Bibliographie de Médecine d'Urgence

Mois de septembre 2019


Academic Emergency Medicine

A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation.
Scheuermeyer FX, Andolfatto G, Christenson J, Villa-Roel C, Rowe B. | Acad Emerg Med. 2019 Sep;26(9):969-981
DOI: https://doi.org/10.1111/acem.13669  | Télécharger l'article au format  
Keywords: Aucun

EDITOR'S PICK

Introduction : Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical-first and electrical-first strategies have been advocated, there are no comparative effectiveness data to guide clinicians.

Méthode : At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS2 score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length-of-stay (LOS); prespecified ED-based adverse events; and 30-day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL).

Résultats : Eighty-four patients were analyzed: 41 in the chemical-first group and 43 in the electrical-first group. Groups were balanced in terms of age, sex, vital signs, and CHADS2 scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical-first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical-first group (p = 0.001). In the chemical-first group, the median ED LOS was 5.1 hours (interquartile range [IQR] = 3.5 to 5.9 hours) compared to 3.5 hours (IQR = 2.4 to 4.6 hours) in the electrical-first group, for a median difference of 1.2 hours (95% confidence interval = 0.4 to 2.0 hours, p < 0.001). No patients experienced stroke or death. All other outcomes, including adverse events, ED revisits, and QoL, were similar.

Conclusion : In uncomplicated ED AF patients managed with rhythm control, chemical-first and electrical-first strategies both appear to be successful and well tolerated; however, an electrical-first strategy results in a significantly shorter ED LOS.

Conclusion (proposition de traduction) : Dans les cas de fibrillation atriale non compliquées au service des urgences qui sont pris en charge pour le contrôle du rythme, les stratégies chimique d'abord et électrique d'abord semblent toutes deux être efficaces et bien tolérées ; cependant, une stratégie électrique d'abord se traduit par une durée de séjour beaucoup plus courte au service des urgences.

Commentaire : Voir à se sujet, le document de la SFMU :
Prise en charge de la fibrillation atriale en médecine d’urgence. Recommandations de la Société française de médecine d’urgence en partenariat avec la Société française de cardiologie  .

Prehospital Double Sequential Defibrillation: A Matched Case-Control Study.
Mapp JG, Hans AJ, Darrington AM, Ross EM, Ho CC, Miramontes DA, Harper SA, Wampler DA; Prehospital Research and Innovation in Military and Expeditionary Environments (PRIME) Research Group.. | Acad Emerg Med. 2019 Sep;26(9):994-1001
DOI: https://doi.org/10.1111/acem.13672
Keywords: Aucun

Original contributions

Introduction : The goal of our study was to determine whether prehospital double sequential defibrillation (DSD) is associated with improved survival to hospital admission in the setting of refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).

Méthode : This project is a matched case-control study derived from prospectively collected quality assurance/quality improvement data obtained from the San Antonio Fire Department out-of-hospital cardiac arrest (OHCA) database between January 2013 and December 2015. The cases were defined as OHCA patients with refractory VF/pVT who survived to hospital admission. The control group was defined as OHCA patients with refractory VF/pVT who did not survive to hospital admission. The primary variable in our study was prehospital DSD. The primary outcome of our study was survival to hospital admission.

Résultats : Of 3,469 consecutive OHCA patients during the study period, 205 OHCA patients met the inclusion criterion of refractory VF/pVT. Using a predefined algorithm, two blinded researchers identified 64 unique cases and matched them with 64 unique controls. Survival to hospital admission occurred in 48.0% of DSD patients and 50.5% of the conventional therapy patients (p > 0.99; odds ratio = 0.91, 95% confidence interval = 0.40-2.1).

Conclusion : Our matched case-control study on the prehospital use of DSD for refractory VF/pVT found no evidence of associated improvement in survival to hospital admission. Our current protocol of considering prehospital DSD after the third conventional defibrillation in OHCA is ineffective.

Conclusion (proposition de traduction) : Notre étude cas-témoins appariée sur l'utilisation préhospitalière de la double défibrillation pour la FV/TVP réfractaire n'a révélé aucune preuve d'amélioration associée de la survie à l'hospitalisation.
Notre protocole actuel consistant à envisager une double défibrillation préhospitalière après la troisième défibrillation conventionnelle, lors d’un arrêt cardiaque extra-hospitalier est inefficace.

Commentaire : Voir l'article de Jordan Chenkin de mai 2019 : Fibrillation Ventriculaire réfractaire: mise-a-jour et discussion  
"La double défibrillation, plus connu sous le nom de « dual shock therapy », n’est pas une idée nouvelle, et après avoir été initialement mis de coté en 1989, commence à reprendre le devant de la scène #FOAMed grâce a de récentes études. Le principe est le suivant : en cas de FV réfractaire, un deuxième set de patch est place en parallèle sur le patient, et la personne en charge de défibriller charge et déclenche les deux défibrillateurs en même temps (si possible, sinon délai minimal en secondes). Le principe étant de dépolariser le maximum de myocarde afin de permettre une resynchronisation (Physiologie : l’hyperstimulation sympathique, présente dans la FV est potentialisée par l’utilisation d’adrénaline, préconise une défibrillation permettant la dépolarisation > 90 % du myocarde afin de permettre une resynchronisation)".

Comme dans cet article, les toutes dernières études n'ont pas montré la supériorité de la double défibrillation comparée à la défibrillation standard. Voir :
• Beck LR and al. Effectiveness of Prehospital Dual Sequential Defibrillation for Refractory Ventricular Fibrillation and Ventricular Tachycardia Cardiac Arrest. Prehosp Emerg Care. 2019 Sep-Oct;23(5):597-602  .
• Emmerson AC1 and al. Double sequential defibrillation therapy for out-of-hospital cardiac arrests: The London experience. Resuscitation. 2017 Aug;117:97-101  .

Drug Order in Rapid Sequence Intubation.
Driver BE, Driver BE, Klein LR, Prekker ME, Cole JB, Satpathy R, Kartha G, Robinson A, Miner JR, Reardon RF. | Acad Emerg Med. 2019 Sep;26(9):1014-1021
DOI: https://doi.org/10.1111/acem.13723
Keywords: Aucun

Original contributions

Introduction : The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated.
OBJECTIVE : We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.

Méthode : We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model.

Résultats : Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).

Conclusion : Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.

Conclusion (proposition de traduction) : L'administration du curare ou de l'hypnotique en premier est acceptable. L'administration du curare en premier peut entraîner un temps d'intubation légèrement plus rapide.
Pour le moment, il est raisonnable que les médecins continuent de pratiquer l'ISR de la manière qui leur convient le mieux. Si des recherches ultérieures montrent que l’ordre d’administration des médicaments n’est pas associé à une mémorisation lors du blocage neuromusculaire, l’administration de curare semble être une méthode d’administration logique par défaut, pour tenter de minimiser le temps d’apnée pendant l’intubation.

Benefits of Rhythm Control and Rate Control in Recent-onset Atrial Fibrillation: The HERMES-AF Study.
Martín A, Coll-Vinent B, Suero C, Fernández-Simón A, Sánchez J, Varona M, Cancio M, Sánchez S, Carbajosa J, Malagón F, Montull E, Del Arco C; HERMES-AF investigators. | Acad Emerg Med. 2019 Sep;26(9):1034-1043
DOI: https://doi.org/10.1111/acem.13703
Keywords: Aucun

Original contribution

Introduction : Although rhythm control has failed to demonstrate long-term benefits over rate control in longstanding episodes of atrial fibrillation (AF), there is little evidence concerning recent-onset ones. We analyzed the benefits of rhythm and rate control in terms of symptoms alleviation and need for hospital admission in patients with recent-onset AF.

Méthode : This was a multicenter, observational, cross-sectional study with prospective standardized data collection carried out in 124 emergency departments (EDs). Clinical variables, treatment effectiveness, and outcomes (control of symptoms, final disposition) were analyzed in stable patients with recent-onset AF consulting for AF-related symptoms.

Résultats : Of 421 patients included, rhythm control was chosen in 352 patients (83.6%), a global effectiveness of 84%. Rate control was performed in 69 patients (16.4%) and was achieved in 67 (97%) of them. Control of symptoms was achieved in 396 (94.1%) patients and was associated with a heart rate after treatment ≤ 110 beats/min (odds ratio [OR] = 14.346, 95% confidence interval [CI] = 3.90 to 52.70, p < 0.001) and a rhythm control strategy (OR = 2.78, 95% CI = 1.02 to 7.61, p = 0.046). Sixty patients (14.2%) were admitted: discharge was associated with a rhythm control strategy (OR = 2.22, 95% CI = 1.20-4.60, p = 0.031) and admission was associated with a heart rate > 110 beats/min after treatment (OR = 29.71, 95% CI = 7.19 to 123.07, p < 0.001) and acute heart failure (OR = 9.45, 95% CI = 2.91 to 30.65, p < 0.001).

Conclusion : In our study, recent-onset AF patients in whom rhythm control was attempted in the ED had a high rate of symptoms' alleviation and a reduced rate of hospital admissions.

Conclusion (proposition de traduction) : Dans notre étude, les patients atteints de FA paroxystique chez qui un contrôle du rythme cardiaque avait été tenté au service des urgences présentaient un taux élevé d'atténuation des symptômes et un taux réduit d'hospitalisations.

Commentaire : • Sur le même sujet avec les mêmes conclusions, voir l'article :
Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, Meeder JG, Lenderink T, Widdershoven J, Bucx JJJ, Rienstra M, Kamp O, Van Opstal JM, Alings M, Oomen A, Kirchhof CJ, Van Dijk VF, Ramanna H, Liem A, Dekker LR, Essers BAB, Tijssen JGP, Van Gelder IC, Crijns HJGM; RACE 7 ACWAS Investigators.Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019 Apr 18;380(16):1499-15.  .
• Pour la technique de réduction du rythme :
Milojevic K, Beltramini A, Nagash M, Muret A, Richard O, Lambert Y. Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF): An Emergency Medicine External Validity Study. J Emerg Med. 2019 Mar;56(3):308-318  .
• Et enfin, l'intérêt de l'utilisation du magnésium, en association, dans cette indication…
Bouida W, Beltaief K, Msolli MA, Azaiez N, Ben Soltane H, Sekma A, Trabelsi I, Boubaker H, Grissa MH, Methemem M, Boukef R, Dridi Z, Belguith A, Nouira S. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med. 2019 Feb;26(2):183-191  .

Subdissociative-dose Ketamine Is Effective for Treating Acute Exacerbations of Chronic Pain.
Lumanauw DD, Youn S, Horeczko T, Yadav K, Tanen DA. | Acad Emerg Med. 2019 Sep;26(9):1044-1051
DOI: https://doi.org/10.1111/acem.13755
Keywords: Aucun

Original contribution

Introduction : Subdissociative-dose ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is effective in relieving acute exacerbations of chronic pain.

Méthode : This study was a randomized double-blind placebo-controlled trial conducted May 2017 to June 2018 at a public teaching hospital. The primary endpoint was a 20-mm decrease on a 100-mm visual analog scale (VAS) at 60 minutes. Power analysis using three groups (0.5 mg/kg ketamine, 0.25 mg/kg ketamine, or placebo infused over 20 minutes) estimated that 96 subjects were needed for 90% power. Inclusion criteria included age > 18 years, chronic pain > 3 months, and acute exacerbation (VAS ≥ 70 mm). Pain, agitation, and sedation were assessed by VAS at baseline and 20, 40, and 60 minutes after initiation of study drug. Telephone follow-up at 24 to 48 hours used a 10-point numeric rating scale for pain.

Résultats : A total of 106 subjects were recruited, with three excluded for baseline pain < 70 mm. After randomization, 35 received 0.5 mg/kg ketamine, 36 received 0.25 mg/kg ketamine, and 35 received placebo. Three subjects receiving 0.5 mg/kg withdrew during the infusion due to adverse effects, and one subject in each group had incomplete data, leaving 97 for analysis. Initial pain scores (91.9 ± 8.9 mm), age (46.5 ± 12.6 years), sex distribution, and types of pain reported were similar. Primary endpoint analysis found that 25 of 30 (83%) improved with 0.5 mg/kg ketamine, 28 of 35 (80%) with 0.25 mg/kg ketamine, and 13 of 32 (41%) with placebo (p = 0.001). More adverse effects occurred in the ketamine groups with one subject in the 0.25 mg/kg group requiring a restraint code for agitation. A total of 89% of subjects were contacted at 24 to 48 hours, and no difference in pain level was detected between groups.

Conclusion : Ketamine infusions at both 0.5 and 0.25 mg/kg over 20 minutes were effective in treating acute exacerbations of chronic pain but resulted in more adverse effects compared to placebo. Ketamine did not demonstrate longer-term pain control over the next 24 to 48 hours.

Conclusion (proposition de traduction) : Les perfusions de kétamine à 0,5 et 0,25 mg/kg pendant 20 minutes ont été efficaces dans le traitement des exacerbations aiguës de douleur chronique, mais ont entraîné plus d'effets indésirables que le placebo. La kétamine n'a pas démontré de maîtrise de la douleur à long terme au cours des 24 à 48 heures suivantes.

