely accurately (PW10: 100%).

Conclusion : The Broselow tape predicted IBW, but not TBW, accurately. The Mercy method estimated TBW very accurately, but not IBW. The PAWPER XL tape estimated both TBW and IBW accurately. The PAWPER XL tape should be considered when choosing a weight-estimation strategy for obese and underweight children.

Conclusion (proposition de traduction) : La bande de Broselow prédit avec précision PI, mais pas PT. La méthode Mercy a estimé PT de manière très précise, mais pas PI. La bande PAWPER XL estimait à la fois PT et PI avec précision. La bande PAWPER XL doit être prise en compte lors du choix d’une stratégie d’estimation du poids pour les enfants obèses et en insuffisance pondérale.

Commentaire : Autres références :
• Wells M. A validation of the PAWPER XL-MAC tape for total body weight estimation in preschool children from low- and middle-income countries. PLoS One. 2019 Jan 7;14(1):e0210332    ;
• Wells M, Goldstein LN, Bentley A. The accuracy of paediatric weight estimation during simulated emergencies: The effects of patient position, patient cooperation, and human errors. Afr J Emerg Med. 2018 Jun;8(2):43-50   ;
• Wells M, Goldstein L, Bentley A. A validation study of the PAWPER XL tape: accurate estimation of both total and ideal body weight in children up to 16 years of age. Trauma Emerg Care 2017;2(5):1-8   .

Échographie thoracique : revue descriptive |

Thoracic ultrasonography: a narrative review.
Mayo PH, Copetti R, Feller-Kopman D, Mathis G, Maury E, Mongodi S, Mojoli F, Volpicelli G, Zanobetti M. | Intensive Care Med. 2019 Sep;45(9):1200-1211
DOI: https://doi.org/10.1007/s00134-019-05725-8
Keywords: Critical care ultrasonography; Lung ultrasonography; Pleural ultrasonography; Ultrasonography

Review

Editorial : This narrative review focuses on thoracic ultrasonography (lung and pleural) with the aim of outlining its utility for the critical care clinician. The article summarizes the applications of thoracic ultrasonography for the evaluation and management of pneumothorax, pleural effusion, acute dyspnea, pulmonary edema, pulmonary embolism, pneumonia, interstitial processes, and the patient on mechanical ventilatory support. Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the management of a wide variety of disease processes that are common features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonography the "go to" modality for imaging the lung and pleura in an efficient, cost effective, and safe manner, such that it can largely replace chest imaging in critical care practice. It is best used in conjunction with other components of critical care ultrasonography to yield a comprehensive evaluation of the critically ill patient at point of care.

Conclusion : Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the manage- ment of a wide variety of disease processes that are com- mon features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonogra- phy the “go to” modality for imaging the lung and pleura in an efficient, cost effective, and safe manner. Thoracic ultrasonography can largely replace CXR in the ICU and may reduce the need of for chest CT in critical care prac- tice. It is best combined with other components of CCUS at point of care to result in a comprehensive evaluation of the critically ill patient.

Conclusion (proposition de traduction) : La maîtrise de l'échographie pulmonaire et pleurale permet au réanimateur de diagnostiquer et de guider rapidement la prise en charge d'une grande variété de processus pathologiques communs aux maladies graves. Sa facilité d'utilisation, sa rapidité, sa répétabilité et sa fiabilité font de l'échographie thoracique le moyen idéal de réaliser une imagerie du poumon et de la plèvre de manière efficace, économique et sûre. L'échographie thoracique peut largement remplacer la radiographie thoracique en réanimation et peut réduire le besoin de scanner thoracique en pratique de soins intensifs. Il est préférable de le combiner avec d'autres composantes de l'échographie de soins intensifs au point d'intervention pour obtenir une évaluation complète du patient gravement malade.

Commentaire : Voir les articles sur le même sujet :
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25  .
Lichtenstein DA. Lung ultrasound in the critically ill. Curr Opin Crit Care. 2014 Jun;20(3):315-22   .
Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest. 2015 Jun;147(6):1659-1670   .
Mojoli F, Bouhemad B, Mongodi S, Lichtenstein DA. Lung Ultrasound for Critically Ill Patients. Am J Respir Crit Care Med. 2019 Mar 15;199(6):701-714  .

Détection du délire chez les patients âgés en urgence médicale: validation et modification ultérieure de l'échelle allemande de dépistage du délire chez les infirmières |

Detecting delirium in elderly medical emergency patients: validation and subsequent modification of the German Nursing Delirium Screening Scale.
Brich J, Baten V, Wußmann J, Heupel-Reuter M, Perlov E, Klöppel S, Busch HJ. | Intern Emerg Med. 2019 Aug;14(5):767-776
DOI: https://doi.org/10.1007/s11739-018-1989-5
Keywords: Delirium; Emergency department; Geriatric medicine; Germany; Nu-DESC; Nursing; Validity

EM - ORIGINAL

Editorial : Detecting delirium in elderly emergency patients is critical to their outcome. The Nursing Delirium Screening Scale (Nu-DESC) is a short, feasible instrument that allows nurses to systematically screen for delirium. This is the first study to validate the Nu-DESC in a German emergency department (ED). The Nu-DESC was implemented in a high-volume, interdisciplinary German ED. A consecutively recruited sample of medical patients aged ≥ 70 years was screened by assigned nurses who performed the Nu-DESC as part of their daily work routine. The results were compared to a criterion standard diagnosis of delirium. According to the criterion standard diagnosis, delirium was present in 47 (14.9%) out of the 315 patients enrolled. The Nu-DESC shows a good specificity level of 91.0% (95% CI 87.0-94.2), but a moderate sensitivity level of 66.0% (95% CI 50.7-79.1). Positive and negative likelihood ratios are 7.37 (95% CI 4.77-11.36) and 0.37 (95% CI 0.25-0.56), respectively. In an exploratory analysis, we find that operationalizing the Nu-DESC item "disorientation" by specifically asking patients to state the day of the week and the name of the hospital unit would raise Nu-DESC sensitivity to 77.8%, with a specificity of 84.6% (positive and negative likelihood ratio of 5.05 and 0.26, respectively). The Nu-DESC shows good specificity but moderate sensitivity when performed by nurses during their daily work in a German ED. We have developed a modified Nu-DESC version, resulting in markedly enhanced sensitivity while maintaining a satisfactory level of specificity.

Conclusion : The Nu-DESC is a short delirium screening tool that can be performed within 1 min by a nurse during the patient’s admission to the ED. It shows good specificity but only moderate sensitivity when conducted in elderly medical patients in a German ED. The moderate sensitivity of the test can potentially be improved by providing nurses with extra training and applying a modified version of the Nu-DESC in which the assessment of disorientation (Item 1) is operationalized by asking two predefined questions about the day of the week and the name of the hospital unit. With such a modification, the Nu-DESC might address the urgent need for systematic delirium screening in German EDs by serving as an instrument with a suf- ficient diagnostic performance.

Conclusion (proposition de traduction) : Le Nu-DESC est un outil rapide de dépistage d'un épisode délirant qui peut être effectué en 1 minute par une infirmière lors de l'admission du patient aux urgences. Il offre une bonne spécificité mais une sensibilité modérée chez les patients âgés d'un service d'urgence allemand.
La sensibilité modérée du test peut potentiellement être améliorée en donnant aux infirmières une formation supplémentaire et en appliquant une version modifiée du Nu- DESC dans laquelle l'évaluation de la désorientation est affinée en posant deux questions prédéfinies sur le jour de la semaine et le nom de l'unité hospitalière.
Avec une telle modification, le Nu-DESC pourrait répondre au besoin urgent de dépistage systématique d'un épisode délirant dans les services des urgences allemands en servant d'instrument aux performances diagnostiques satisfaisantes.