Diagnostic Accuracy of Ultrasound for Confirmation of Endotracheal Tube Placement.
Long B, Koyfman A, Gottlieb M. | Acad Emerg Med. 2019 Sep;26(9):1096-1098
DOI: https://doi.org/10.1111/acem.13773
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

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

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

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

Annales françaises de médecine d’urgence

Cachera D, Balen F, Charpentier S. | Ann. Fr. Med. Urgence. 2019 sep;9(5):289 - 294
DOI: https://doi.org/10.3166/afmu-2019-0159
Keywords: Aucun

Original Article

Introduction : La cardiopathie ischémique est une des principales causes de mortalité en Europe. Cette mortalité importante est l’apanage particulier des syndromes coronariens avec élévation du segment ST (SCA ST+). Si la prise en charge préhospitalière de ces patients (de l’appel à la table de coronarographie) est sous la responsabilité des Samu, certains patients échappent à la filière malgré un appel au Centre 15. Notre objectif était de décrire ces patients porteurs d’un SCA ST+, admis en structure d’urgence (SU) après régulation par un Centre 15.

Méthode : Il s’agit d’une étude observationnelle de cohorte rétrospective incluant tous les patients admis en SU du CHU de Toulouse du 1er avril 2015 au 31 janvier 2017 avec un diagnostic final de SCA ST+.

Résultats : Sur les 139 patients qui ont été admis en SU pour SCA ST+, 96 (69 %) avaient contacté le Centre 15. Les dossiers de 89 patients ont été analysés. On retrouve une importante proportion de patientes de plus de 75 ans, qui représentent un quart de la population. Seulement 30 patients (34 %) présentaient une douleur typique.

Conclusion : Our study shows an important proportion of atypical chest pain and of old women, compared to the STEMI population usually described in the literature. This could explain the difficulty to evaluate the probability of STEMI when a patient calls MDC for chest pain.

Conclusion (proposition de traduction) : Notre étude retrouve un taux de douleurs atypiques et une proportion de femmes âgées plus importante que la littérature portant sur la description des patients porteurs de SCA ST+. Ces atypies de présentation peuvent expliquer la difficulté à réguler et orienter ces patients

Pasquier M, Blancher M. | Ann Fr Med Urgence. 2019 sep;9(5):307-318
DOI: https://doi.org/10.3166/afmu-2019-0152
Keywords: Cardiac arrest; Extracorporeal life support; Score; Hypothermia; Temperature

Mise au point / Update

Editorial : L’hypothermie accidentelle est définie comme une baisse non intentionnelle de la température centrale du corps en dessous de 35 °C. La prévention de l’hypothermie est essentielle. La mesure de la température centrale est nécessaire au diagnostic d’hypothermie et permet d’en juger la sévérité. En présence de signes de vie, et en présence d’une hypothermie pure, l’instabilité hémodynamique apparente ne devrait en principe pas faire l’objet d’une prise en charge spécifique. Un risque d’arrêt cardiaque (AC) est présent si la température chute en dessous de 30–32 °C. En raison du risque d’AC, un patient hypotherme devrait bénéficier de l’application d’un monitoring avant toute mobilisation, laquelle devra être prudente. En cas d’AC, seule la mesure de la température oesophagienne est fiable. Si l’hypothermie est suspectée comme étant potentiellement responsable de l’AC du patient, celui-ci doit être transporté sous réanimation cardiopulmonaire vers un hôpital disposant d’une méthode de réchauffement par circulation extracorporelle (CEC). La valeur de la kaliémie ainsi que les autres paramètres à disposition (âge, sexe, valeur de la température corporelle, durée du low flow, présence d’une asphyxie) permettront de décider de l’indication d’une CEC de réchauffement. Le pronostic des patients victimes d’un AC sur hypothermie est potentiellement excellent, y compris sur le plan neurologique.

Conclusion (proposition de traduction) : L’hypothermie accidentelle est définie comme une diminution de la température centrale du corps en dessous de 35 °C. Un risque d’AC est présent si la température chute en dessous de 30–32 °C. En cas d’AC, seule la mesure de la température œsophagienne est fiable. Si l’hypothermie est suspectée comme étant potentiellement responsable de l’AC du patient, celui-ci doit être transporté sous RCP vers un hôpital disposant d’une méthode de réchauffement par CEC. À l’hôpital, la valeur de la kaliémie ainsi que les autres paramètres à disposition (âge, sexe, température corporelle, durée du low flow, présence d’une asphyxie) permettront de décider de l’indication d’une CEC de réchauffement. Le pronostic des patients victimes d’un AC sur hypothermie est potentiellement excellent, y compris sur le plan neurologique.

Annals of Cardiac Anaesthesia

Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care.
Nagre AS | Ann Card Anaesth. 2019 Jul-Sep;22(3):302-308
DOI: https://doi.org/10.4103/aca.ACA_88_18  | Télécharger l'article au format  
Keywords: Aucun

REVIEW ARTICLE

Editorial : Transthoracic echocardiography is a potent and appealing diagnostic tool by virtue of rapidity, noninvasiveness, and repeatability. Focus-assessed transthoracic echocardiography (FATE) forms quick guidance to interpret the echocardiographic information and relates it to the clinical context. It can be applied in the perioperative period, intensive care units (ICUs), and emergency situations, in trauma and as resuscitation aids. FATE intents to assess cardiac function including contractility, chamber size and hypertrophy, valvular dysfunction, cardiac tamponade, and pericardial and pleural effusions. Thence, FATE has become a quintessential scanning tool perioperatively and in ICUs.

Conclusion : The FATE protocol is a comprehensive, rapid, and noninvasive approach contemplated to find the potential causes of hemodynamic instability. The fundamentals scanned are the chamber dimensions, wall thickness, ventricular function, pleura, and obvious pathology. Moreover, the information incurred from scanning is used analogously to the clinical context for bettering patient management. Hence, FATE protocol can be verily consolidated into routine as well as emergency clinical practice.

Conclusion (proposition de traduction) : Le protocole FATE est une approche globale, rapide et non invasive envisagée pour rechercher les causes potentielles d'une instabilité hémodynamique. Les données fondamentales analysées sont les dimensions de la chambre de chasse, l’épaisseur de la paroi, la fonction ventriculaire, la plèvre et une pathologie évidente. De plus, les informations résultant de la numérisation sont utilisées de manière analogue au contexte clinique pour améliorer la gestion des patients. Par conséquent, le protocole FATE peut être véritablement intégré aux pratiques cliniques de routine et d’urgence.

Annals of Emergency Medicine

Emergency Department Management of Out-of-Hospital Laryngeal Tubes.
Driver BE, Scharber SK, Horton GB, Braude DA, Simpson NS, Reardon RF. | Ann Emerg Med. 2019 Sep;74(3):403-409
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.025
Keywords: Aucun

Airway

Introduction : Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes.

Méthode : Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management.

Résultats : We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients (<1%) required a surgical airway.

Conclusion : In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.

Conclusion (proposition de traduction) : Dans cette cohorte, les urgentistes ont remplacé avec succès une sonde laryngée d'intubation posée en extra-hospitalier par une sonde endotrachéale, en utilisant les techniques de gestion des voies respiratoires couramment disponibles. Les cliniciens des services d'urgence doivent bien connaître les techniques permettant de remplacer les voies aériennes supraglottiques posées en extra-hospitaliers par une sonde endotrachéale.

Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department.
Caputo ND, Oliver M, West JR, Hackett R, Sakles JC. | Ann Emerg Med. 2019 Sep;74(3):410-415
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.038
Keywords: Aucun

Airway

Introduction : Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department.

Méthode : This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%.

Résultats : We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction.

Conclusion : ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.

Conclusion (proposition de traduction) : L'ETO2 variait selon les différentes techniques de préoxygénation utilisées au service des urgences. La plupart des patients qui bénéficiaient d'une intubation à séquence rapide n'ont pas atteint la préoxygénation maximale. La mesure de l'ETO2 dans le service des urgences peut constituer un complément précieux pour optimiser la préoxygénation lors de la gestion des voies aériennes.

Managing the Out-of-Hospital Extraglottic Airway Device.
Braude D, Steuerwald M, Wray T, Galgon R. | Ann Emerg Med. 2019 Sep;74(3):416-422
DOI: https://doi.org/10.1016/j.annemergmed.2019.03.002  | Télécharger l'article au format  
Keywords: Aucun

Airway

Editorial : Extraglottic devices (commonly referred to as supraglottic airways) are often placed in the out-of-hospital setting either as a primary airway or after a failed attempt at intubation.1–4 They may be used in any critically ill patient with the need for airway management, including those with cardiac arrest, trauma, medication or drug toxicity, pneumonia, and pulmonary edema. Recent evidence from 2 large, international, randomized controlled trials suggests that extraglottic device placement may be the preferred airway management strategy for out-of-hospital cardiac arrest,3,4 which likely means that more patients will arrive in emergency departments (EDs) with extraglottic devices in place in the near future. Because of their unique features and deployment in critically ill patients, rapid, reflexive removal of a functioning extraglottic device without a well-considered plan may lead to aspiration, hypoxemia, loss of the airway, or all three. ED providers must therefore be comfortable assessing and managing patients who arrive in the ED with an extraglottic device placed by emergency medical services (EMS).

Conclusion : Management of an extraglottic device is a critical skill for emergency physicians. Most extraglottic devices provide adequate oxygenation and ventilation, with or without simple troubleshooting, and may be left in place while competing priorities are addressed. Exchange of an extraglottic device to an endotracheal tube should be performed in a systematic, planned manner.

Conclusion (proposition de traduction) : L'utilisation d'un dispositif supraglottique est une compétence essentielle pour un urgentiste. La plupart des dispositifs supraglottiques permettent une oxygénation et une ventilation adéquates, en tant qu'alternative ou non, et peuvent rester en place pendant le traitement des autres prises en charge nécessaires. Le remplacement d'un dispositif supraglottique par une sonde endotrachéale doit être effectué de manière systématique et planifiée.

Effect of Initial Bedside Ultrasonography on Emergency Department Skin and Soft Tissue Infection Management.
Mower WR, Crisp JG, Krishnadasan A, Moran GJ, Abrahamian FM, Lovecchio F, Karras DJ, Steele MT, Rothman RE, Talan DA. | Ann Emerg Med. 2019 Sep;74(3):372-380
DOI: https://doi.org/10.1016/j.annemergmed.2019.02.002
Keywords: Aucun

Imaging

Introduction : We examine the utility of emergency department (ED) ultrasonography in treatment of skin and soft tissue infections.

Méthode : We enrolled ED patients with skin and soft tissue infections and surveyed clinicians in regard to their pre-ultrasonography certainty about the presence or absence of an abscess, their planned management, post-ultrasonography findings, and actual management. We determined sensitivity and specificity of ultrasonography and clinical evaluation, and assessed appropriateness of management changes based on initial clinical assessment and outcomes through 1-week follow-up.

Résultats : Among 1,216 patients, clinicians were uncertain of abscess presence in 105 cases (8.6%) and certain for 1,111 cases (91.4%). Based on surgical exploration and follow-up through 1 week, sensitivity and specificity for abscess detection by clinical evaluation were 90.3% and 97.7%, and by ultrasonography were 94.0% and 94.1%, respectively. Among 1,111 cases for which the clinician was certain, sensitivity and specificity of clinical evaluation were 96.6% and 97.3% compared with ultrasonographic evaluation sensitivity and specificity of 95.7% and 96.2%, respectively. Of 105 uncertain cases, sensitivity and specificity of ultrasonography were 68.5% and 80.4%. Ultrasonography changed management in 13 of 1,111 certain cases (1.2%), appropriately in 10 of 13 (76.9%) and inappropriately in 3 of 13 (23.1%). Of 105 uncertain cases, ultrasonography changed management in 25 (23.8%), appropriately in 21 of 25 (84.0%) and inappropriately in 4 of 25 (16.0%).

Conclusion : Ultrasonography rarely changed management when clinicians were certain about the presence or absence of an abscess. When they were uncertain, ultrasonography changed drainage decisions in approximately one quarter of cases, of which most (84%) were appropriate.

Conclusion (proposition de traduction) : L'échographie changeait rarement de traitement lorsque les cliniciens étaient certains de la présence ou de l'absence d'un abcès.
Lorsqu'elles étaient incertaines, l'échographie changeait les décisions de drainage dans environ un quart des cas, dont la plupart (84 %) étaient appropriées.

The Utility and Survivorship of Peripheral Intravenous Catheters Inserted in the Emergency Department.
Shokoohi H, Boniface KS, Kulie P, Long A, McCarthy M. | Ann Emerg Med. 2019 Sep;74(3):381-390
DOI: https://doi.org/10.1016/j.annemergmed.2019.02.003
Keywords: Aucun

Imaging

Introduction : We compare the use and survivorship rate of peripheral intravenous catheters placed in the emergency department (ED) by insertion method.

Méthode : We analyzed a prospective cohort of ED patients who received a peripheral intravenous catheter in the ED by ultrasonographically guided or landmark insertion. Research assistants recorded the uses of the ED-inserted catheters during the ED visit and hospitalization. Among subjects admitted, research assistants tracked catheter survivorship for 72 hours or hospital discharge, whichever came first. Research assistants documented reason for catheter removal and whether it was replaced during hospitalization. Premature removal was defined as catheters that were replaced because of mechanical failure, complication, or discomfort. We used multivariate binomial regression to estimate the relative risk of insertion method on premature removal and a Kaplan-Meier curve to compare survivorship duration by insertion method.

Résultats : A cohort of 1,174 patients with a mean age of 45 years and 63% female predominance was analyzed. Catheter use was 73% and 78% in the ED and hospital for the administration of fluids, medications, or contrast agents (and 96% if blood drawn for testing was included). Peripheral intravenous use did not differ significantly in the ED or hospital by insertion method. For 330 patients who were admitted, 132 of 182 patients (73%) in the ultrasonographically guided group and 117 of 148 (79%) in the landmark group had 72-hour catheter survival. Premature removal was not significantly more likely to occur if the catheter was inserted by the ultrasonographically guided method compared with the landmark one (relative risk 1.26; 95% confidence interval 0.88 to 1.80).