Commentaire : Nursing Delirium Screening Scale (Nu-DESC) : Échelle de dépistage infirmier du délire

Signes prédictifs précoces pour le diagnostic d'abcès du foie aux urgence |

Early predictors for the diagnosis of liver abscess in the emergency department.
Chia DWJ, Kuan WS, Ho WH Sim TB, Chua MT. | Intern Emerg Med. 2019 Aug;14(5):783-791
DOI: https://doi.org/10.1007/s11739-019-02061-z
Keywords: Emergency services; Liver abscess; Point-of-care ultrasonography; Systemic inflammatory response syndrome

EM - ORIGINAL

Editorial : Diagnosing pyogenic liver abscess (PLA) in the emergency department (ED) is challenging due to its non-specific clinical presentation. We aim to identify predictors that aid in diagnosis of PLA in ED patients. This retrospective chart review included patients diagnosed with PLA in a tertiary hospital between January 2008 and December 2012. We compared the demographics, clinical characteristics, investigations and outcomes between patients with PLA diagnosed and missed in the ED. During the study period, 155 patients were admitted via the ED with a cause of death or discharge diagnosis of PLA. Mean age was 58.1 (standard deviation [SD] 15.8) years, with male predominance of 69.7%. There were 79.4% of patients with diagnosis of PLA missed in the ED. Fulfillment of SIRS criteria was associated with increased odds of diagnosing PLA in the ED (adjusted OR 3.20, 95% CI 1.03-9.92), while a higher SpO2/FiO2 ratio was associated with decreased odds of a timely ED diagnosis (adjusted OR 0.993, 95% CI 0.988-0.998). Missed ED diagnosis of PLA did not result in significant differences in mortality or treatment failure (p = 0.939), and median length of stay (11 days [IQR 8-16] vs. 11 days [IQR 7-17], p = 0.48). Non-fulfillment of the SIRS criteria and a higher SpO2/FiO2 ratio at ED presentation were associated with higher likelihood of missed diagnosis. Despite that, a missed diagnosis of PLA in the ED did not appear to affect outcomes.

Conclusion : A missed diagnosis of PLA in the ED did not appear to affect outcomes. Further studies should be conducted to evaluate the utility of POCUS in ED for diagnosis of liver abscess in patients with suspected infection with no clear source.

Conclusion (proposition de traduction) : Un diagnostic manqué d'abcès hépatique aux urgences ne semble pas avoir d'incidence sur l'évolution des patients. D'autres études devraient être menées pour évaluer l'utilité de l'échographie au point d'intervention (POCUS) aux urgences pour le diagnostic d'un abcès hépatique chez les patients suspects d'avoir une infection sans foyer identifié.

Combinaison optimale du taux de compression et de la profondeur pendant la réanimation cardiopulmonaire pour une survie fonctionnellement favorable | Accès libre

Optimal Combination of Compression Rate and Depth During Cardiopulmonary Resuscitation for Functionally Favorable Survival.
Duval S, Pepe PE, Aufderheide TP, Goodloe JM, Debaty G, Labarère J, Sugiyama A, Yannopoulos D. | JAMA Cardiol. 2019 Aug 14
DOI: https://doi.org/10.1001/jamacardio.2019.2717 | Télécharger l'article au format
Keywords: Aucun

Original Investigation

Introduction : IMPORTANCE: Previous studies of basic cardiopulmonary resuscitation (CPR) indicate that both chest compression rate (CCR) and chest compression depth (CCD) each are associated with survival probability after out-of-hospital cardiac arrest. However, an optimal CCR-CCD combination has yet to be identified, particularly with respect to age, sex, presenting cardiac rhythm, and CPR adjunct use. OBJECTIVES: To identify an ideal CCR-CCD combination associated with the highest probability of functionally favorable survival and to assess whether this combination varies with respect to age, sex, presenting cardiac rhythm, or CPR adjunct use.

Méthode : DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data collected between June 2007 and November 2009 from a National Institutes of Health (NIH) clinical trials network registry of out-of-hospital and in-hospital emergency care provided by 9-1-1 system agencies participating in the network across the United States and Canada (n = 150). The study sample included 3643 patients who had out-of-hospital cardiac arrest and for whom CCR and CCD had been simultaneously recorded during an NIH clinical trial of a CPR adjunct. Subgroup analyses included evaluations according to age, sex, presenting cardiac rhythm, and application of a CPR adjunct. Data analysis was performed from September to November 2018. INTERVENTIONS: Standard out-of-hospital cardiac arrest interventions compliant with the concurrent American Heart Association guidelines as well as use of the CPR adjunct device in half of the patients. MAIN OUTCOMES AND MEASURES: The optimal combination of CCR-CCD associated with functionally favorable survival (modified Rankin scale ≤3) overall and by age, sex, presenting cardiac rhythm, and CPR adjunct use.

Résultats : Of 3643 patients, 2346 (64.4%) were men; the mean (SD) age was 67.5 (15.7) years. The identified optimal CCR-CCD for all patients was 107 compressions per minute and a depth of 4.7 cm. When CPR was performed within 20% of this value, survival probability was significantly higher (6.0% vs 4.3% outside that range; odds ratio, 1.44; 95% CI, 1.07-1.94; P = .02). The optimal CCR-CCD combination remained similar regardless of age, sex, presenting cardiac rhythm, or CPR adjunct use. The identified optimal CCR-CCD was associated with significantly higher probabilities of survival when the CPR device was used compared with standard CPR (odds ratio, 1.90; 95% CI, 1.06-3.38; P = .03), and the device's effectiveness was dependent on being near the target CCR-CCD combination.

Conclusion : The findings suggest that the combination of 107 compressions per minute and a depth of 4.7 cm is associated with significantly improved outcomes for out-of-hospital cardiac arrest. The results merit further investigation and prospective validation.

Conclusion (proposition de traduction) : Les résultats suggèrent que la combinaison de 107 compressions par minute et d'une profondeur de 4,7 cm est associée à une amélioration significative des résultats lors d'un arrêt cardiaque extra-hospitalier. Les résultats méritent d'être approfondis et validés de manière prospective.

Le consentement du patient aux actes de secours lors d’interventions extrahospitalières |

Quaglierini B, Genotelle N. | Med Droit. 2019 August;2019(157):89-101
DOI: https://doi.org/10.1016/j.meddro.2019.03.002
Keywords: Consent; Care refusal; First aid response; Emergencies

Protection de la personne

Editorial : Le recueil du consentement de la personne aux soins qui lui sont proposés est un principe quasi-absolu. Ce recueil s’impose également aux secouristes intervenant comme primo-intervenants en amont de la chaîne de santé stricto sensu ; d’autant plus que, du fait de la régulation médicale par le SAMU, cette intervention s’assimile à un acte de soins. Le principe du consentement aux soins s’impose donc à la fois dans un but d’humanisme et dans celui de prévenir tout éventuel contentieux. Pour autant, il existe de nombreuses situations où la gestion du consentement de la personne secourue pourra poser des difficultés pour les secours non médicalisés. Il convient alors d’analyser comment les systèmes de secours peuvent gérer et limiter le risque face aux différentes situations de refus de prise en charge, afin de respecter la dignité des personnes, mais ne pas non plus commettre un abandon de soins. Un travail de concert entre secouristes et médecin régulateur est alors indispensable, surtout à défaut de consentement. Il permettra de déceler les hypothèses où la lucidité est altérée et de mettre en œuvre proportionnellement les mesures utiles. Il permettra également de délivrer une information efficace au patient, corollaire de la question du consentement, et de sensibiliser ce dernier sur les conséquences de sa décision, en veillant qu’elle ait été exprimée en parfaite connaissance de cause. Il semblerait alors utile que les référentiels et recommandations portant sur le secours d’urgence à personne, émanant de la Direction générale de la sécurité civile et gestion de crise, détaillent plus ces situations difficiles afin que les secouristes puissent les anticiper plus efficacement. Enfin, nous proposons un formalisme qui pourrait être envisagé et mis en place dans les cas de refus de prise en charge chez une personne lucide, et nous présentons les intérêts d’une telle mise en place.

Conclusion (proposition de traduction) : La recherche du consentement de la personne aux soins qui lui sont proposés est un principe fondamental aussi bien par les textes que par la jurisprudence. Cette recherche du consentement, qui s’impose aux professionnels de santé, est tout aussi fondamentale pour les secouristes qui interviennent en préhospitalier. En effet, ces primo-intervenants font partie de la chaîne de soins lato sensu, car du fait de la régulation médicale par le SAMU, l’intervention des secours (non médicalisés) prend déjà des caractéristiques de soins.
Ce principe du respect du consentement de la personne, y compris par des services de secours non médicalisés, s’impose donc avant tout dans un but d’humanisme. Ainsi, il est indispensable que les secouristes et le médecin régulateur travaillent de concert afin que la personne bénéficie d’un secours approprié à sa pathologie et, surtout, qu’elle y consente. Cela permettra d’assurer la qualité de l’action des secours, et ainsi de prévenir les contentieux.
À défaut de consentement, c’est véritablement le travail d’équipe qui permettra de déceler les hypothèses où la lucidité est altérée et de mettre en œuvre proportionnellement les mesures utiles. C’est également ce travail d’équipe entre le médecin et les secouristes qui permettra de délivrer une information efficace au patient, corollaire de la question du consentement, et de sensibiliser ce dernier sur les conséquences de sa décision, en veillant qu’elle ait été exprimée en parfaite connaissance de cause.
À cet effet aussi, il serait sans doute utile que les référentiels et recommandations portant sur le secours d’urgence à personne et émanant de la Direction générale de la sécurité civile et gestion de crise, détaillent plus ces situations difficiles afin que les secouristes puissent en appréhender toute la dimension et les anticiper d’autant plus efficacement.Déclaration de liens d’intérêtsLes auteurs déclarent ne pas avoir de liens d’intérêts.

Profil clinique, étiologie et résultats du traumatisme oculaire chez l'enfant : point de vue d'un pays en voie de développement |

Clinical Profile, Etiology, and Outcome of Infantile Ocular Trauma: A Developing Country Perspective.
Shah VD, Uddaraju M, Singh A, Das RR. | Pediatr Emerg Care. 2019 Aug;35(8):558-560
DOI: https://doi.org/10.1097/PEC.0000000000001209
Keywords: Aucun

Original articles

Introduction : The aim of this article was to study the clinical profile, etiology, and outcome of infantile ocular trauma in a developing country setting.

Méthode : A retrospective study on corneal trauma in infants (≤12 months old) was undertaken in a tertiary care hospital during a 2-year period. An analysis of clinical profile, etiology, microbiological profile, clinical course, and outcome was studied.

Résultats : Seventy-six infants were included. Approximately 69% presented within 24 hours of injury. The common presentations were inability to open the eyelids, redness of eyes, and watering. Self-infliction by child's hand (49%) was found to be the main cause of corneal trauma. Corneal abrasion was seen in 34 cases (45%), isolated epithelial defects were seen in 30%, and infective keratitis was seen in 25%. Infection was found in 14 cases (fungal filaments in 7 and gram-positive cocci in 7). Only 36 infants followed up regularly in the hospital. All the infants following up in the hospital recovered in due course.

Conclusion : Infantile ocular trauma is a common morbidity that is underreported. Self-infliction by child's hand was found to be the main cause of corneal trauma. Cases presenting early and following up regularly till recovery have a favorable clinical course with good outcome. A high loss to follow-up indicates that awareness needs to be created among the caregivers.

Conclusion (proposition de traduction) : Les traumatismes oculaires infantiles sont une morbidité commune qui est sous-déclarée. L’auto-infliction de la main de l’enfant est la principale cause de traumatisme cornéen. Les cas qui se présentent tôt et qui sont suivis régulièrement jusqu'à la guérison présentent une évolution clinique favorable avec de bons résultats. Une perte de suivi élevée indique qu'il faut sensibiliser les aidants naturels.

Validation du score de triage physiologique et anatomique de l'enfant chez des patients pédiatriques blessés |

Validation of the Pediatric Physiological and Anatomical Triage Score in Injured Pediatric Patients.
Muguruma T, Toida C, Furugori S, Abe T, Takeuchi I. | Prehosp Disaster Med. 2019 Aug;34(4):363-369.
DOI: https://doi.org/10.1017/S1049023X19004552
Keywords: Triage Revised Trauma Score; injured pediatric patient; mass-casualty incident; physiological and anatomical triage; secondary triage

Original Research

Introduction : Triaging plays an important role in providing suitable care to a large number of casualties in a disaster setting. A Pediatric Physiological and Anatomical Triage Score (PPATS) was developed as a new secondary triage method. This study aimed to validate the accuracy of the PPATS in identifying injured pediatric patients who are admitted at a high frequency and require immediate treatment in a disaster setting. The PPATS method was also compared with the current triage methods, such as the Triage Revised Trauma Score (TRTS).

Méthode : A retrospective review of pediatric patients aged ≤15 years, registered in the Japan Trauma Data Bank (JTDB) from 2012 through 2016, was conducted and PPATS was performed. The PPATS method graded patients from zero to 22, and was calculated based on vital signs, anatomical abnormalities, and the need for life-saving interventions. It categorized patients based on their priority, and the intensive care unit (ICU)-indicated patients were assigned a PPATS ≥six. The accuracy of PPATS and TRTS in predicting the outcome of ICU-indicated patients was compared.

Résultats : Of 2,005 pediatric patients, 1,002 (50%) were admitted to the ICU. The median age of the patients was nine years (interquartile range [IQR]: 6-13 years). The sensitivity and specificity of PPATS were 78.6% and 43.7%, respectively. The area under the receiver-operating characteristic (ROC) curve (AUC) was larger for PPATS (0.61; 95% confidence interval [CI], 0.59-0.63) than for TRTS (0.57; 95% CI, 0.56-0.59; P <.01). Regression analysis showed a significant correlation between PPATS and the Injury Severity Score (ISS; r2 = 0.353; P <.001), predicted survival rate (r2 = 0.396; P <.001), and duration of hospital stay (r2 = 0.252; P <.001).

Conclusion : The accuracy of PPATS for injured pediatric patients was superior to that of current secondary triage methods. The PPATS method is useful not only for identifying high-priority patients, but also for determining the priority ranking for medical treatments and evacuation.

Conclusion (proposition de traduction) : L'exactitude du score de triage physiologique et anatomique pédiatrique (PPATS) pour les enfants blessés était supérieure à celle des méthodes actuelles de triage secondaire.
La méthode du Score de triage physiologique et anatomique pédiatrique est utile non seulement pour identifier les patients hautement prioritaires, mais aussi pour déterminer le classement prioritaire pour les traitements médicaux et l'évacuation.

Déterminants du patient, du voisinage et de l'espace sur les résultats des arrêts cardiaques extra-hospitalier tout au long de la chaîne de survie : analyse multi-niveau axée sur la communauté |

Patient, Neighborhood, and Spatial Determinants of Out-of-Hospital Cardiac Arrest Outcomes Throughout the Chain of Survival: A Community-Oriented Multilevel Analysis.
Gul SS, Cohen SA, Becker TK, Huesgen K, Jones JM, Tyndall JA. | Prehosp Emerg Care. 2019 Aug 5:1-12
DOI: https://doi.org/10.1080/10903127.2019.1640324
Keywords: chain of survival; community-based; neurological outcomes; out-of-hospital cardiac arrest; prehospital; spatial distribution

Article

Introduction : Global and national trends of out-of-hospital cardiac arrest (OHCA) have been examined; however, geographic variation and socioeconomic disparities of OHCA outcomes in the community setting are less understood. We developed and tested a replicable, community-oriented assessment strategy aimed to identify spatial variations in OHCA outcomes using socioeconomic, prehospital, and in-hospital factors.

Méthode : Emergency medical service (EMS) records of adult, non-traumatic OHCA within Alachua County, FL (2012-2017) were retrospectively reviewed and matched to corresponding medical records at the University of Florida (UF). Incidence of cardiac arrest was geocoded to census tracts and connected to U.S. census socioeconomic attribute data. Primary outcomes include survival to emergency department (ED), hospital admission, discharge, and discharge to home. Multilevel mixed-effects logistic regression models were developed to assess sub-county geographic variance, probabilities of survival, and prehospital risk factors. Getis-Ord Gi statistic and Moran's I-test was applied to assess spatial clustering in outcome survival rates.

Résultats : Of the 1562 OHCA cases extracted from EMS records, 1,335 (85.5%) were included with 372 transported to study site. Predicted probability of survival to ED was 57.0% (95CI: 51.3-62.3%). Of transported cases to study site ED, predicted probabilities of survival was to 41.7% (95CI: 36.1-47.6%) for hospital admission, 16.1% (95CI: 10.7-23.5%) for hospital discharge, and 7.1% (95CI: 3.7-13.3%) for home discharge. Census tracts accounted for significant variability in survival to ED (p < 0.001), discharge (p = 0.031), and home discharge outcomes (p = 0.036). There was no significant geographic variation in survival to admission outcome. Neighborhood-level factors significantly improved model fit for survival to ED, discharge, and discharge home outcomes. Multiple modifiable patient- and neighborhood-level variables of interest were identified, including rural-urban differences.