Conclusion : ED-inserted peripheral intravenous catheters were frequently used in the ED and hospital. Peripheral intravenous use and hospital survivorship of ED-inserted peripheral intravenous catheters were similar by insertion method.

Conclusion (proposition de traduction) : Les cathéters veineux périphériques posés aux urgences ont été fréquemment utilisés aux urgences et à l'hôpital. L'utilisation intraveineuse périphérique et la durée d'utilisation à l'hôpital des cathéters veineux périphériques insérés aux urgences étaient similaires par la méthode d'insertion.

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus.
Moore CL, Carpenter CR, Heilbrun ME, Klauer K, Krambeck A, Moreno C, Remer EM, Scales C, Shaw MM, Sternberg KM. | Ann Emerg Med. 2019 Sep;74(3):391-399
DOI: https://doi.org/10.1016/j.annemergmed.2019.04.021  | Télécharger l'article au format  
Keywords: Aucun

Imaging

Introduction : Renal colic is common and computed tomography (CT) is frequently used when the diagnosis of kidney stone is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multiorganizational transdisciplinary collaboration seeks evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting.

Méthode : In conjunction with the American College of Emergency Physicians (ACEP) Emergency Quality Network, we formed a 9-member panel with 3 physician representatives each from ACEP, the American College of Radiology, and the American Urology Association. A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios.

Résultats : From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, out of the 29 scenarios agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%). There were no scenarios in which at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasonography in 9 (31%) and no further imaging needed in 12 (45%).

Conclusion : Evidence and multispecialty consensus support ultrasonography or no further imaging in specific clinical scenarios, with reduced-radiation-dose CT to be used when CT is needed for patients with suspected renal colic.

Conclusion (proposition de traduction) : Les données probantes et les consensus multispécialités appuient l'échographie ou l'abandon de l'imagerie dans des scénarios cliniques spécifiques, avec une dose de rayonnement réduite à utiliser lorsque la tomodensitométrie est nécessaire chez les patients pour suspicion de coliques néphrétiques.

What Is the Diagnostic Accuracy of Point-of-Care Ultrasonography in Patients With Suspected Blunt Thoracoabdominal Trauma?.
Long B, April MD. | Ann Emerg Med. 2019 Sep;74(3):400-402
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.016  | Télécharger l'article au format  
Keywords: Aucun

Imaging

Introduction : Authors searched Ovid MEDLINE, PubMed, Ovid EMBASE, and the BIOSIS database from inception to July 15, 2017; evaluated reference lists of included studies for additional articles; and searched Google Scholar for additional studies.

Méthode : Authors identified prospective or retrospective diagnostic cohort studies enrolling patients with blunt trauma (defined as any nonpenetrating force) to the abdomen or chest who underwent point-of-care ultrasonography as the primary imaging modality to screen for thoracoabdominal injuries and received predefined reference standard confirmatory testing: computed tomography (CT) scan, magnetic resonance imaging (MRI), laparotomy or laparoscopy, thoracotomy, or autopsy. Two authors independently assessed studies for eligibility and resolved disagreements through discussion with a third author.

Résultats : Two authors independently used predefined standard procedures to extract data, and a third author resolved discrepancies. Authors then pooled data to estimate the diagnostic accuracy of point-of-care ultrasonography for detecting thoracoabdominal injury, including free fluid in the thoracic or abdominal cavity, retroperitoneum, pericardium, or mediastinum; organ injury (eg, splenic, other solid organ, hollow viscera, other organ laceration); vascular lesion (eg, dissection or rupture of aorta or other vessels); and other injuries 1 (eg, pneumothorax). Authors calculated sensitivity and specificity with 95% confidence intervals (CIs), positive and negative likelihood ratios, positive predictive value, negative predictive value, and the summary receiver operating characteristic (ROC) curve. Two authors independently used the Quality Assessment of Diagnostic Accuracy Studies–2 tool to assess 2 methodological quality of studies. Authors assessed heterogeneity visually by inspecting the coupled forest plots and plots of study results in the summary ROC curve space; they also assessed for possible sources of heterogeneity by adding single covariates to the bivariate random-effects model. Authors performed subgroup analyses based on patient age, reference standard (single CT versus CT plus laparotomy), injury anatomic location (abdominal versus thoracic), and injury pattern (free fluid or air only versus free fluid or air in addition to organ and vascular lesions). They conducted sensitivity analyses based on study risk of bias, the variable accuracy of imaging interpretation as reported by studies in which multiple investigators interpreted each study, and patient age.

Conclusion : In patients with blunt trauma, a positive point-of-care ultrasonography result can identify thoracoabdominal injury with high specificity; however, a negative point-of-care ultrasonography result has inadequate sensitivity to reliably exclude injury.

Conclusion (proposition de traduction) : Chez les patients présentant un traumatisme contondant, un résultat positif de l'échographie au point d'intervention peut identifier une lésion thoraco-abdominale avec une spécificité élevée ; cependant, un résultat négatif de l'échographie au point d'intervention présente une sensibilité insuffisante pour exclure de manière fiable une blessure.

Annals of Intensive Care

Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score.
Duan J, Wang S, Liu P, Han X, Tian Y, Gao F, Zhou J, Mou J, Qin Q, Yu J, Bai L, Zhou L, Zhang R. | Ann Intensive Care. 2019 Sep 30;9(1):108
DOI: https://doi.org/10.1186/s13613-019-0585-9  | Télécharger l'article au format  
Keywords: COPD exacerbations; Critical care; Noninvasive ventilation

Research

Introduction : Early identification of noninvasive ventilation (NIV) failure is a promising strategy for reducing mortality in chronic obstructive pulmonary disease (COPD) patients. However, a risk-scoring system is lacking.

Méthode : To develop a scale to predict NIV failure, 500 COPD patients were enrolled in a derivation cohort. Heart rate, acidosis (assessed by pH), consciousness (assessed by Glasgow coma score), oxygenation, and respiratory rate (HACOR) were entered into the scoring system. Another two groups of 323 and 395 patients were enrolled to internally and externally validate the scale, respectively. NIV failure was defined as intubation or death during NIV.

Résultats : Using HACOR score collected at 1-2 h of NIV to predict NIV failure, the area under the receiver operating characteristic curves (AUC) was 0.90, 0.89, and 0.71 for the derivation, internal-validation, and external-validation cohorts, respectively. For the prediction of early NIV failure in these three cohorts, the AUC was 0.91, 0.96, and 0.83, respectively. In all patients with HACOR score > 5, the NIV failure rate was 50.2%. In these patients, early intubation (< 48 h) was associated with decreased hospital mortality (unadjusted odds ratio = 0.15, 95% confidence interval 0.05-0.39, p < 0.01).

Conclusion : HACOR scores exhibited good predictive power for NIV failure in COPD patients, particularly for the prediction of early NIV failure (< 48 h). In high-risk patients, early intubation was associated with decreased hospital mortality.

Conclusion (proposition de traduction) : Les scores HACOR ont montré un bon pouvoir prédictif de l'échec de la VNI chez les patients atteints de BPCO, en particulier pour la prédiction de l'échec précoce de la VNI (<48 h). Chez les patients à haut risque, l'intubation précoce a été associée à une baisse de la mortalité hospitalière.

BMC Emergency Medicine

Diagnostic accuracy of clinical tools for assessment of acute stroke: a systematic review.
Antipova D, Eadie L, Macaden A, Wilson P. | BMC Emerg Med. 2019 sept:19(49)
DOI: https://doi.org/10.1186/s12873-019-0262-1  | Télécharger l'article au format  
Keywords: Acute cerebral ischaemia; Clinical prediction rules; Emergency care; Intracerebral haemorrhage; Large vessel occlusion; Recanalization; Stroke; Scoring methods; Thrombectomy Thrombolysis

Research article

Introduction : Recanalisation therapy in acute ischaemic stroke is highly time-sensitive, and requires early identification of eligible patients to ensure better outcomes. Thus, a number of clinical assessment tools have been developed and this review examines their diagnostic capabilities.

Méthode : Diagnostic performance of currently available clinical tools for identification of acute ischaemic and haemorrhagic strokes and stroke mimicking conditions was reviewed. A systematic search of the literature published in 2015–2018 was conducted using PubMed, EMBASE, Scopus and The Cochrane Library. Prehospital and in-hospital studies with a minimum sample size of 300 patients reporting diagnostic accuracy were selected.

Résultats : Twenty-five articles were included. Cortical signs (gaze deviation, aphasia and neglect) were shown to be significant indicators of large vessel occlusion (LVO). Sensitivity values for selecting subjects with LVO ranged from 23 to 99% whereas specificity was 24 to 97%. Clinical tools, such as FAST-ED, NIHSS, and RACE incorporating cortical signs as well as motor dysfunction demonstrated the best diagnostic accuracy. Tools for identification of stroke mimics showed sensitivity varying from 44 to 91%, and specificity of 27 to 98% with the best diagnostic performance demonstrated by FABS (90% sensitivity, 91% specificity). Hypertension and younger age predicted intracerebral haemorrhage whereas history of atrial fibrillation and diabetes were associated with ischaemia. There was a variation in approach used to establish the definitive diagnosis. Blinding of the index test assessment was not specified in about 50% of included studies.

Conclusion : A wide range of clinical assessment tools for selecting subjects with acute stroke has been developed in recent years. Assessment of both cortical and motor function using RACE, FAST-ED and NIHSS showed the best diagnostic accuracy values for selecting subjects with LVO. There were limited data on clinical tools that can be used to differentiate between acute ischaemia and haemorrhage. Diagnostic accuracy appeared to be modest for distinguishing between acute stroke and stroke mimics with optimal diagnostic performance demonstrated by the FABS tool. Further prehospital research is required to improve the diagnostic utility of clinical assessments with possible application of a two-step clinical assessment or involvement of simple brain imaging, such as transcranial ultrasonography.

Conclusion (proposition de traduction) : Un large éventail d’outils d’évaluation clinique pour la sélection des patients présentant un AVC aigu a été mis au point ces dernières années. L'évaluation des fonctions corticales et motrices à l'aide des scores RACE, FAST-ED et NIHSS a montré les meilleures valeurs de précision du diagnostic pour la sélection de patients présentant une occlusion de gros vaisseaux. Il y avait peu de données sur les outils cliniques pouvant être utilisés pour différencier l’ischémie aiguë de l’hémorragie. La précision diagnostique semblait être modeste pour distinguer les accidents vasculaires cérébraux aigus et simulés, avec une performance diagnostique optimale démontrée par l'outil FABS. Des recherches préhospitalières supplémentaires sont nécessaires pour améliorer l'utilité diagnostique des évaluations cliniques avec l'application possible d'une évaluation clinique en deux étapes ou l'implication d'une imagerie cérébrale simple, telle que l'échographie transcrânienne.

Uncompleted emergency department care and discharge against medical advice in patients with neurological complaints: a chart review.
Hoyer C, Stein P, Alonso A. | BMC Emerg Med. 2019 sept:19(52);
DOI: https://doi.org/10.1186/s12873-019-0273-y  | Télécharger l'article au format  
Keywords: Neurology; Emergency department; Patient discharge

Research article

Introduction : Uncompleted emergency department care and against-medical-advice discharge represent relevant medical problems with impact on patient safety and potential medicolegal and socioeconomic consequences. They may also indicate structural or procedural problems in the emergency department (ED) relating to patient management and flow. While patients with neurological complaints frequently leave the ED against medical advice or without being seen, no dedicated analysis of this group of patients aiming at the identification of characteristics associated with irregular ED discharge has been performed so far.

Méthode : A chart review was performed of all patients with neurological complaints presenting to a German interdisciplinary emergency department between January and December 2017 for neurological evaluation. Demographics, mode of presentation, process times, presenting symptoms and diagnosis were recorded. Patients leaving against medical advice after an informed consent discussion and signing of documentation (DAMA) or leaving prematurely without notifying ED staff (PL) were compared to the total of patients who were admitted or discharged (non-DAMA/PL).

Résultats : Of all patients presenting with neurological symptoms or complaints, 3% left against medical advice and 2.2% left prematurely. DAMA/PL patients were younger (p < .001), and they were more frequently self-presenting (p < 0.001). Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients, and 56.1% of those presenting with a seizure had a history of epilepsy. The most common documented reason for leaving was the duration of door-to-doctor time.

Conclusion : Younger age, self-presenting mode of presentation and presentation with headache, seizures or sensory deficits are associated with premature leave or against-medical-advice discharge of patients with neurological complaints from the ED, and long waiting times were given as the major reason for leaving the ED. Increasing ED staff’s awareness of these factors and the optimization of pre-hospital assessment and demand management, thereby positively impacting on patient flow and ED process times, may help to prevent irregular discharges from the ED.

Conclusion (proposition de traduction) : Un âge plus jeune, un mode de présentation spontané et une symptomatologie de maux de tête, de convulsions ou de déficits sensoriels sont associés à un refus de soins ou à la sortie contre l'avis d'un médecin pour des patients souffrant de problèmes neurologiques au service des urgences. Les longues durées d'attente sont le motif principalement retrouvé pour quitter le service d'urgence. En sensibilisant davantage le personnel des urgences à ces facteurs et en optimisant l'évaluation préhospitalière et la gestion de la demande, cela aurait une incidence positive sur le flux des patients et les délais de traitement aux urgences, et pourrait contribuer à prévenir les départs irréguliers des urgences.

Canadian Journal of Emergency Medicine

Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension?.
Brunet M, Chaplin T. | CJEM. 2019 Sep;21(5):593-594
DOI: https://doi.org/10.1017/cem.2019.346
Keywords: Aucun

Commentary

Introduction : Background: Point-of-care ultrasound (POCUS) is commonly used in the management of hemodynamically unstable emergency department (ED) patients. Its effect on clinical outcomes has not been evaluated in a prospective randomized controlled trial.
Objectives: To compare patient outcomes following a standardized POCUS protocol, compared with usual care, in ED patients with undifferentiated hypotension.

Méthode : Design: Multicenter randomized controlled trial.
Setting: Six EDs in North America and South Africa, between September 2012 and December 2016.
Subjects: Patients aged >18 years old presenting with undifferentiated hypotension (sustained systolic blood pressure of <100 mm Hg or shock index of >1). Exclusion criteria included pregnancy, cardiopulmonary resuscitation (CPR) or life support prior to screening, significant trauma within 24 hours, electrocardiogram (ECG) diagnostic of myocardial infarction, evident mechanism for shock, or vagal episode.
Intervention: Standardized POCUS protocol including cardiac (parasternal long axis, parasternal short axis, apical, and subcostal), lung (sliding and presence of effusion), and abdominal (focused assessment with sonography for trauma [FAST] and inferior vena cava) views.
Outcomes: Primary outcome was survival at 30 days or hospital discharge.

Résultats : Two hundred seventy-three patients (of a planned 400) were randomized and the most common diagnosis was occult sepsis (52%). There was no significant difference in survival at either 30 days or hospital discharge. Survival was 76.5% (95% confidence interval [CI] 68.4%–83.3%) in the POCUS group and 76.1% (95% CI 68%–83.1%) in the control group; the absolute risk reduction was 0.35% (95% CI −10.2% to 11.1%). There were also no significant differences in any of the secondary outcomes: median volume of fluid administered, hospital admission, inotrope administration, rate of computed tomography (CT) use, intensive care unit (ICU) admission, and length of stay. The study was stopped early because of slow recruitment and futility.

Conclusion : The results of this study suggest that the addition of a Point-of-Care UltraSound protocol to standard care does not translate into a survival benefit for emergency department patients with undifferentiated hypotension. This was an international randomized controlled trial of an important emergency department diagnostic test. However, there are several factors that limit the impact of these findings. For example, the exclusion of several diagnoses for which Point-of-Care UltraSound may be helpful (abdominal aortic aneurysm, myocardial infarction, ectopic pregnancy, and trauma). Despite the lack of benefit, we suggest there is no harm in using Point-of-Care UltraSound for the assessment of patients presenting with undifferentiated hypotension. Future study is required.

Conclusion (proposition de traduction) : Les résultats de cette étude suggèrent que l'ajout d'un protocole d'échographie au point d'intervention aux soins standard ne se traduit pas par un bénéfice en termes de survie pour les patients des services d'urgence présentant une hypotension indifférenciée. Il s'agissait d'un essai contrôlé randomisé international d'un important test de diagnostic effectué par un service d'urgence.
Cependant, plusieurs facteurs limitent l'impact de ces résultats. Par exemple, l'exclusion de plusieurs diagnostics pour lesquels l'échographie au point d'intervention peut être utile (anévrisme de l'aorte abdominale, infarctus du myocarde, grossesse extra-utérine et traumatisme). Malgré le manque d'avantages, nous suggérons qu'il n'y a aucun inconvénient à utiliser l'échographie au point d'intervention pour l'évaluation des patients présentant une hypotension indifférenciée. Une étude future est nécessaire.

Does the addition of dextrose to IV crystalloid therapy provide clinical benefit in acute dehydration? A systematic review and meta-analysis.
Grigsby A, Herron J, Hunter BR. | CJEM. 2019 Sep;21(5):638-645
DOI: https://doi.org/10.1017/cem.2018.500
Keywords: dehydration; dextrose; intravenous fluids

Original Research

Introduction : Les perfusions de dextrose aident à neutraliser la cétose chez les patients en état de déshydratation qui ne tolèrent pas la prise orale de glucose, et le traitement est souvent recommandé dans ces situations cliniques. L’étude visait donc à déterminer si l'adjonction de dextrose aux solutions de réhydratation intraveineuse se traduisait par une réduction du nombre d'hospitalisations ou offrait d'autres avantages cliniques importants chez les enfants et les adultes.

Méthode : Une recherche a été menée dans les bases de données MEDLINE, EMBASE, SCOPUS, la plateforme Web of Science et la bibliothèque Cochrane Library par un bibliothécaire spécialisé dans le domaine médical, depuis leur mise sur pied jusqu’à novembre 2017. Les critères de sélection consistaient en la recherche d'essais à répartition aléatoire, dans lesquels étaient comparées des solutions de perfusion additionnées de dextrose à celles n'en contenant pas chez les patients externes, traités pour de la déshydratation.

Résultats : La recherche documentaire dans les bibliographies et les bases de données a permis de relever 1472 citations uniques; toutefois, 2 essais (n = 333) seulement satisfaisaient aux critères de sélection. Dans les deux cas, on comparait des solutions physiologiques salées à des solutions physiologiques salées additionnées de dextrose. Il n'est ressorti aucun écart significatif en ce qui concerne le taux d'hospitalisation (taux relatif [TR] = 0,83; intervalle de confiance [IC] à 95% = 0,62–1,10) ou de reconsultation (TR = 0,54; IC à 95% = 0,24–1,22). Quant à l'hétérogénéité, elle était faible (I2 = 0). Aucun autre résultat ne se prêtait à une mise en commun, mais il ne s'est pas dégagé non plus de différence entre les deux études à l’égard de quelque résultat clinique que ce soit. Enfin, aucun événement indésirable n'a été signalé dans l'un ou l'autre des essais.

Conclusion : The addition of dextrose to intravenous saline has not been shown to improve clinical outcomes in dehydrated children presenting to the emergency department with gastroenteritis, but the confidence intervals around the estimate of effect are wide and include the possibility of substantial benefit.

Conclusion (proposition de traduction) : L'adjonction de dextrose aux solutions physiologiques salées ne s'est pas traduite par une amélioration des résultats cliniques chez les enfants en état de déshydratation, traités au service des urgences pour une gastroentérite; toutefois, les intervalles de confiance entourant l'estimation des effets sont larges et pourraient comporter des avantages importants.

Canadian Journal of Emergency Medicine. 2019 Sep;21(5):618-621

A simple intervention to reduce your chance of missing an acute aortic dissection.
Ohle R, Mc Isaac S, Perry JJ. | CJEM. 2019 Sep;21(5):618-621
DOI: https://doi.org/10.1017/cem.2019.1
Keywords: Aortic dissection; diagnostic accuracy; history taking

Original Research

Introduction : Acute aortic dissection (AAD) is a time sensitive, difficult to diagnose, aortic emergency. We sought to explore the quality of history taking in AAD and assess its impact on misdiagnosis.

Méthode : We studied a retrospective cohort of patients >18 years old who presented to two tertiary care emergency departments from January 1st 2004 - December 31st 2012 and were diagnosed with an acute aortic dissection (AAD) on CT, MRI or TEE. Trained reviewers' extracted data using a standardized data collection form. The definitions of 5 pain characteristics - character, onset, duration, quality, and radiation were defined a priori.

Résultats : Data were collected for 194 cases of acute aortic dissection with a mean age of 65(SD 14.1) and 66.7% male, 34(17.6%) missed on initial presentation. Only 20(14.8%) patients were asked all 5 questions. The most common initial incorrect diagnosis were acute coronary syndrome (16, 47%), pulmonary embolism (5, 14.7%) and stroke (4, 11.7%). If <2 questions were asked 1 in 5 cases were missed, 4 times greater than if >2 were asked (P < 0.01).

Conclusion : Clinicians should ask and document the character, onset, duration, radiation and severity of pain in any patient presenting with chest, abdominal or flank pain. A focused history still remains the keystone to reducing misdiagnosis.

Conclusion (proposition de traduction) : Les praticiens doivent interroger et documenter la caractèristique, l'apparition, la durée, l'irradiation et l'intensité de la douleur, chez tout patient présentant des douleurs thoracique, abdominale ou du flanc. Une histoire ciblée reste la clé de voûte de la réduction des diagnostics erronés.

Current Opinion in Critical Care

Acute respiratory failure: nonintubation assist methods for the acutely deteriorating patient.
Frat JP, Marie D, Thille AW. | Curr Opin Crit Care. 2019 Sep 20
DOI: https://doi.org/10.1097/MCC.0000000000000670
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION AND OTHER EMERGENCIES

Introduction : Noninvasive ventilation is strongly recommended in acute hypercapnic respiratory failure, whereas high-flow nasal oxygen therapy could be an alternative in de novo respiratory failure.

Discussion : High-flow nasal oxygen may improve the outcome of patients de novo respiratory failure as compared with standard oxygen. Its success within 2 h after initiation is well predicted by a ROX index (ratio of SpO2/FiO2 to respiratory rate) greater than 4.88, as failure when less than 3.85 at 12 h after initiation. However, the superiority of high-flow nasal oxygen to standard oxygen has not been confirmed in immunocompromised patients. Although noninvasive ventilation may be deleterious through barotrauma in patients with de novo respiratory failure, its use seems to be an optimal strategy for preoxygenation before intubation in preventing severe hypoxemia in most hypoxemic patients. In mild hypoxemic patient, high-flow nasal oxygen may be more efficient than bag-valve mask in preventing severe adverse events. After anesthetic induction further positive-pressure ventilation can better secure intubation procedure than absence of ventilation.

Conclusion : Despite the growing use of high-flow nasal oxygen, new studies are needed to confirm its superiority to standard oxygen in de novo respiratory failure and others causes of acute respiratory failure in place of standard oxygen.

Conclusion (proposition de traduction) : Malgré l'utilisation croissante de l'oxygénothérapie nasal à haut débit, de nouvelles études sont nécessaires pour confirmer sa supériorité sur l'oxygénothérapie standard en cas d'insuffisance respiratoire de novo et d'autres causes d'insuffisance respiratoire aiguë à la place de l'oxygène standard.

Emergency bedside ultrasound: benefits as well as caution - part 1. General.
Wong A, Vieillard-Baron A, Malbrain MLNG. | Curr Opin Crit Care. 2019 Sep 30
DOI: https://doi.org/10.1097/MCC.0000000000000678
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION AND OTHER EMERGENCIES

Introduction : The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed.

Discussion : Despite its widespread use, definitive studies demonstrating improved patient outcomes are limited. The list of indications for POCUS nonetheless is increasing as practitioners acknowledge clinical benefits, and technological advancement improves diagnostic accuracy and efficiency of use.

Conclusion : We believe that a core level of POCUS should be achievable by practicing clinicians. Ultimately, the integration of POCUS findings into a patient management strategy must be holistic, and hence requires prudent consideration of the clinical scenario.

Conclusion (proposition de traduction) : Nous pensons qu'un niveau de base en échographie au point d'intervention devrait être réalisable par les cliniciens en exercice. En fin de compte, l'intégration des résultats de l'échographie au point d'intervention dans une stratégie de gestion des patients doit être holistique et nécessite donc une réflexion prudente sur le scénario clinique.

Emergency bedside ultrasound-benefits as well as caution: Part 2: Echocardiography.
Godement M, Malbrain MLNG, Vieillard-Baron A. | Curr Opin Crit Care. C2019 Sep 20
DOI: https://doi.org/10.1097/MCC.0000000000000674
Keywords: Aucun

CARDIOPULMONARY RESUSCITATION AND OTHER EMERGENCIES

Introduction : Critical care echocardiography (CCE) has become an important component of general critical care ultrasonography, and a current review of its performance is presented.

Discussion : Basic CCE should be performed as a goal-directed examination to better identify specific signs and to answer important clinical questions concerning acute hemodynamic concerns. It has evolved in the ICU and also in the emergency department not only for improved diagnostic capability but also as an effective part of the triage process. It remains an efficacious procedure even in patients with respiratory failure when combined with lung ultrasonography. Numerous acronyms were proposed, but in all cases, CCE responds to the same rules as fundamental echocardiography. Basic CCE requires accessible and comprehensive training for physicians and is mandatory for all intensivists. Development of pocket echo devices may increase the use of basic CCE as has miniaturization of other medical technologies. Performance should be managed by guidelines, and the CCE training program should be standardized worldwide. More trials are welcome to evaluate its impact on patient outcomes.

Conclusion : Thanks to its ability to quickly obtain a diagnostic orientation at the bedside and to implement targeted therapy, basic CCE over the past decade has become an essential tool for hemodynamic assessment of the cardiopulmonary unstable patient. Its more recent incorporation into the education of trainees in medical school and residencies/fellowships has reinforced its perceived importance in critical care management, despite the relative paucity as yet of rigorous scientific evidence demonstrating positive outcome modification from its use.

Conclusion (proposition de traduction) : Grâce à sa capacité à obtenir rapidement une orientation diagnostique au lit et à mettre en œuvre un traitement ciblé, l’échocardiographie en soins critiques de base est devenue au cours de la dernière décennie un outil essentiel pour l’évaluation hémodynamique du patient cardiopulmonaire instable. Son intégration plus récente dans la formation des stagiaires en faculté de médecine et des résidences a renforcé son importance perçue dans la gestion des soins critiques, malgré le manque relatif de preuves scientifiques rigoureuses démontrant une modification positive de son utilisation.

Emergency Medicine Journal

Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting.
O'Connell KJ, Yang S, Cheng M, Sandler AB, Cochrane NH, Yang J, Webman RB, Marsic I, Burd R. | Emerg Med J. 2019 Sep;36(9):520-528
DOI: https://doi.org/10.1136/emermed-2018-208133
Keywords: Aucun

PAEDIATRIC EM

Introduction : Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes.