Conclusion : We identified important geographic disparities that exist in OHCA outcomes at the community level. By using a replicable schematic, this variation can be explained through community-oriented modifiable socioeconomic and prehospital factors.

Conclusion (proposition de traduction) : Nous avons relevé d'importantes disparités géographiques sur les résultats des arrêts cardiaques extra-hospitalier au niveau communautaire. En utilisant un schéma reproductible, cette variation peut s'expliquer par des facteurs socioéconomiques et préhospitaliers modifiables et axés sur la communauté.

Weighing CAM : une nouvelle application mobile pour l'estimation du poids en réanimation pédiatrique |

"Weighing CAM": A New Mobile Application for Weight Estimation in Pediatric Resuscitation.
Park JW, Kwon H, Jung JY, Choi YJ, Lee JS, Cho WS, Lee JC, Kim HC, Lee SU, Kwak YH, Kim DK. | Prehosp Emerg Care. 2019 Aug 1:1-14
DOI: https://doi.org/10.1080/10903127.2019.1651432
Keywords: Body Weight; Mobile Applications; Pediatric Emergency Medicine; Resuscitation; Smartphone

Article

Introduction : We evaluated the validity of a newly developed mobile application (i.e., the Weighing Cam) for pediatric weight estimation compared with that of the Broselow tape.

Méthode : We developed an application that estimates the weight of pediatric patients using a smartphone camera and displays the drug dosage, device size, and defibrillation energy on the screen of the smartphone. We enrolled a convenience sample of pediatric patients aged <16 years who presented at two pediatric emergency departments of two tertiary academic hospitals in South Korea. The pediatric patients' heights and weights were measured; then, one researcher estimated the weights using the application. Using the measured height, we determined the weight estimated by the Broselow tape. We compared the estimated measurements by determining the mean percentage error (MPE), mean absolute percentage error, root mean square percentage error, and percentages predicted within 10% and 20% of the actual.

Résultats : In total, 480 patients were enrolled in 16 age categories, each with 15 males and 15 females of different ages. The Weighing Cam demonstrated a lower bias (mean difference: -1.98% [95% confidence interval -2.91% to -1.05%] for MPE) and a higher proportion of estimated weights within 10% of the actual weights than the Broselow tape (mean difference: 9.1% [95% confidence interval 3.0% to 15.1%]). The Weighing Cam showed better performance in terms of accuracy and precision than the Broselow tape in all subgroups stratified by age or body mass index percentile.

Conclusion : The Weighing Cam may estimate pediatric patients' weights more accurately than the Broselow tape. The Weighing Cam may be useful for pediatric resuscitation in both prehospital and hospital settings.

Conclusion (proposition de traduction) : La caméra de pesée peut estimer le poids des patients pédiatriques avec plus de précision que la règle de Broselow. La caméra de pesée peut être utile pour la réanimation pédiatrique dans les environnements préhospitaliers et hospitaliers.

Commentaire : Seulement sur Google Play : Weighing cam . Mise à jour : 21 novembre 2017. Nécessite Android : 4.0 ou version ultérieure.

Height estimation algorithm.

Déterminants du patient, du voisinage et de l'espace sur les résultats des arrêts cardiaques extra-hospitaliers tout au long de la chaîne de survie : analyse multiniveau axée sur la communauté |

Patient, Neighborhood, and Spatial Determinants of Out-of-Hospital Cardiac Arrest Outcomes Throughout the Chain of Survival: A Community-Oriented Multilevel Analysis.
Gul SS, Cohen SA, Becker TK, Huesgen K, Jones JM, Tyndall JA. | Prehosp Emerg Care. 2019 Aug 5:1-12
DOI: https://doi.org/10.1080/10903127.2019.1640324
Keywords: chain of survival; community-based; neurological outcomes; out-of-hospital cardiac arrest; prehospital; spatial distribution

Original Articles

Introduction : Global and national trends of out-of-hospital cardiac arrest (OHCA) have been examined; however, geographic variation and socioeconomic disparities of OHCA outcomes in the community setting are less understood. We developed and tested a replicable, community-oriented assessment strategy aimed to identify spatial variations in OHCA outcomes using socioeconomic, prehospital, and in-hospital factors.

Méthode : Emergency medical service (EMS) records of adult, non-traumatic OHCA within Alachua County, FL (2012-2017) were retrospectively reviewed and matched to corresponding medical records at the University of Florida (UF). Incidence of cardiac arrest was geocoded to census tracts and connected to U.S. census socioeconomic attribute data. Primary outcomes include survival to emergency department (ED), hospital admission, discharge, and discharge to home. Multilevel mixed-effects logistic regression models were developed to assess sub-county geographic variance, probabilities of survival, and prehospital risk factors. Getis-Ord Gi statistic and Moran's I-test was applied to assess spatial clustering in outcome survival rates.

Résultats : Of the 1562 OHCA cases extracted from EMS records, 1,335 (85.5%) were included with 372 transported to study site. Predicted probability of survival to ED was 57.0% (95CI: 51.3-62.3%). Of transported cases to study site ED, predicted probabilities of survival was to 41.7% (95CI: 36.1-47.6%) for hospital admission, 16.1% (95CI: 10.7-23.5%) for hospital discharge, and 7.1% (95CI: 3.7-13.3%) for home discharge. Census tracts accounted for significant variability in survival to ED (p < 0.001), discharge (p = 0.031), and home discharge outcomes (p = 0.036). There was no significant geographic variation in survival to admission outcome. Neighborhood-level factors significantly improved model fit for survival to ED, discharge, and discharge home outcomes. Multiple modifiable patient- and neighborhood-level variables of interest were identified, including rural-urban differences.

Conclusion : We identified important geographic disparities that exist in OHCA outcomes at the community level. By using a replicable schematic, this variation can be explained through community-oriented modifiable socioeconomic and prehospital factors.

Conclusion (proposition de traduction) : Nous avons identifié d’importantes disparités géographiques dans les résultats des arrêt cardiaques extra-hospitaliers au niveau des communautés. En utilisant un schéma reproductible, cette variation peut s'expliquer par des facteurs socioéconomiques et préhospitaliers modifiables et axés sur la communauté.

Oxygénation de l'apnée pour prévenir la désaturation en oxyhémoglobine lors d'une intubation en séquence rapide dans un service d'urgence pédiatrique |

Apneic oxygenation to prevent oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department.
Overmann KM, Boyd SD, Zhang Y, Kerrey BT. | Am J Emerg Med. 2019 Aug;37(8):1416-1421
DOI: https://doi.org/10.1016/j.ajem.2018.10.030
Keywords: Airway management; Apneic oxygenation; Emergency department; Intubation; Pediatrics

Original contribution

Introduction : Apneic oxygenation is the delivery of oxygen to the nasopharynx during intubation. It may mitigate the risk of oxyhemoglobin desaturation but has not been well-studied in children.

Méthode : We conducted a retrospective, observational study of patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department. We compared patients who received apneic oxygenation, delivered via simple nasal cannula at age-specific flow rates, to patients who did not receive apneic oxygenation. The main outcome was occurrence of oxyhemoglobin desaturation during RSI, defined as oxyhemoglobin saturation dropping to <90% at any time after the administration of paralytic medication and before the endotracheal tube was secured. Data were analyzed using logistic regression, with groups as a fixed effect and patients' age and number of attempts as covariates.

Résultats : Data were collected for 305 of 323 patients who underwent RSI over a 49 month period. Oxyhemoglobin desaturation occurred for 50 patients when apneic oxygenation was used (22%, 95% CI 17% to 28%) and 11 patients without apneic oxygenation (14%, 95% CI 7% to 24%; p > 0.05). There was no difference in the median duration of desaturation or depth of desaturation for the apneic oxygenation group (52 s, 71%) compared to the group without apneic oxygenation (65 s, 79%; p > 0.05). Controlling for covariates, apneic oxygenation was not associated with a lower risk of oxyhemoglobin desaturation, time to desaturation, or depth/duration of desaturation episodes.

Conclusion : In an observational, video-based study of pediatric patients, apneic oxygenation was not associated with a lower risk of oxyhemoglobin desaturation during RSI.