Méthode : An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence.

Résultats : We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99).

Conclusion : Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.

Conclusion (proposition de traduction) : La conformité avec un modèle de processus basé sur des experts pour l’intubation d’urgence était associée à un taux de réussite plus élevé lors de la première tentative d’intubation par laryngoscopie directe et à une probabilité plus faible d’événements indésirables associés. Une évaluation plus approfondie de l'impact des facteurs humains, tels que le travail en équipe et la prise de décision, sur la conformité et la réussite des processus d'intubation, ainsi que sur les résultats obtenus, est nécessaire.

Commentaire : Intubation process model :

BVM, bag-valve-mask; NRB, non-rebreather mask; RSI, rapid sequence intubation

Why are people increasingly attending the emergency department? A study of the French healthcare system.
Colineaux H, Pelissier F, Pourcel L, Lang T, Kelly-Irving M, Azema O, Charpentier S, Lamy S. | Emerg Med J. 2019 Sep;36(9):548-553
DOI: https://doi.org/10.1136/emermed-2018-208333
Keywords: access to care; emergency care systems, admission avoidance; emergency care systems, primary care; emergency department utilisation; epidemiology

WHO'S USING THE ED

Introduction : It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types.

Méthode : This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients' condition during ED visit was determined through the 'Clinical Classification of Emergency' score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures.

Résultats : The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes.

Conclusion : It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.

Conclusion (proposition de traduction) : Il semble que l’augmentation de recours au service des urgences ne repose pas sur une augmentation du nombre de types de visites non sévères, l’impact des types de visites de sévérité moyenne exigeant des procédures diagnostiques ou thérapeutiques dans les cas de services d’urgence.

The panoramic dental radiograph for emergency physicians.
Sklavos A, Beteramia D, Delpachitra SN, Kumar R. | Emerg Med J. 2019 Sep;36(9):565-571
DOI: https://doi.org/10.1136/emermed-2018-208332
Keywords: X-ray; imaging; infection; maxillo-facial; trauma

PRACTICE REVIEW

Editorial : Dental emergencies are common reasons for presenting to hospital emergency departments. Here, we discuss the panoramic radiograph (orthopantomogram (OPG, OPT) as a diagnostic tool for the assessment of mandibular trauma and odontogenic infections. In this article, we review the radiographic principles of image acquisition, and how to conduct a systematic interpretation of represented maxillofacial anatomy. The aim is to equip the emergency physician with the skills to use the OPG radiograph when available, and to rapidly assess the image to expedite patient management. Included is a discussion of a number of cases seen in the emergency setting and some common errors in diagnosis.

Conclusion : Facial trauma and odontogenic infections are frequent presen- tations to hospital emergency departments. This paper has outlined the utility of the panoramic radiograph in the emer- gency setting, and provides a clinical algorithm for its use. In some settings, a panoramic radiograph will provide sufficient diagnostic information for facial swellings, and when a PA mandible is also obtained, the two images canbe sufficient to diagnose and manage isolated mandible fractures. Interpretation of the panoramic image requires familiarity with the method of acquisition, and understanding of the presence of image aretfacts which may mimic pathology. The low radiation dose and lack of requirement for intravenous contrast make the panoramic image a safe method of imaging when CT is not required. However, for patients who are bedridden, unable to remain still or severely kyphotic, it may not be feasible to obtain a diagnostic quality image. An understanding of the nomenclature and relevant anatomic features imaged will help facilitate a diagnosis, inter- pretation of the radiologists report and communication between treating teams.

Conclusion (proposition de traduction) : Les traumatismes du visage et les infections odontogènes sont des manifestations fréquentes dans les services d'urgence des hôpitaux. Cet article décrit l'utilité de la radiographie panoramique en situation d'urgence et fournit un algorithme clinique pour son utilisation. Dans certains contextes, une radiographie panoramique fournira suffisamment d'information diagnostique pour les oedèmes faciaux, et lorsqu'une incidence de la mandibule postéro-antérieure est également obtenue, les deux images peuvent être suffisantes pour diagnostiquer et gérer les fractures isolées de la mandibule. L'interprétation de l'image panoramique exige une bonne connaissance de la méthode d'acquisition et la compréhension de la présence des situations qui peuvent imiter une pathologie. La faible dose de rayonnement et l'absence d'exigence de contraste intraveineux font de l'image panoramique une méthode sûre d'imagerie lorsque la tomodensitométrie n'est pas nécessaire. Cependant, pour les patients alités, incapables de rester immobiles ou gravement kyphotiques, il n'est pas toujours possible d'obtenir une image diagnostique de qualité. Une compréhension de la nomenclature et des caractéristiques anatomiques pertinentes représentées par imagerie facilitera le diagnostic, l'interprétation du rapport du radiologue et la communication entre les équipes de traitement.

Commentaire :  
• Clinical algorithm outlining role of the panoramic radiograph in facial trauma assessment :
PA, posteroanterior.
• An algorithm for the assessment of facial swelling and the role of the panoramic radiograph :

Internal and Emergency Medicine

Intensity of care delivered by prehospital emergency medical service physicians to patients with deliberate self-poisoning: results from a 2-day cross-sectional study in France.
Maignan M, Viglino D, Collomb Muret R, Vejux N, Wiel E, Jacquin L, Laribi S, N-Gueye P, Joly LM, Dumas F, Beaune S; IRU-SFMU Group. | Intern Emerg Med. 2019 Sep;14(6):981-988
DOI: https://doi.org/10.1007/s11739-019-02108-1
Keywords: Attempted suicide; Emergency medical services; Emergency medicine; Poisoning

EM - ORIGINAL

Introduction : Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients.

Méthode : The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not.

Résultats : Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p < 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p < 0.001].

Conclusion : Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.

Conclusion (proposition de traduction) : Les patients présentant une intoxication volontaire pris en charge par des médecins des services d'urgence préhospitaliers ont fréquemment reçu des soins intensifs. Le niveau de soins semblait approprié à la gravité de l’intoxication.

International Journal of Emergency Medicine

Prospective comparison of capillary and venous brain biomarker S100B: capillary samples have large inter-sample variation and poor correlation with venous samples.
Vedin T, Karlsson M, Edelhamre M, Bergenheim M, Larsson PA. | Int J Emerg Med. 2019 Sep 2;12(1):26
DOI: https://doi.org/10.1186/s12245-019-0239-6  | Télécharger l'article au format  
Keywords: Blood specimen collection; Brain injuries traumatic; Capillary; S100 calcium-binding protein beta subunit; S100B; Venous

Original Research

Introduction : Guidelines for the emergency management of mild traumatic brain injury have been used for over a decade and are considered safe. However, they recommend computerized tomography for at least half of these patients. The Scandinavian Neurotrauma Committee guideline uses serum S100B protein level to rule out intracranial hemorrhage. Analysis of capillary serum S100B protein level has not yet been employed for this purpose. The primary aim of this study was to investigate the correlation and agreement of capillary and venous serum S100B protein level over a spectrum of concentrations typical for mild traumatic brain injury.

Méthode : Eighteen patients with traumatic intracranial hemorrhage and 39 volunteers without trauma to the head within the past 7 days were recruited. Blood was sampled from patients with intracranial hemorrhage daily up to four consecutive days and healthy volunteers were sampled once during the study. One venous and two capillary samples were drawn at each sampling event. Samples were analyzed using the Cobas e411 S100 electrochemiluminescence assay.

Résultats : Median serum S100B protein level of capillary sampling 1 was 0.12 (IQR 0.075-0.21) μg/l and median serum S100B protein level of capillary sampling 2 was 0.13 (IQR 0.08-0.22) μg/l. Median serum S100B protein level of all venous samples was 0.05 (IQR 0.03-0.07) μg/l. Correlation plots of capillary and venous samples showed poor correlation and Bland-Altman plots showed a large dispersion of samples and wide limits of agreement.

Conclusion : The results of this study indicate that correlation and agreement between capillary and venous samples are low, and because of this, we cannot recommend studies on capillary serum S100B protein level to rule out intracranial hemorrhage in mild traumatic brain injury. Given the limitations of the current sampling and analysis methods of capillary protein S100B protein level, we conclude that evaluating its predictive ability to rule out intracranial hemorrhage should be withheld until more reliable methods can be incorporated into the study design.

Conclusion (proposition de traduction) : Les résultats de cette étude indiquent que la corrélation et la concordance entre les échantillons capillaires et veineux sont faibles et que, pour cette raison, nous ne pouvons pas recommander d'études sur le taux de protéine S100B dans le sérum capillaire afin d'éliminer les hémorragies intracrâniennes dans les lésions cérébrales traumatiques légères. Etant donné les limites des méthodes actuelles d'échantillonnage et d'analyse du niveau de protéine capillaire S100B, nous concluons qu'il convient de ne pas évaluer sa capacité prédictive à exclure les hémorragies intracrâniennes jusqu'à ce que des méthodes plus fiables puissent être intégrées au plan de l'étude.

Journal of Emergency Medicine

Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department.
Hercz D, Montrief TD, Kukielski CJ, Supino M. | J Emerg Med. 2019 Sep;57(3):279-289
DOI: https://doi.org/10.1016/j.jemermed.2019.06.010
Keywords: blunt; imaging; rule; spine; thoracolumbar; trauma

Original Contributions

Introduction : Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear.
OBJECTIVE : The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases.

Méthode : Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning.

Résultats : Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65 years. No patients in this cohort with these four findings had a TL spine injury.

Conclusion : In certain lower-risk blunt trauma patients < 65 years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65 years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon.

Conclusion (proposition de traduction) : Chez certains patients à faible risque de traumatisme contondant < 65 ans, un examen ciblé combiné à un mécanisme de lésion peut être très sensible (100 %) pour écarter la possibilité d'une lésion thoracolombaire sans avoir recours à une imagerie spécialisée. Toutefois, la validation est nécessaire, étant donné les multiples limites de l'étude.
Instrument potentiel pour dépister les lésions thoraco-lombaires en cas de traumatisme mineur : une lésion thoraco-lombaire est peu probable si les quatre éléments suivants sont tous présents :
1) aucune sensibilité ou déformation de la ligne médiane du dos,
2) aucun signe ou symptôme neurologique focal ou altération de la mentation,
3) âge < 65 ans ; et
4) absence de mécanisme de blessure grave, par exemple, chute plus importante que debout, collision avec un véhicule à moteur, renversement/éjection/ piéton ou véhicule non fermé, et agression avec une arme.

Journal of the American College of Cardiology

Oral Fluoroquinolones and Risk of Mitral and Aortic Regurgitation.
Etminan M, Sodhi M, Ganjizadeh-Zavareh S, Carleton B, Kezouh A, Brophy JM. | J Am Coll Cardiol. 2019 sep;74(11):1444-1450
DOI: https://doi.org/10.1016/j.jacc.2019.07.035
Keywords: Aucun

ORIGINAL INVESTIGATION

Introduction : Recent studies have linked fluoroquinolones (FQs) to cardiac adverse events, including aortic dissection and aneurysm. To date, whether FQs can increase the risk of aortic or mitral regurgitation has not been studied.
Objectives : This disproportionality analysis and case-control study examined whether FQs increase the risk of aortic and mitral regurgitation.

Méthode : Data from the U.S. Food and Drug Administration’s adverse reporting system database was used to undertake a disproportionality analysis, and a random sample of 9,053,240 patients from the U.S. PharMetrics Plus database (IQVIA) was used for the matched nested case-control study. Current FQ exposure implied an active prescription at the index date or 30 days prior to the event date. Recent FQ exposure was defined as FQ use within days 31 to 60 and past within days 61 to 365 prior to the event date. Rate ratios (RRs) were compared to users of amoxicillin and azithromycin. Conditional logistic regression was used to compute RRs adjusting for confounders.

Résultats : The reported odds ratio for the disproportionality analysis was 1.45 (95% confidence interval [CI]: 1.20 to 1.77). A total of 12,505 cases and 125,020 control subjects were identified in the case-control study. The adjusted RRs for current users of FQ compared with amoxicillin and azithromycin users were 2.40 (95% CI: 1.82 to 3.16) and 1.75 (95% CI: 1.34 to 2.29), respectively. The adjusted RRs for recent and past FQ users when compared with amoxicillin were 1.47 (95% CI: 1.03 to 2.09) and 1.06 (95% CI: 0.91 to 1.21), respectively.

Conclusion : These results show that the risk of aortic and mitral regurgitation is highest with current use followed by recent use. No risk was observed with past use of FQs. Future studies are necessary to confirm or refute these associations.

Conclusion (proposition de traduction) : Ces résultats montrent que le risque de régurgitation aortique et mitrale est le plus élevé avec l'utilisation actuelle suivie de l'utilisation récente. Aucun risque n'a été observé lors de l'utilisation antérieure de fluoroquinolones. Des études futures sont nécessaires pour confirmer ou réfuter ces associations.

Commentaire : Pour mémoire 
Fluroquinolones par voie systémique ou inhalée: risque de survenue d'anévrisme et de dissection aortique - Lettre aux professionnels de santé. ANSM, 06/11/2018.
Information destinée aux médecins généralistes, cardiologues, médecins internistes, infectiologues, pneumologues, ORL, pédiatres, gastro-entérologues, dermatologues, gynécologues, néphrologues, urologues, réanimateurs, gériatres, radiologues, urgentistes, pharmaciens d’officine et pharmaciens hospitaliers.
Les quinolones et les fluoroquinolones sont des antibiotiques administrés par voie systémique (forme injectable ou orale) ou par voie inhalée1, utilisés pour traiter des infections bactériennes au cours desquelles le pronostic vital peut être engagé.
Des données provenant d'études épidémiologiques et d'études non cliniques indiquent une augmentation du risque de survenue d'anévrisme et de dissections aortiques après traitement par des fluoroquinolnes (ciprofloxacine, lévofloxacine, loméfloxacine, moxifloxacine, norfloxacine, fluméquine et ofloxacine).
Ainsi, chez les patients présentant un risque de survenue d'anévrisme et de dissection aortique, les fluoroquinolones ne doivent être utilisées qu'après une évaluation attentive du rapport bénéfice/risque et après prise en compte des alternatives thérapeutiques.
Les facteurs prédisposant à la survenue d’un anévrisme et d’une dissection aortique comprennent les antécédents familiaux d’anévrisme, la préexistence d’un anévrisme ou d’une dissection aortique, le syndrome de Marfan, le syndrome vasculaire d’Ehlers-Danlos, l’artérite de Takayasu, l’artérite à cellules géantes (ou maladie de Horton), la maladie de Behçet, l’hypertension artérielle et l’athérosclérose.
Les patients doivent être informés du risque d'anévrisme et de dissection aortiques. Ils doivent être avertis de la nécessité d’une prise en charge immédiate par un médecin au sein d’un service d’urgence en cas d’apparition brutale d’une douleur intense abdominale, thoracique ou dorsale.
Fluroquinolones par voie systémique ou inhalée: risque de survenue d'anévrisme et de dissection aortique   - Lettre aux professionnels de santé (06/11/2018, 47 ko).

Impact of New Guidelines of Unscheduled and Scheduled Sedation for Cardiologists: JACC Council Perspectives.
Fisher JD, Welt FG, Villines TC, Truesdell AG, Young MN, Lakkireddy D, Lee BK; ACC’s Electrophysiology Section Leadership Council; ACC’s Interventional Section Leadership Council; ACC’s Imaging Section Leadership Council. | J Am Coll Cardiol. 2019 Sep 17;74(11):1505-1511
DOI: https://doi.org/10.1016/j.jacc.2019.07.038
Keywords: guidelines; procedural sedation; sedation; unscheduled sedation

JACC COUNCIL PERSPECTIVES

Editorial : Until 2019, guidelines for procedural sedation emphasized a detailed process most applicable for elective procedures scheduled well in advance. These guidelines provided by the American Society of Anesthesiologists were adopted by many specialties and institutions, and they have historically served the medical field well. However, cardiologists and other specialists often encounter urgent situations that demand unscheduled sedation. Physicians have been concerned about performing procedures in a fashion that "departs from the guidelines." In response, the American College of Emergency Physicians (ACEP) has developed a set of guidelines for patients requiring urgent unscheduled sedation. Many of the recommendations made within the novel ACEP guidelines are appropriate for cardiology, but there remain fundamental differences between trauma and other emergencies encountered in the emergency department and urgent cardiac procedures. This paper examines the differences between the American Society of Anesthesiologists and ACEP guidelines and provides some points to consider regarding best practices for cardiologists.

Conclusion : For many years, the American Society of Anesthesiologists guidelines have served us well, providing an organized framework for procedural sedation by nonanesthesiologists. The American Society of Anesthesiologists guidelines emphasize order and process, and are best suited for scheduled procedures. To deal with more urgent situations, the new American College of Emergency Physicians guidelines are helpful for cardiologists, but many details and cardiac procedures are not covered. Together, the American Society of Anesthesiologists and American College of Emergency Physicians guidelines provide stepping stones for the development of cardiology–oriented best practices statements.

Conclusion (proposition de traduction) : Pendant de nombreuses années, les directives de la Société américaine des anesthésiologistes nous ont bien servi en fournissant un cadre organisé pour la sédation procédurale par des nonanesthésiologistes. Les directives de l'American Society of Anesthesiologists insistent sur l'ordre et le processus, et conviennent mieux aux procédures programmées. Pour traiter les situations plus urgentes, les nouvelles directives du Collège américain des médecins d'urgence sont utiles pour les cardiologues, mais de nombreux détails et procédures cardiaques ne sont pas couverts. Ensemble, les directives de la Société américaine des anesthésiologistes et du Collège américain des médecins d'urgence constituent un tremplin pour l'élaboration de déclarations de pratiques optimales axées sur la cardiologie.

Major Bleeding in Patients With Coronary or Peripheral Artery Disease Treated With Rivaroxaban Plus Aspirin.
Eikelboom JW, Bosch JJ, Connolly SJ, Shestakovska O, Dagenais GR, Hart RG, Leong DP, O'Donnell M, Fox KAA, Bhatt DL, Cairns JA, Tasto C, Berkowitz SD, Cook Bruns N, Muehlhofer E, Diaz R, Maggioni AP, Yusuf S. | J Am Coll Cardiol. 2019 Sep 24;74(12):1519-1528
DOI: https://doi.org/10.1016/j.jacc.2019.07.065
Keywords: aspirin; bleeding; coronary artery disease; dual pathway; peripheral artery disease; rivaroxaban

ORIGINAL INVESTIGATIONS

Introduction : In patients with coronary or peripheral artery disease, the combination of rivaroxaban 2.5 mg twice daily and aspirin 100 mg once daily compared with aspirin 100 mg once daily reduced major adverse cardiovascular events and mortality and increased bleeding. OBJECTIVES: This study sought to explore the effects of the combination of rivaroxaban and aspirin compared with aspirin on sites, timing, severity, and management of bleeding in the COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) study.

Méthode : This study reports, by treatment group, the number and proportion of patients; hazard rate ratios for bleeding according to site and severity; the timing of bleeding using landmark analyses; and the number and proportion of patients who received blood products and other hemostatic treatments.

Résultats : Of 27,395 patients enrolled (mean age 68 years, 22% women), 18,278 were randomized to the combination of rivaroxaban and aspirin or to aspirin alone and followed for a mean of 23 months. Compared with aspirin alone, the combination increased modified International Society on Thrombosis and Hemostasis major bleeding (288 of 9,152 [3.1%] vs. 170 of 9,126 [1.9%]), (HR: 1.70; 95% CI: 1.40 to 2.05; p < 0.001), International Society on Thrombosis and Hemostasis major bleeding (206 of 9,152 [2.3%] vs. 116 of 9,126 [1.3%]), (HR: 1.78; 95% CI: 1.41 to 2.23; p < 0.0001), and minor bleeding (838 of 9,152 [9.2%] vs. 503 of 9,126 [5.5%]), (HR: 1.70; 95% CI 1.52 to 1.90; p < 0.0001); the combination also increased the need for any red cell transfusion (87 of 9,152 [1.0%] vs. 44 of 9,126 [0.5%]), (HR: 1.97; 95% CI 1.37 to 2.83, p = 0.0002). The gastrointestinal (GI) tract was the most common site of increased major bleeding (140 of 9,152 [1.5%] vs. 65 of 9,126 [0.7%]), (HR: 2.15; 95% CI: 1.60 to 2.89; p < 0.001), and the increase in bleeding was predominantly in the first year after randomization. Approximately one-third of major GI bleeding was gastric or duodenal, one-third was colonic or rectal, and one-third was from an unknown GI site. The study investigators reported that approximately three-quarters of major bleeding episodes were of mild or moderate intensity. A similar proportion of patients in each treatment group who experienced major bleeding received platelets, clotting factors, or other hemostatic agents.

Conclusion : The combination of rivaroxaban and aspirin compared with aspirin alone increased major bleeding, mainly from the GI tract. Most excess bleeding occurred during the first year after randomization, was of mild or moderate intensity, and was managed with conventional supportive therapy.

Conclusion (proposition de traduction) : La combinaison de rivaroxaban et d’aspirine par rapport à l’aspirine seule a entraîné une augmentation des saignements majeurs, principalement au niveau du tube digestif. La plupart des saignements importants sont survenus au cours de la première année suivant la randomisation, étaient d'intensité légère ou modérée et étaient gérés par un traitement habituel.

Pediatric Emergency Care

Clinical Characteristics of Allergy to Hymenoptera Stings.
Visitsunthorn N, Kijmassuwan T, Visitsunthorn K, Pacharn P, Jirapongsananuruk O. | Pediatr Emerg Care. 2019 Sep;35(9):600-604
DOI: https://doi.org/10.1097/PEC.0000000000001200
Keywords: Aucun

Original Articles

Introduction : The purpose of this study was to evaluate the clinical characteristics of allergy to stings from the Hymenoptera order of insects in a hospital in Thailand.

Méthode : A descriptive retrospective analytical study was carried out in inpatients and outpatients suffering from Hymenoptera stings from 2009 to 2013 in Siriraj Hospital.

Résultats : Medical records of 386 patients with an allergy to Hymenoptera stings were evaluated. Anaphylaxis was more common in patients younger than 15 years, who comprised 22.3% of patients in this study. The most common sting type was from wasps (58.3%). Eighty-five percent of patients sought medical treatment less than 24 hours after being stung. A systemic reaction and anaphylaxis were found in 9.9% and 4.4% of subjects, respectively. In 17 patients with anaphylaxis, only 11 patients (64.7%) received an epinephrine (adrenaline) injection as treatment, and only 8 (47.1%) received epinephrine autoinjectors or epinephrine-prefilled syringes to prevent a possible subsequent severe reaction. Significantly more patients younger than 15 years received epinephrine for prevention of an allergic reaction than did those older than 15 years (87.5% vs 11.7%, P < 0.001). Antibiotics were given to 43.0% of patients.

Conclusion : Anaphylaxis from Hymenoptera stings was more common in children than in adults. Only half of the patients visited the emergency room within 1 hour of being stung. Overuse of antibiotics and underuse of epinephrine were found. More information about Hymenoptera stings should be provided to the public, and the use of epinephrine should be encouraged in the case of severe reactions and anaphylaxis.

Conclusion (proposition de traduction) : L'anaphylaxie causée par les piqûres d'hyménoptères était plus fréquente chez les enfants que chez les adultes. Seulement la moitié des patients se sont rendus aux urgences dans l'heure qui a suivi leur piqûre. On a constaté une surutilisation des antibiotiques et une sous-utilisation de l'épinéphrine.
De plus amples renseignements sur les piqûres d'hyménoptères devraient être fournis au public et l'utilisation de l'épinéphrine devrait être encouragée dans le cas de réactions graves et d'anaphylaxie.

Commentaire : Etude réalisée à Bangkok en Thaïland

Prehospital and Disaster Medicine

A Novel Algorithm for Improving the Diagnostic Accuracy of Prehospital ST-Elevation Myocardial Infarction.
Goebel M, Vaida F, Kahn C, Donofrio JJ. | Prehosp Disaster Med. 2019 Sep 11:1-8
DOI: https://doi.org/10.1017/S1049023X19004849
Keywords: Aucun

First View

Introduction : ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation.
Hypothesis: An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers.

Méthode : Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another.

Résultats : There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01).

Conclusion : Prehospital STEMI ECGs can be accurately stratified to high, intermediate, and low probabilities for STEMI using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in CCL activation and decreased requirements for physician overread. This may have significant clinical and quality implications.

Conclusion (proposition de traduction) : Les ECG de syndrome coronarien avec élévation du segment ST préhospitalier peuvent être stratifiés avec précision en probabilités élevée, intermédiaire et faible pour l'infarctus du myocarde avec élévation du segment ST en utilisant les quatre critères. Bien qu'une étude supplémentaire soit nécessaire, l'utilisation de cette approche algorithmique à plusieurs niveaux dans les ECG préhospitaliers pourrait entraîner des changements dans l'activation des laboratoires de cathétérisme cardiaque et une diminution des exigences de surlecture des médecins. Cela peut avoir d'importantes répercussions cliniques et qualitatives.

Commentaire :  Cet algorithme est destiné aux ambulanciers paramédicaux, pour l'interprétation des ECG sans lecture médicale pour adresser les patients directement en angioplastie coronaire…

Criteria False Positive Source
Must be free of artifact or baseline wander Artifact or baseline wander
≥1 mm of ST elevation in ≥2 contiguous leads Minimal ST elevation
Heart rate <130 bpm Atrial flutter
QRS duration ≤100 ms Bundle branch block, pacemaker, metabolic derangement
Algorithm Criteria and Associated Source of Computer Interpretation False-Positive

Prehospital Emergency Care

Effectiveness of Prehospital Dual Sequential Defibrillation for Refractory Ventricular Fibrillation and Ventricular Tachycardia Cardiac Arrest.
Beck LR, Ostermayer DG, Ponce JN, Srinivasan S, Wang HE. | Prehosp Emerg Care. 2019 Sep-Oct;23(5):597-602
DOI: https://doi.org/10.1080/10903127.2019.1584256
Keywords: cardiac arrest; defibrillation; double sequential defibrillation; refractory ventricular fibrillation

Original Contributions

Introduction : Dual sequential defibrillation (DSD) - successive defibrillations with two defibrillators - offers a novel approach to refractory ventricular fibrillation (RVF) and tachycardia (VF/VT). While associated with rescue shock success, the effect of DSD upon out-of-hospital cardiac arrest (OHCA) is unknown. We evaluated the association of DSD with survival after refractory VF/VT OHCA.

Méthode : We used data from a large metropolitan fire-based EMS service. We included all adult OHCA during 2013-2016 with ≥3 standard defibrillations. Physicians authorized subsequent DSD use by two separate defibrillators (PhysioControl LIFEPAK® 12/15) with pads placed anterior-lateral and anterior-posterior. Evaluated outcomes included return of spontaneous circulation (ROSC), survival to hospital admission, survival to 72 hours, and survival to hospital discharge. Using multivariable logistic regression, we evaluated the association between defibrillation type and OHCA outcomes, adjusting for patient demographics and event characteristics.