Conclusion (proposition de traduction) : Dans une étude observationnelle par vidéo chez des patients pédiatriques, l'oxygénation apnéique n'a pas été associée à un risque moindre de désaturation de l'oxyhémoglobine pendant l'intubation en séquence rapide.

Comparaison des effets analgésiques de l'halopéridol avec ou sans morphine chez des patients présentant une colique néphrétique aiguë : une étude clinique en double aveugle randomisée |

Comparison of the analgesic effects of haloperidol with or without morphine in patients with acute renal colic: A randomized double-blind clinical trial study.
Masoumi K, Delirrooyfard A, Salehzadeh M. | Am J Emerg Med. 2019 Aug;37(8):1422-1427
DOI: https://doi.org/10.1016/j.ajem.2018.10.031
Keywords: Haloperidol; Pain management; Renal colic; Sedation

Original contribution

Introduction : Given the increasing number of patients with acute renal colic, the present study examined the analgesic effects of haloperidol with or without morphine in order to find an effective method with fewer side effects for pain reduction in these patients.

Méthode : In the present randomized double-blind clinical trial study, patients with a pain severity score of above 3 were randomly divided into 2 equal groups: Group A received intravenous morphine and haloperidol, and Group B received intravenous morphine with normal saline. Pain severity was recorded at Times 0, 20, 40, and 60 min following the injections based on a visual pain analog scale (VPAS) from 0 to 10.

Résultats : A total of 140 patients were included in this study. A comparison of the recorded pain severity scores did not show a significant difference between the 2 study groups (P = 0.38). The mean heart rate, the mean systolic and diastolic blood pressures, and the mean incidence rate of nausea and vomiting were not significantly different between Group A and Group B. The frequency of extrapyramidal side effects was 4.3% in the haloperidol group, which was not significantly different from that of the other group. The frequency of extra analgesic requirement was not significantly different between the 2 groups (P = 0.05).

Conclusion : In our patients with acute renal colic, haloperidol failed to reduce pain and the incidence of nausea or vomiting, while it caused extrapyramidal side effects. Therefore, the prescription of this medication for acute pains, especially in renal colic, is not recommended.

Conclusion (proposition de traduction) : Chez nos patients présentant une colique rénale aiguë, l'halopéridol n'a pas permis de réduire la douleur et l'incidence des nausées ou des vomissements, alors qu'il provoquait des effets indésirables extrapyramidaux. Par conséquent, la prescription de ce médicament pour les douleurs aiguës, en particulier les coliques néphrétiques, n'est pas recommandée.

Reconnaissance précoce du sepsis par le dépistage préhospitalier des services médicaux d'urgence |

Early recognition of sepsis through emergency medical services pre-hospital screening.
Borrelli G, Koch E, Sterk E, Lovett S, Rech MA. | Am J Emerg Med. 2019 Aug;37(8):1428-1432
DOI: https://doi.org/10.1016/j.ajem.2018.10.036
Keywords: Emergency medical services; Pre-hospital; Sepsis

Original contribution

Introduction : BACKGROUND: The Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance.
OBJECTIVES: To determine if pre-hospital sepsis screening improves 3-hour bundle compliance.

Méthode : Prospective implementation of an EMS sepsis screening tool (June 2016-November 2016) was compared to a historical control (August 2015-March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components.

Résultats : Of 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2-8] vs. 2 [IQR 1-4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0-35] vs. 46 min [IQR 34-57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0-38] vs. 46 min [IQR 27.5-72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44-92] vs. 72 min [IQR 59.5-112], p = 0.26).

Conclusion : Implementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.

Conclusion (proposition de traduction) : La mise en œuvre d'un outil de dépistage du sepsis par les services médicaux d'urgence a permis d'améliorer la conformité des processus de soins de trois heures par rapport au contrôle rétrospectif.

Règle de prédiction clinique pour prédire la pneumonie chez l'adulte atteint d'une maladie respiratoire fébrile aiguë |

Clinical prediction rule to predict pneumonia in adult presented with acute febrile respiratory illness.
Tse CF, Chan YYF, Poon KM, Lui CT. | Am J Emerg Med. 2019 Aug;37(8):1433-1438
DOI: https://doi.org/10.1016/j.ajem.2018.10.039
Keywords: Aucun

Original contribution

Introduction : To derive a clinical prediction rule to predict pneumonia in patients with acute febrile respiratory illness to emergency departments.

Méthode : This was a prospective multicentre study. 537 adults were recruited. Those requiring resuscitation or were hypoxaemic on presentation were excluded. Pneumonia was defined as new onset infiltrates on chest X-ray (CXR), or re-attendance within 7 days and diagnosed clinically as having pneumonia. A predictive model, the Acute Febrile Respiratory Illness (AFRI) rule was derived by logistic regression analysis based on clinical parameters. The AFRI rule was internally validated with bootstrap resampling and was compared with the Diehr and Heckerling rule.

Résultats : In the 363 patients who underwent CXR, 100 had CXR confirmed pneumonia. There were 7 weighted factors within the ARFI rule, which on summation, gave the AFRI score: age ≥ 65 (1 point), peak temperature within 24 h ≥ 40 °C (2 points), fever duration ≥3 days (2 points), sore throat (-2 points), abnormal breath sounds (1 point), history of pneumonia (1 point) and SpO2 ≤ 96% (1 point). With the bootstrap resampling, the AFRI rule was found to be more accurate than the Diehr and Heckerling rule (area under ROC curve 0.816, 0.721 and 0.566 respectively, p < 0.001). At a cut-off of AFRI≥0, the rule was found to have 95% sensitivity, with a negative predictive value of 97.2%. Using the AFRI score, we found CXR could be avoided for patients having a score of <0.

Conclusion : AFRI score could assist emergency physicians in identifying pneumonia patients among all adult patients presented to ED for acute febrile respiratory illness.

Conclusion (proposition de traduction) : Le score de maladie respiratoire aiguë fébrile pourrait aider les urgentistes à identifier les patients atteints de pneumopathie parmi tous les patients adultes admis aux urgences pour une maladie respiratoire aiguë fébrile.

Effet de l'emplacement sur l'utilisation du défibrillateur automatisé externe et association de l'âge avec le retour d'une circulation spontanée sur les lieux. |

Locational effect on automated external defibrillator use and association of age with on-site return of spontaneous circulation.
Wang TH, Lin HA, Kao WF, Chao CC. | Am J Emerg Med. 2019 Aug;37(8):1446-1449
DOI: https://doi.org/10.1016/j.ajem.2018.10.043
Keywords: Aucun

Original contribution

Introduction : Emergency medical services (EMSs) are used by approximately 383,000 patients with out-of-hospital sudden cardiac arrest (SCA) in the United States. Hence, it is crucial to implement automated external defibrillator (AED) programs to prepare responders for an SCA emergency. Taiwanese pass legislature to enforce AED installation in 8 mandatory areas since 2013. Our study investigated the efficacy of the policy regarding AED installation.

Méthode : We collected data of patients who had sudden cardiac arrest (SCA) in pre-hospital settings, and received resuscitative efforts, including cardiopulmonary resuscitation or defibrillation with AEDs. The data were from July 11, 2013 to July 31, 2015. In total, 209 adult patients were documented by on-site caregivers of different facilities, and a report was mailed to the central health and welfare unit.

Résultats : Schools, large-scale gathering places, and special institutions used AEDs the most, accounting for 33 (15.3%) cases. From non-mandatory AED areas, long-term care facilities had the maximum cases of AED use (32 cases; 14.9%). With commuting stations as a reference, long-distance transport had the lowest odds ratio (OR) of 0.481 (95% confidence interval [CI], 0.24-0.962). The OR for schools, large-scale gathering places, and special institutions was 4.474 (95% CI: 2.497-8.015). Regarding failure of return of spontaneous circulation (ROSC), the OR for the ≥80-year age group was higher than that for the 20-39-year age group.

Conclusion : The policy regarding the legislation to install AEDs in mandatory areas improved AED accessibility. Elderly patients aged ≥80 years have a higher rate of ROSC failure.

Conclusion (proposition de traduction) : La politique relative à la législation visant à installer des DEA dans des zones obligatoires a amélioré l’accessibilité des DEA. Les patients âgés âgés de 80 ans et plus présentent un taux d'échec plus élevé de RACS.