Résultats : We included 310 patients in the analysis, 71 patients receiving DSD and 239 receiving conventional defibrillation. Patient demographics and event characteristics were similar between both groups. ROSC was lower for DSD than standard defibrillation: 39.4% vs. 60.3%, adjusted OR 0.46 (95% CI: 0.25-0.87). There were no differences in survival to hospital admission (35.2% vs. 49.2%, adjusted OR 0.57 [95% CI: 0.30-1.08]), survival to 72 hours (21.4% vs. 32.3%, adjusted OR 0.52 [95% CI: 0.26-1.10]), or survival to hospital discharge (14.3% vs. 20.9%, adjusted OR 0.63 [95% CI: 0.27-1.45]).

Conclusion : Compared with conventional defibrillation, DSD was associated with lower odds of prehospital ROSC. Defibrillation type was not associated with other OHCA endpoints. DSD may not be beneficial in refractory VF/VT OHCA.

Conclusion (proposition de traduction) : Comparativement à la défibrillation conventionnelle, la défibrillation séquentielle double était associée à une probabilité moindre de retour à une circulation spontanée en préhospitalier. Le type de défibrillation n'a pas été associé à d'autres paramètres d'arrêt cardiaque extrahospitalier. La double défibrillation séquentielle pourrait ne pas être bénéfique en cas d'arrêt cardiaque extra-hospitalier dans la FV/TV réfractaire.

Safety and Effectiveness of Field Nitroglycerin in Patients with Suspected ST Elevation Myocardial Infarction.
Bosson N, Isakson B, Morgan JA, Kaji AH, Uner A, Hurley K, Henry TD, Niemann JT. | Prehosp Emerg Care. 2019 Sep-Oct;23(5):603-611
DOI: https://doi.org/10.1080/10903127.2018.1558318
Keywords: ST elevation myocardial infarction; emergency medical services; nitrates; pharmacology

Original Contributions

Introduction : While widely used in the treatment of cardiac conditions, only limited data characterize out-of-hospital nitroglycerin (NTG) use. We sought to determine the safety of out-of-hospital sublingual NTG administered for suspected ST-segment elevation myocardial infarction (STEMI) and its effect on the patient's pain score.

Méthode : We prospectively identified adult patients with suspected STEMI transported by paramedics to three percutaneous Coronary Intervention PCI-capable hospitals in a large urban-suburban emergency medical services (EMS) system. We compared patients who received field NTG to those who did not. The primary outcome was the change in systolic blood pressure (SBP) between initial EMS measurement and emergency department (ED) triage vital signs. Secondary outcomes included the frequency of hypotension (SBP < 100 mmHg) and bradycardia (HR < 60) on ED arrival, drop in SBP ≥ 30 mmHg, out-of-hospital cardiac arrest (OHCA), and the change in pain score compared to an a priori threshold of -1.39.

Résultats : Among 940 EMS transports for suspected STEMI, we excluded 160 for initial SBP < 100 mmHg, leaving 780 subjects for the analysis. Median age was 67 with 61% male. NTG was administered to 340 (44%) patients. The median change in SBP was -10 mmHg (IQR -27, 2) and -3 mmHg (IQR -20, 9) in patients treated with and without NTG, respectively. The median difference in the decrease in SBP was 6 mmHg (95% CI 3, 9 mmHg). The frequencies of ED hypotension and bradycardia, the drop in SBP ≥ 30 mmHg, and the OHCA did not differ between groups. For patients with an initial pain score > 0, the average change in pain score for patients treated with NTG was -2.6 (95% CI -3.0, -2.2), while patients who did not receive NTG had a change in pain score of -1.4 (95% CI -1.8, -1.0).

Conclusion : In this cohort, field NTG did not result in a clinically significant decrease in blood pressure when compared with patients who did not receive NTG. However, NTG did cause a clinically significant reduction in pain.

Conclusion (proposition de traduction) : Dans cette cohorte, la nitroglycérine sur les lieux d'intervention n'a pas entraîné de baisse cliniquement significative de la tension artérielle comparativement aux patients n'ayant pas reçu de nitroglycérine. Cependant, la nitroglycérine a causé une réduction cliniquement significative de la douleur.

Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting.
Sobieraj DM, Martinez BK, Miao B, Cicero MX, Kamin RA, Hernandez AV, Coleman CI, Baker WL. | Prehosp Emerg Care. 2019 Sep 23:1-12
DOI: https://doi.org/10.1080/10903127.2019.1657213
Keywords: acute pain; analgesics; opioids

Article

Introduction : The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting.

Méthode : We searched MEDLINE®, Embase®, and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE).

Résultats : We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, there is no evidence of a clinically important difference in the change of pain scores with opioids vs. ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE). Opioids may cause fewer adverse events than ketamine (low SOE) when primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but there is no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), both administered primarily IV.

Conclusion : As initial analgesia, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Combining an opioid and ketamine may reduce acute pain more than an opioid alone but comparative harms are uncertain. When initial morphine is inadequate, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, strength of evidence is generally low, and future research in the prehospital setting is needed.

Conclusion (proposition de traduction) : En tant qu'analgésie initiale, les opioïdes ne sont pas différents de la kétamine, de l'acétaminophène (paracétamol) et des AINS dans la réduction de la douleur aiguë en milieu préhospitalier. Les opioïdes peuvent provoquer moins d'effets secondaires que la kétamine, mais plus que l'acétaminophène (paracétamol) ou les AINS. La combinaison d'un opioïde et de la kétamine peut réduire la douleur aiguë davantage qu'un opioïde seul, mais les effets nocifs comparés sont incertains. Lorsque la morphine initiale est insuffisante, donner de la kétamine peut procurer un soulagement de la douleur aiguë plus important et plus rapide que de donner de la morphine supplémentaire, bien que les effets nocifs comparés soient incertains. En raison de leur caractère indirect, la force probante des preuves est généralement faible et des recherches futures dans le contexte préhospitalier sont nécessaires.

Validity of the Pediatric Early Warning Score and the Bedside Pediatric Early Warning Score in Classifying Patients Who Require the Resources of a Higher Level Pediatric Hospital.
Studnek JR, Browne LR, Shah MI, Fumo N, Hansen M, Lerner EB. | Prehosp Emerg Care. 2019 Sep 6:1-8
DOI: https://doi.org/10.1080/10903127.2019.1645924
Keywords: emergency medical services; pediatrics; validation studies

Article

Introduction : The pediatric early warning score (PEWS) and the bedside pediatric early warning score (BPEWS) are validated tools that help determine the need for critical care in children with acute medical conditions. These tools could be used by EMS and have not been evaluated outside of the hospital. This study retrospectively tested the validity of these tools in the prehospital setting to identify children who needed a hospital with higher level pediatric resources.

Méthode : This was a multi-center retrospective validation of screening tools using prehospital and in-hospital data obtained from 3 EMS agencies. EMS patient records from April 1, 2013 to April 30, 2015 were used to identify subjects for this analysis. Pediatric patients were retrospectively classified using the PEWS based on the clinical information documented in the EMS medical record. Those with PEWS scores greater than 4 were matched to a subject with scores less than 4 based on age, gender, and paramedic primary impression. Hospital medical record review was then used to determine whether the patient required a hospital with higher level pediatric resources. These classifications were used to calculate sensitivity, specificity, and resultant 95% confidence intervals. The analysis was repeated for included subjects who had sufficient data to calculate BPEWS.

Résultats : There were 386 patients enrolled. A PEWS ≥ 4 demonstrated a sensitivity of 62.8 (95% CI 53.6-71.4) and a specificity of 55.9 (95% CI 49.6-61.9) in identifying a patient who required a hospital with higher level pediatric resources. There were 44 pairs of patients that had sufficient EMS data documented to calculate a BPEWS. A BPEWS ≥ 7 demonstrated a sensitivity of 46.4 (95% CI 27.5-66.1) and a specificity of 76.7 (95% CI 64.0-86.6) to correctly classify a patient who required a hospital with higher level pediatric resources.

Conclusion : In the prehospital setting neither PEWS nor BPEWS exhibited sufficient sensitivity for clinical use to accurately identify children who need a hospital with higher level pediatric resources. Further research should be conducted to identify variables that are captured by prehospital care providers and are associated with children who need a hospital with higher level pediatric resources.

Conclusion (proposition de traduction) : Dans le contexte préhospitalier, ni le score pédiatrique d'alerte précoce ni le score d'alerte précoce au chevet du patient ne présentaient une sensibilité suffisante pour une utilisation clinique afin d'identifier avec précision les enfants ayant besoin d'une hospitalisation dans un établissement disposant de ressources pédiatriques de niveau supérieur. Des recherches supplémentaires devraient être menées pour identifier les variables saisies par les prestataires de soins préhospitaliers et associées aux enfants ayant besoin d'une hospitalisation dans un établissement disposant de ressources pédiatriques de niveau supérieur.

Resuscitation

A simple decision rule predicts futile resuscitation of out-of-hospital cardiac arrest.
Glober NK, Tainter CR, Abramson TM, Staats K, Gilbert G, Kim D. | Resuscitation. 2019 Jun 19;142:8-13
DOI: https://doi.org/10.1016/j.resuscitation.2019.06.011
Keywords: EMS; Out-of-Hospital cardiac arrest; Prehospital; Resuscitation

Clinical Papers

Introduction : Resuscitation of cardiac arrest involves invasive and traumatic interventions and places a large burden on limited EMS resources. Our aim was to identify prehospital cardiac arrests for which resuscitation is extremely unlikely to result in survival to hospital discharge.

Méthode : We performed a retrospective cohort analysis of all cardiac arrests in San Mateo County, California, for which paramedics were dispatched, from January 1, 2015 to December 31, 2018, using the Cardiac Arrest Registry to Enhance Survival (CARES) database. We described characteristics of patients, arrests, and EMS responses, and used recursive partitioning to develop decision rules to identify arrests unlikely to survive to hospital discharge, or to survive with good neurologic function.

Résultats : From 2015-2018, 1750 patients received EMS dispatch for cardiac arrest in San Mateo County. We excluded 44 patients for whom resuscitation was terminated due to DNR directives. Median age was 69 years (IQR 57-81), 563 (33.0%) patients were female, 816 (47.8%) had witnessed arrests, 651 (38.2%) received bystander CPR, 421 (24.7%) had an initial shockable rhythm, and 1178 (69.1%) arrested at home. A simple rule (non-shockable initial rhythm, unwitnessed arrest, and age 80 or greater) excludes 223 (13.1%) arrests, of whom none survived to hospital discharge.

Conclusion : A simple decision rule (non-shockable rhythm, unwitnessed arrest, age ≥ 80) identifies arrests for which resuscitation is futile. If validated, this rule could be applied by EMS policymakers to identify cardiac arrests for which the trauma and expense of resuscitation are extremely unlikely to result in survival.

Conclusion (proposition de traduction) : Une règle de décision simple (rythme non choquable, pas de témoin de l'ACR et âge supérieur à 80 ans) identifie les arrêts cardiaques pour lesquelles la réanimation est futile. Si elle est validée, cette règle pourrait être appliquée par les décideurs des services médicaux d'urgence pour identifier les arrêts cardiaques pour lesquels le traumatisme (ndlr : causé au patient par l'intervention) et le coût de réanimation sont extrêmement peu susceptibles de garantir la survie.

Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest.
Yamamoto M, Witsch T, Kubota S, Hara H, Hiroi Y. | Resuscitation. 2019 Jul 19;142:97-103
DOI: https://doi.org/10.1016/j.resuscitation.2019.07.017
Keywords: Acute coronary lesion; Lead aVR; Out-of-hospital cardiac arrest

Clinical Papers

Introduction : There is no simple clinical tool that reliably indicates the presence of acute coronary lesions in out-of-hospital cardiac arrest (OHCA) patients without typical ST-segment elevations. ST-segment elevation in electrocardiographic lead aVR suggests global subendocardial ischemia. This study aimed to evaluate the diagnostic value of lead aVR for identifying acute coronary lesions following resuscitation from OHCA.

Méthode : A total of 74 patients without evidence of ST-segment elevations, who were resuscitated from OHCA, were examined. The degree of ST-segment elevation in lead aVR was measured directly after return of spontaneous circulation (ROSC) and at early follow-up. Coronary angiograms were retrospectively reviewed.

Résultats : Acute coronary lesions were detected in 20 patients (27%). No difference in ST-segment elevation in lead aVR directly after ROSC was observed between patients with or without acute coronary lesions. However, ST-segment elevation values significantly decreased at early follow-up (median, 137 min) in patients without acute coronary lesions. An ST-segment elevation ≥0.5 mm in lead aVR at early follow-up was associated with a higher prevalence of multivessel coronary artery disease and was an independent indicator of the presence of acute coronary lesions (odds ratio, 4.41; 95% confidence interval, 1.12-17.4; p = 0.034).

Conclusion : ST-segment elevation in lead aVR at early follow-up was associated with the presence of acute lesions accompanied by severe coronary artery disease in post-cardiac arrest patients without other ST-segment elevations. The analysis of ST-segment elevation in lead aVR may aid in the identification of patients who will benefit from further invasive coronary diagnostic procedures.

Conclusion (proposition de traduction) : Un sus-décalage du segment ST dans la dérivation aVR, au début de la prise en charge après une RACS, était associé à la présence de lésions aiguës de coronaropathie grave chez les patients, post-arrêt cardiaque, sans élévation du segment ST dans les autres dérivations.
L’analyse d'un sus-décalage du segment ST dans la dérivation aVR peut aider à identifier des patients qui devraient bénéficier d'une procédure invasive à la recherche d'une étiologie coronarienne (ndlr : de l'arrêt cardiaque).