Temps corrigé du flux carotidien et élévation passive de la jambe en tant que mesure du statut volumique |

Corrected carotid flow time and passive leg raise as a measure of volume status.
Chebl RB, Wuhantu J, Kiblawi S, Dagher GA, Zgheib H, Bachir R, Carnell J. | Am J Emerg Med. 2019 Aug;37(8):1460-1465
DOI: https://doi.org/10.1016/j.ajem.2018.10.047
Keywords: Carotid; Flow time; Hemodialysis; Passive leg raise; Responsiveness; Shock; Volume status

Original contribution

Introduction : The aim of this study was to investigate the value of corrected carotid flow time (FTc) with passive leg raise (PLR) as a non-invasive marker of volume status in end stage renal disease (ESRD) patients.

Méthode : Prospective observational study of ESRD patients presenting to the Emergency department requiring hemodialysis. The common carotid artery was evaluated in long axis. Flow time measurements pre- and post-dialysis as well as before and after PLR were recorded.

Résultats : 54 patients were enrolled, of which, 30 (55%) were male. The mean age was 47.4 years. The mean volume of fluid removed was 3.89 ± 0.91 L. In the pre-dialysis cohort, the mean FTc was 340.16 ms (95% CI, 330.36-349.95). Following PLR, the mean FTc was 341.34 ms (95% CI 331.74-350.94). In the post hemodialysis cohort, the mean FTc was 302.48 ms (95% CI, 293.63-311.32). Following the PLR maneuver, the mean FTc was 340.49 ms (95% CI 331.97-349.02). The mean decrease in corrected carotid flow time was 19.15 ms (95% CI, 22.86-41.17), 32.02 ms (95% CI 4.05-34.25) and 41.17 ms (95% CI, 36.47-54.76) for patients who had <3 L, 3-4 L and >4 L removed, respectively. In patients without CHF, the mean decrease in FTc after hemodialysis was 38.80 ms (95% CI, 30.12-47.49) whereas for CHF patients the mean decrease was 35.60 ms (95% CI, 25.05-46.15).

Conclusion : Corrected flow time in conjunction with passive leg raise seem to correlate with volume status in hemodialysis patients.

Conclusion (proposition de traduction) : Le temps de flux corrigé associé à l’élévation passive de la jambe semble être corrélé au statut du volume chez les patients hémodialysés.

Le rapport de neutrophiles/lymphocytes comme marqueur de diagnostic d'une bactériémie : revue systématique et méta-analyse |

The neutrophil-lymphocyte count ratio as a diagnostic marker for bacteraemia: A systematic review and meta-analysis.
Jiang J, Liu R, Yu X, Yang R, Xu H, Mao Z, Wang Y. | Am J Emerg Med. 2019 Aug;37(8):1482-1489
DOI: https://doi.org/10.1016/j.ajem.2018.10.057
Keywords: Bacteraemia; Diagnosis; Meta-analysis; Neutrophil-lymphocyte count ratio

Original contribution

Introduction : Bacteraemia is a common cause of increased morbidity and mortality in critically ill patients, but its early diagnosis and identification are complicated. The neutrophil-lymphocyte count ratio (NLCR) has been suggested as a useful indicator for the diagnosis of bacteraemia. We performed this meta-analysis to investigate the diagnostic accuracy of the NLCR for bacteraemia.

Méthode : We searched the PubMed, Embase, Web of Science, and Cochrane Library databases for this meta-analysis. We calculated individual and pooled sensitivities and specificities. I2 statistics and Cochran's Q test were used to evaluate heterogeneity, and the cause of heterogeneity was explored with sensitivity analyses.

Résultats : In total, 8 of 1086 eligible articles were included in the present meta-analysis. The pooled analyses revealed that the diagnostic accuracy of the NLCR in terms of its bacteraemia sensitivity was 0.723 [95% CI: 0.660, 0.777], and its specificity was 0.596 [95% CI: 0.556, 0.634]. The area under the summary receiver operating characteristic curve was 0.69 [95% CI 0.65-0.73].

Conclusion : The NLCR is an easy-to-collect marker for bacteraemia. However, the NLCR is inadequate, and only a combination of multiple biomarkers will improve its diagnostic accuracy for bacteraemia.

Conclusion (proposition de traduction) : Le rapport de neutrophiles/lymphocytes est un marqueur facile à recueillir pour la bactériémie. Cependant, le rapport de numération neutrophiles-lymphocytes est inadéquat et seule une combinaison de plusieurs biomarqueurs améliorera sa précision diagnostique pour la bactériémie.

Comparaison du SIRS, qSOFA et NEWS pour le dépistage précoce d'une septicémie au service des urgences |

Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department.
Usman OA, Usman AA, Ward MA. | Am J Emerg Med. 2019 Aug;37(8):1490-1497
DOI: https://doi.org/10.1016/j.ajem.2018.10.058
Keywords: Critical care; NEWS; SIRS; Sepsis; Triage; qSOFA

Original contribution

Introduction : The increasing use of sepsis screening in the Emergency Department (ED) and the Sepsis-3 recommendation to use the quick Sepsis-related Organ Failure Assessment (qSOFA) necessitates validation. We compared Systemic Inflammatory Response Syndrome (SIRS), qSOFA, and the National Early Warning Score (NEWS) for the identification of severe sepsis and septic shock (SS/SS) during ED triage.

Méthode : This was a retrospective analysis from an urban, tertiary-care academic center that included 130,595 adult visits to the ED, excluding dispositions lacking adequate clinical evaluation (n = 14,861, 11.4%). The SS/SS group (n = 930) was selected using discharge diagnoses and chart review. We measured sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) for the detection of sepsis endpoints.

Résultats : NEWS was most accurate for triage detection of SS/SS (AUROC = 0.91, 0.88, 0.81), septic shock (AUROC = 0.93, 0.88, 0.84), and sepsis-related mortality (AUROC = 0.95, 0.89, 0.87) for NEWS, SIRS, and qSOFA, respectively (p < 0.01 for NEWS versus SIRS and qSOFA). For the detection of SS/SS (95% CI), sensitivities were 84.2% (81.5-86.5%), 86.1% (83.6-88.2%), and 28.5% (25.6-31.7%) and specificities were 85.0% (84.8-85.3%), 79.1% (78.9-79.3%), and 98.9% (98.8-99.0%) for NEWS ≥ 4, SIRS ≥ 2, and qSOFA ≥ 2, respectively.

Conclusion : NEWS was the most accurate scoring system for the detection of all sepsis endpoints. Furthermore, NEWS was more specific with similar sensitivity relative to SIRS, improves with disease severity, and is immediately available as it does not require laboratories. However, scoring NEWS is more involved and may be better suited for automated computation. QSOFA had the lowest sensitivity and is a poor tool for ED sepsis screening.

Conclusion (proposition de traduction) : NEWS était le système de notation le plus précis pour la détection de tous les paramètres du sepsis. De plus, NEWS était plus spécifique avec une sensibilité similaire par rapport au SIRS, s'améliorait avec la gravité de la maladie, et était immédiatement disponible car il ne nécessite pas de laboratoires. Cependant, la réalisation du score NEWS est plus complexe et peut être mieux adaptée à un calcul automatisé.
Le qSOFA avait la sensibilité la plus faible et constituait un outil médiocre pour le dépistage de la septicémie aux urgences.

Commentaire : Retrouver la présentation du score NEWS sur le site Internet de la National Health Service (NHS).
Calculateur en ligne du score NEWS (Attention, le score NEWS 2 est recommandé par le NHS en tant que version mise à jour du NEWS d'origine) et NEWS 2 .

Fiabilité des mesures des paramètres vitaux sur un smartphone : une étude prospective utilisant une méthode de référence |

Reliability of smartphone measurements of vital parameters: A prospective study using a reference method.
Tayfur İ, Afacan MA. | Am J Emerg Med. 2019 Aug;37(8):1527-1530
DOI: https://doi.org/10.1016/j.ajem.2019.03.021
Keywords: Aucun

Original contribution

Introduction : In this study, we aimed to evaluate the accuracy of HR and SaO2 data obtained using a smartphone compared with the measurements of a vital signs monitor (VSM) and an arterial blood gas (ABG) device, respectively.

Méthode : In this single-center prospective study, the HR and SaO2 measurements were performed using the built-in sensor and light source of a Samsung Galaxy S8 smartphone and compared to the results of VSM and ABG device. The Bland-Altman analysis was used to evaluate and visualize the agreement between the methods.

Résultats : The data of 101 patients were analyzed. There was a high correlation between HR measured by smartphone and HR measured by VSM [P < 0.0001; 0.9918 (95% CI = 0.987-0.994)]. In addition, the SaO2 values obtained by smartphone were highly correlated with those by ABG (P < 0.0001; 0.968 (95% CI = 0.952-0.978)).

Conclusion : The HR and SaO2 values obtained by smartphone were found to be consistent with the measurements of the reference devices. With the growing use of smartphone technology in the health field, we foresee that patients will be able to make their own triage assessment before presenting to the hospital.

Conclusion (proposition de traduction) : Les valeurs de fréquence cardiaque et de la saturation en oxygène obtenues par smartphone se sont révélées cohérentes avec les mesures des appareils de référence.
Avec l'utilisation croissante de la technologie des smartphones dans le domaine de la santé, nous prévoyons que les patients pourront effectuer leur propre évaluation de triage avant de se présenter à l'hôpital.

Échographie au point d'intervention pour l'évaluation des perturbations visuelles non traumatiques dans les services d'urgence : protocole VIGMO |

Point-of-care ultrasound for the evaluation of non-traumatic visual disturbances in the emergency department: The VIGMO protocol.
Gandhi K, Shyy W, Knight S, Teismann N. | Am J Emerg Med. 2019 Aug;37(8):1547-1553
DOI: https://doi.org/10.1016/j.ajem.2019.04.049
Keywords: Eye ultrasound; Ultrasound for optic nerve pathology; Ultrasound for retinal detachment; Ultrasound for vitreous detachment; Ultrasound for vitreous hemorrhage

Diagnostics

Introduction : o establish a standardized approach for the rapid and accurate identification of non-traumatic, ophthalmologic pathology in patients with eye complaints in the emergency department.

Méthode : In this detailed protocol we offer an easy, reproducible method for the use of ocular point-of-care ultrasound (POCUS) in helping practitioners identify and distinguish between common eye pathology encountered in the emergency setting: retinal detachment, vitreous detachment, vitreous hemorrhage, optic nerve pathology, and syneresis.

Conclusion : This protocol can help identify patients that may need urgent ophthalmology consultation those that can follow-up on an outpatient, and those that may need additional emergent testing.

Conclusion (proposition de traduction) : Ce protocole peut aider à identifier les patients devant nécessiter une consultation urgente en ophtalmologie, ceux pouvant faire un suivi en ambulatoire et ceux pouvant nécessiter des examens complémentaires supplémentaires en urgence.

Troubles du rythme et insuffisance cardiaque compliquant un infarctus aigu du myocarde : une revue de la médecine d’urgence |

Dysrhythmias and heart failure complicating acute myocardial infarction: An emergency medicine review.
Davis WT, Montrief T, Koyfman A, Long B. | Am J Emerg Med. 2019 Aug;37(8):1554-1561
DOI: https://doi.org/10.1016/j.ajem.2019.04.047
Keywords: Acute myocardial infarction; Atrial fibrillation; Bradycardia; Cardiogenic shock; Dysrhythmia; Heart block; Heart failure; Ventricular tachycardia

Reviews

Introduction : Patients with acute myocardial infarction (AMI) may suffer several complications after the acute event, including dysrhythmias and heart failure (HF). These complications place patients at risk for morbidity and mortality.

Méthode : This narrative review evaluates literature and guideline recommendations relevant to the acute emergency department (ED) management of AMI complicated by dysrhythmia or HF, with a focus on evidence-based considerations for ED interventions.

Discussion : Limited evidence exists for ED management of dysrhythmias in AMI due to relatively low prevalence and frequent exclusion of patients with active cardiac ischemia from clinical studies. Management decisions for bradycardia in the setting of AMI are determined by location of infarction, timing of the dysrhythmia, rhythm assessment, and hemodynamic status of the patient. Atrial fibrillation is common in the setting of AMI, and caution is warranted in acute rate control for rapid ventricular rate given the possibility of compensation for decreased ventricular function. Regular wide complex tachycardia in the setting of AMI should be managed as ventricular tachycardia with electrocardioversion in the majority of cases. Management directed towards HF from left ventricular dysfunction in AMI consists of noninvasive positive pressure ventilation, nitroglycerin therapy, and early cardiac catheterization. Norepinephrine is the first line vasopressor for patients with cardiogenic shock and hypoperfusion on clinical examination. Early involvement of a multi-disciplinary team is recommended when caring for patients in cardiogenic shock.

Conclusion : This review discusses considerations of ED management of dysrhythmias and HF associated with AMI.

Conclusion (proposition de traduction) : Cette revue de la littérature discute des considérations relatives à la gestion aux urgences des troubles du rythme et de l'insuffisance cardiaque associées à un infarctus aigu du myocarde.

Dispositifs d'assistance ventriculaire gauche et leurs complications : une revue pour les cliniciens d'urgence |

Left ventricular assist devices and their complications: A review for emergency clinicians.
Long B, Robertson J, Koyfman A, Brady W. | Am J Emerg Med. 2019 Aug;37(8):1562-1570
DOI: https://doi.org/10.1016/j.ajem.2019.04.050
Keywords: Controller; Driveline; Heart failure; Left ventricular assist device bridge; Pump; Ventricular assist device

Reviews

Introduction : End stage heart failure is associated with high mortality. However, recent developments such as the ventricular assist device (VAD) have improved patient outcomes, with left ventricular assist devices (LVAD) most commonly implanted.

Méthode : This narrative review evaluates LVAD epidemiology, indications, normal function and components, and the assessment and management of complications in the emergency department (ED).

Résultats : The LVAD is a life-saving device in patients with severe heart failure. While first generation devices provided pulsatile flow, current LVAD devices produce continuous flow. Normal components include the pump, inflow and outflow cannulas, driveline, and external controller. Complications related to the LVAD can be divided into those that are LVAD-specific and LVAD-associated, and many of these complications can result in severe patient morbidity and mortality. LVAD-specific complications include device malfunction/failure, pump thrombosis, and suction event, while LVAD-associated complications include bleeding, cerebrovascular event, infection, right ventricular failure, dysrhythmia, and aortic regurgitation. Assessment of LVAD function, patient perfusion, and mean arterial pressure is needed upon presentation. Electrocardiogram and bedside ultrasound are key evaluations in the ED. LVAD evaluation and management require a team-based approach, and consultation with the LVAD specialist is recommended.

Conclusion : Emergency clinician knowledge of LVAD function, components, and complications is integral in optimizing care of these patients.

Conclusion (proposition de traduction) : La connaissance des urgentistes du fonctionnement, des composants et des complications des dispositifs d’assistance ventriculaire gauche fait partie intégrante de l’optimisation des soins fournis à ces patients.

Commentaire : Voir l'article :
Perim D, Mazer-Amirshahi M, Trvalik A, Pourmand A. Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider. J Emerg Med. 2019 Jun;56(6):611-623  .

Survie à long terme après un arrêt cardiaque par noyade |

Long-Term Survival After Drowning-Related Cardiac Arrest.
Reynolds JC, Hartley T, Michiels EA, Quan L. | J Emerg Med. 2019 Aug;57(2):129-139
DOI: https://doi.org/10.1016/j.jemermed.2019.05.029
Keywords: cardiac arrest; drowning; long-term follow-up; mortality; national death index

Original Contributions

Introduction : Long-term outcomes after drowning-related cardiac arrest are not well characterized.
OBJECTIVE: Our aims were to estimate long-term survival and identify prognostic factors in a large, population-based cohort of drowning victims with cardiac arrest.

Méthode : We conducted a population-based prospective cohort study (1974-1996) of Western Washington Drowning Registry (WWDR) subjects with out-of-hospital cardiac arrest and attempted professional resuscitation. The primary outcome was long-term survival through 2012. We tabulated Utstein-style exposure variables, estimated Kaplan-Meier curves, and identified prognostic factors with Cox proportional hazard modeling.

Résultats : Of 2824 WWDR cases, 407 subjects (median age 17 years [interquartile range 3-33 years], 81% were male) were included. Only 54 (13%) were still alive after 1663 person-years of follow-up. Most deaths occurred after termination of initial resuscitation or during initial hospitalization. Risk of subsequent death after hospital discharge was 9.6 (95% confidence interval [CI] 5.7-15.9) per 1000 person-years. Long-term survival differed by Utstein variables (older age, illicit substance use, pre-drowning activity, submersion duration, cardiopulmonary resuscitation duration, intubation, defibrillation, and medications) and inpatient markers of illness severity (vital signs, Glasgow Coma Scale, laboratory values, shock). In adjusted analyses, older age (hazard ratio [HR] 1.01; 95% CI 1.01-1.02), epinephrine administration (HR 1.92; 95% CI 1.31-2.80), antiepileptic administration (HR 0.53; 95% CI 0.35-0.81), initial arterial pH (HR 0.49; 95% CI 0.26-0.92), and shock (HR 2.19; 95% CI 1.16-4.15) were associated with higher risk of death.

Conclusion : Most cases of drowning-related cardiac arrest were fatal, but survivors to hospital discharge had a low risk of subsequent death that was independently associated with older age and clinical evidence of shock.

Conclusion (proposition de traduction) : La plupart des cas d'arrêt cardiaque par noyade étaient mortels, mais les survivants à la sortie de l'hôpital présentaient un faible risque de décès subséquent qui était associé indépendamment à un âge plus avancé et à des signes cliniques de choc.

Commentaire : Etude portant sur 407 patients sur les 2 824 patients d'un registre (Registre des noyades dans l'ouest de Washington - WWDR).

La vieillesse associé à un mécanisme traumatique de blessure devrait être un critère d'activation de l'équipe de traumatologie |

Old Age With a Traumatic Mechanism of Injury Should Be a Trauma Team Activation Criterion.
Bardes JM, Benjamin E, Schellenberg M, Inaba K, Demetriades D. | J Emerg Med. 2019 Aug;57(2):151-155
DOI: https://doi.org/10.1016/j.jemermed.2019.04.003
Keywords: geriatric; overtriage; trauma team activation

Original Contributions

Introduction : Age is not a standard trauma team activation (TTA) criteria recommended by the Committee on Trauma. However, there is concern that vital signs in elderly patients are often unreliable. In addition, elderly patients are at risk after moderate trauma. At our institution, age ≥ 70 years with traumatic mechanisms of injury has been a TTA criterion for more than 15 years. OBJECTIVE: Our aim was to determine whether age ≥70 years as a TTA criterion appropriately identifies patients in need of additional resources without significantly impacting overtriage rates.

Méthode : We conducted a retrospective trauma registry study of TTAs for age ≥ 70 years from January 2012-December 2016. Demographics, injury data, Injury Severity Score (ISS), procedures, emergency department (ED) disposition, and hospital data were collected. Primary outcome was mortality, secondary outcomes were intensive care unit (ICU) and hospital lengths of stay. Patients were stratified into meeting standard criteria (TTA-S) or activated based on age alone (TTA-A). TTA patients with ISS > 15, ED intubation, ICU admission, immediate operating room or catheter-based intervention, and mortalities were appropriately triaged.

Résultats : During the study, there were 5436 total TTAs. Seven hundred and thirty-nine TTAs in patients aged ≥ 70 years, of which 198 (26.8%) were TTA-S and 541 (73.2%) were TTA-A. In the TTA-A group, 49 (9%) patients died, 149 (27.5%) had ISS > 15, 65 (12%) underwent immediate intervention, 72 (13%) had ED intubations, and 306 (56.6%) required admission to the ICU. The overtriage rate in the TTA-A group was 39.6%.

Conclusion : Elderly patients with severe trauma patients often do not meet the standard TTA criteria, resulting in potentially dangerous undertriage. Addition of age (≥70 years) criterion for TTA reduces undertriage and does not result in excessive overtriage.

Conclusion (proposition de traduction) : Les patients âgés ayant subi un traumatisme grave ne répondent souvent pas aux critères d'activation standard de l'équipe de traumatologie, ce qui entraîne un sous-triage potentiellement dangereux. L'ajout du critère de l'âge (≥ 70 ans) pour l'activation de l'équipe de traumatologie réduit le sous-triage et n'entraîne pas un surtriage.

Commentaire : Etude rétrospective portant sur 5 436 patients de janvier 2012 à décembre 2016.

Solithromycine versus ceftriaxone plus azithromycine pour le traitement de la gonorrhée génitale non compliquée (SOLITAIRE-U) : un essai randomisé de non-infériorité de phase 3 |

Solithromycin versus ceftriaxone plus azithromycin for the treatment of uncomplicated genital gonorrhoea (SOLITAIRE-U): a randomised phase 3 non-inferiority trial.
Chen MY, McNulty A, Avery A, Whiley D, Tabrizi SN, Hardy D, Das AF, Nenninger A, Fairley CK, Hocking JS, Bradshaw CS, Donovan B, Howden BP, Oldach D; Solitaire-U Team. | Lancet Infect Dis. 2019 Aug;19(8):833-842
DOI: https://doi.org/10.1016/S1473-3099(19)30116-1
Keywords: Aucun

ARTICLES

Introduction : Antibiotic-resistant gonorrhoea represents a global public health threat, and new therapies are needed. We aimed to compare the efficacy and safety of solithromycin, a fourth generation macrolide, with ceftriaxone plus azithromycin for the treatment of gonorrhoea.

Méthode : We did an open-label, multicentre, non-inferiority trial of patients aged 15 years or older with uncomplicated untreated genital gonorrhoea at two sites in Australia and one site in the USA. Patients were randomly assigned (1:1) to receive single dose oral solithromycin 1000 mg or intramuscular ceftriaxone 500 mg plus oral azithromycin 1000 mg. Neisseria gonorrhoeae cultures were obtained at baseline and test of cure (day 7 ± 2). The primary outcome was the proportion of patients with eradication of genital N gonorrhoeae based on culture at test of cure, assessed in the microbiological intention-to-treat (mITT) population, which included all randomly assigned patients who received any dose of study drug and had a positive genital culture for N gonorrhoeae at baseline. Non-inferiority of solithromycin was to be concluded if the lower limit of the 95% CI for the between-group differences was greater than -10%. Safety was analysed in all patients who received any dose of study drug.

Résultats : Between Sept 3, 2014, and Aug 27, 2015, 262 patients were randomly assigned and 261 received treatment (130 in the solithromycin group and 131 in the ceftriaxone plus azithromycin group). In the mITT population, 99 (80%) of 123 patients in the solithromycin group and 109 (84%) of 129 patients in the ceftriaxone plus azithromycin group had N gonorrhoeae eradication at test of cure (difference -4·0%, 95% CI -13·6 to 5·5), thus solithromycin did not meet the criterion for non-inferiority at the prespecified -10% margin. The frequency of adverse events was higher in the solithromycin group than the ceftriaxone plus azithromycin group (69 [53%] of 130 patients vs 45 [34%] of 131 patients), the most common of which were diarrhoea (31 [24%] of 130 patients vs 20 [15%] of 131 patients), and nausea (27 [21%] of 130 patients vs 15 [11%] of 131 patients).

Conclusion : Solithromycin as a single 1000 mg dose is not a suitable alternative to ceftriaxone plus azithromycin as first-line treatment for gonorrhoea. If insufficient duration of solithromycin exposure at the infection site in a subset of individuals was the reason for treatment failures, this might be adequately addressed with dose adjustment. However, any further trials with longer dosing need to consider the potential risk of gastrointestinal effects and liver enzyme elevations.

Conclusion (proposition de traduction) : La solithromycine en dose unique per os de 1 000 mg n'est pas une alternative appropriée à la ceftriaxone plus l'azithromycine comme traitement de première intention pour la gonorrhée. Si une durée insuffisante d'exposition à la solithromycine au site d'infection chez un sous-groupe d'individus était la raison des échecs du traitement, cela pourrait être traité de manière adéquate avec un ajustement de la dose. Cependant, tout autre essai avec une posologie plus longue doit tenir compte du risque potentiel d'effets gastro-intestinaux et d'élévation des enzymes hépatiques.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Solithromycine en dose unique per os (1 g), vs. ceftriaxone intra-musculaire (500 mg) + azithromycine per os (1 g), pour les gonococcies génitales non compliquées . Rédigé par le Dr Pierre Tattevin le 2 septembre 2019.

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