Capnography: A support tool for the detection of return of spontaneous circulation in out-of-hospital cardiac arrest.
Elola A, Aramendi E, Irusta U, Alonso E, Lu Y, Chang MP, Owens P, Idris AH. | Resuscitation. 2019 Apr 18. pii: S0300-9572(19)30132-7
DOI: https://doi.org/10.1016/j.resuscitation.2019.03.048
Keywords: Capnography; Electrocardiogram (ECG); End-tidal CO(2) (EtCO(2)); ROSC detection; Return of spontaneous circulation (ROSC); Thoracic impedance

Clinical papers

Introduction : Automated detection of return of spontaneous circulation (ROSC) is still an unsolved problem during cardiac arrest. Current guidelines recommend the use of capnography, but most automatic methods are based on the analysis of the ECG and thoracic impedance (TI) signals. This study analysed the added value of EtCO2 for discriminating pulsed (PR) and pulseless (PEA) rhythms and its potential to detect ROSC.

Méthode : A total of 426 out-of-hospital cardiac arrest cases, 117 with ROSC and 309 without ROSC, were analysed. First, EtCO2 values were compared for ROSC and no ROSC cases. Second, 5098 artefact free 3-s long segments were automatically extracted and labelled as PR (3639) or PEA (1459) using the instant of ROSC annotated by the clinician on scene as gold standard. Machine learning classifiers were designed using features obtained from the ECG, TI and the EtCO2 value. Third, the cases were retrospectively analysed using the classifier to discriminate cases with and without ROSC.

Résultats : EtCO2 values increased significantly from 41 mmHg 3-min before ROSC to 57 mmHg 1-min after ROSC, and EtCO2 was significantly larger for PR than for PEA, 46 mmHg/20 mmHg (p < 0.05). Adding EtCO2 to the machine learning models increased their area under the curve (AUC) by over 2 percentage points. The combination of ECG, TI and EtCO2 had an AUC for the detection of pulse of 0.92. Finally, the retrospective analysis showed a sensitivity and specificity of 96.6% and 94.5% for the detection of ROSC and no-ROSC cases, respectively.

Conclusion : Adding EtCO2 improves the performance of automatic algorithms for pulse detection based on ECG and TI. These algorithms can be used to identify pulse on site, and to retrospectively identify cases with ROSC.

Conclusion (proposition de traduction) : L'ajout de la mesure de l'EtCO2 améliore les performances des algorithmes automatiques de détection du pouls basés sur l'ECG et le monitorage de l'impédance thoracique. Ces algorithmes peuvent être utilisés pour identifier la présence d'un pouls sur le terrain et pour identifier de manière rétrospective les situations avec RACS.

Commentaire : Lire sur le sujet :
Sandroni C, De Santis P, D'Arrigo S. Capnography during cardiac arrest. Resuscitation. 2018 Nov;132:73-77  .
Heradstveit BE, Heltne JK. PQRST - a unique aide-memoire for capnography interpretation during cardiac arrest. Resuscitation. 2014 Nov;85(11):1619-20
  .

The American Journal of Emergency Medicine

Efficacy of the presence of an emergency physician in prehospital major trauma care: A nationwide cohort study in Japan.
Hirano Y, Abe T, Tanaka H. | Am J Emerg Med. 2019 Sep;37(9):1605-1610
DOI: https://doi.org/10.1016/j.ajem.2018.11.014
Keywords: Emergency physician; Paramedics; Prehospital; Trauma

Original Contribution

Introduction : The beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients.

Méthode : This retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs.

Résultats : A total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival.

Conclusion : Our results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.

Conclusion (proposition de traduction) : Nos résultats n'ont pas montré de différence de survie à la sortie entre les ambulances sans personnel médical et les ambulances avec personnel médical.

Intranasal ketamine reduces pain of digital nerve block; a double blind randomized clinical trial.
Nejati A, Jalili M, Abbasi S, Talebi Sarwari F, Bidari A, Ghajarzadeh M, Akhgar A. | Am J Emerg Med. 2019 Sep;37(9):1622-1626
DOI: https://doi.org/10.1016/j.ajem.2018.11.026
Keywords: Acute pain; Digital nerve block; Intranasal; Ketamine; Visual analogue scale

Original contribution

Introduction :  BACKGROUND : Low dose ketamine can be used as analgesic in acute pain management in the emergency department (ED).
OBJECTIVE : Efficacy of IN ketamine in acute pain management in the ED.

Méthode : This is a double blind randomized clinical trial on patients older than 15 years who needed digital nerve block (DNB). Participants randomly received IN Ketamine (1 ml = 50 mg) or placebo (normal saline, 1 ml) 5 min before DNB. In both groups, patients' pain score was recorded by visual analogue score (VAS) at baseline, after DNB and 45 min after completion of DNB. Adverse effects of ketamine and changes in vital signs were also recorded and compared with placebo group.

Résultats : A total number of 100 patients were enrolled in the study with the median (IQR) age of 36.5 (26) years, including 65 men and 35 women. IN ketamine resulted in less pain compared to placebo after performing DNB and 45 min after the procedure. Median (IQR) basic VAS score was 50 (15) in ketamine group, and 49 (27) in control group. Median (IQR) block pain VAS score was 28.5 (19) in ketamine group and 47.5 (31) in control group. Median (IQR) procedural pain VAS score was 21.5 (16) in ketamine group and 43.5 (29) in control group. Only 7 patients had adverse effects in either group.

Conclusion : The findings of this study suggest that IN ketamine can be effective in reducing pain in patients with acute pain, without adding significant side effects

Conclusion (proposition de traduction) : Les résultats de cette étude suggèrent que la kétamine intranasale peut être efficace pour réduire la douleur chez les patients souffrant de douleur aiguë, sans ajout d'effets secondaires importants.

Prognostic value of lactate in prehospital care as a predictor of early mortality.
Martín-Rodríguez F, López-Izquierdo R, Castro Villamor MA, Mangas IM, Del Brío Ibáñez P, Delgado Benito JF, Martín Conty JL, Manzanares JÁ, Mayo-Iscar A, Del Pozo Vegas C. | Am J Emerg Med. 2019 Sep;37(9):1627-1632
DOI: https://doi.org/10.1016/j.ajem.2018.11.028
Keywords: Early mortality; Lactate; Point-of-care testing; Prehospital care; Prognosis

Original contribution

Introduction : Prehospital Emergency Medical Services must attend to patients with complex physiopathological situations with little data and in the shortest possible time. The objective of this work was to study lactic acid values and their usefulness in the prehospital setting to help in clinical decision-making.

Méthode : We conducted a longitudinal prospective, observational study on patients over 18 years of age who, after being evaluated by the Advanced Life Support Unit, were taken to the hospital between April and June 2018. We analyzed demographic variables, prehospital lactic acid values and early mortality (<30 days). The area under the curve of the receiver operating characteristic was calculated for the prehospital value of lactic acid.

Résultats : A total of 279 patients were included in our study. The median age was 68 years (interquartile range: 54-80 years). Overall 30-day mortality was 9% (25 patients). The area under the curve for lactic acid to predict overall mortality at 30 days of care was 0.82 (95% CI: 0.76-0.89). The lactate value with the best sensitivity and specificity overall was 4.25 mmol/L with a sensitivity of 84% (95% CI: 65.3-93.6) and specificity of 70% (95% CI: 65.0-76.1).

Conclusion : The level of lactic acid can be a complementary tool in the field of prehospital emergencies that will guide us early in the detection of critical patients.

Conclusion (proposition de traduction) : Le taux de lactate peut être un outil complémentaire dans le domaine des urgences préhospitalières en guidant précocement la détection des patients en situation critique.

Can corticosteroids reduce the mortality of patients with severe sepsis? A systematic review and meta-analysis.
Ni YN, Liu YM, Wang YW, Liang BM, Liang ZA. | Am J Emerg Med. 2019 Sep;37(9):1657-1664
DOI: https://doi.org/10.1016/j.ajem.2018.11.040
Keywords: Corticosteroids; Mortality; Sepsis; Septic shock

Original contribution

Introduction : The effects of corticosteroids on clinical outcomes of patients with sepsis remains controversial. We aimed to further determine the effectiveness of corticosteroids in reducing mortality in adult patients with severe sepsis by comparison with placebo.

Méthode : Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that compared corticosteroids and placebo in adult patients with severe sepsis. The primary outcome was the mortality 28-day mortality and the secondary outcomes were mortality at longest follow up, occurrence, and reoccurrence of septic shock.

Résultats : A total of 19 trials involving 7035 patients were pooled in our final analyses. No significant heterogeneity was found in any of the outcome measures. Compared with placebo, corticosteroids were associated with a lower 28-day mortality (RR 0.91, 95% CI 0.85-0.98, Z = 2.57, P = 0.01) both in patients having sepsis and in those who developed septic shock (RR 0.92, 95% CI 0.85-0.99, Z = 2.19, P = 0.03), while no significant difference was found in mortality with the longest follow up in patients either having sepsis (RR 0.94, 95% CI 0.89-1.00, Z = 1.93, P = 0.05), or occurrence (RR 0.83, 95% CI 0.56-1.24, Z = 0.90, P = 0.37) or reoccurrence of septic shock (RR 1.08, 95% CI 1.00-1.16, Z = 1.89, P = 0.06).

Conclusion : Corticosteroids were effective in reducing the 28-day mortality in patients with severe sepsis and in those with septic shock.

Conclusion (proposition de traduction) : Les corticostéroïdes ont été efficaces pour réduire la mortalité à 28 jours chez les patients atteints de sepsis sévère et chez ceux présentant un choc septique.

Interventions affecting blood pressure variability and outcomes after intubating patients with spontaneous intracranial hemorrhage.
Tuteja G, Uppal A, Strong J, Nguyen T, Pope K, Jenkins R, Al Rebh H, Gatz D, Chang WT, Tran QK. | Am J Emerg Med. 2019 Sep;37(9):1665-1671
DOI: https://doi.org/10.1016/j.ajem.2018.11.041
Keywords: Aucun

Original contribution

Introduction : Spontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes.

Méthode : We performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home.

Résultats : We analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BPSV) (31,[IQR 18-45) compared with those receiving 4 or less pMVIs (38[IQR 16-70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BPSV (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home.

Conclusion : In addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.

Conclusion (proposition de traduction) : En plus de la gravité de la maladie, la ventilation mécanique individuelle a été associée de façon significative à la variabilité de la tension artérielle et au devenir des patients. Les urgentistes devraient procéder à une ventilation mécanique plus fréquente afin de prévenir la variabilité de la tension artérielle et d'améliorer les résultats pour les patients.

Can corticosteroids reduce the mortality of patients with severe sepsis? A systematic review and meta-analysis.
Ni YN, Liu YM, Wang YW, Liang BM, Liang ZA. | Am J Emerg Med. 2019 Sep;37(9):1657-1664
DOI: https://doi.org/10.1016/j.ajem.2018.11.040
Keywords: Corticosteroids; Mortality; Sepsis; Septic shock

Original contribution

Introduction : The effects of corticosteroids on clinical outcomes of patients with sepsis remains controversial. We aimed to further determine the effectiveness of corticosteroids in reducing mortality in adult patients with severe sepsis by comparison with placebo.

Méthode : Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that compared corticosteroids and placebo in adult patients with severe sepsis. The primary outcome was the mortality 28-day mortality and the secondary outcomes were mortality at longest follow up, occurrence, and reoccurrence of septic shock.

Résultats : A total of 19 trials involving 7035 patients were pooled in our final analyses. No significant heterogeneity was found in any of the outcome measures. Compared with placebo, corticosteroids were associated with a lower 28-day mortality (RR 0.91, 95% CI 0.85-0.98, Z = 2.57, P = 0.01) both in patients having sepsis and in those who developed septic shock (RR 0.92, 95% CI 0.85-0.99, Z = 2.19, P = 0.03), while no significant difference was found in mortality with the longest follow up in patients either having sepsis (RR 0.94, 95% CI 0.89-1.00, Z = 1.93, P = 0.05), or occ

Conclusion : Corticosteroids were effective in reducing the 28-day mortality in patients with severe sepsis and in those with septic shock.

Conclusion (proposition de traduction) : Les corticostéroïdes ont été efficaces pour réduire la mortalité à 28 jours chez les patients présentant un sepsis sévère et chez ceux présentant un choc septique.

Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants.
Spinola MB, Riccardi A, Minuto P, Campodonico P, Motta G, Malerba M, Guiddo G, Lerza R. | Am J Emerg Med. 2019 Sep;37(9):1677-1680
DOI: https://doi.org/10.1016/j.ajem.2018.12.003
Keywords: Anticoagulants; DOACs; Minor head injury; NOACs

Original contribution

Introduction : The correlation between direct oral anticoagulants (DOACs) or Vitamin K Antagonist (VKAs) intake and the incidence of intracranial complications after minor head injury (MHI) is still object of debate: preliminary observation seems to demonstrate lower incidence in intracranial bleeding complications (ICH) in patients taking DOACs than VKA

Méthode : This prospective and observational study was performed to clarify the incidence of ICH in patients in DOACs compared to VKAs. Between January 2016 and April 2018 we have recorded in our ED patients with MHI taking oral anticoagulants. Their hemorragic risk score was calculated and recorded for each patient (Has Bled, Atria and Orbit).

Résultats : A total of 402 patients with MHI taking anticoagulant were collected: 226 were receiving one of the four DOACs (dabigatran, rivaroxaban, apixaban or edoxaban) while 176 patients were in therapy with VKA. The rate of intracranial complications was significantly lower in patients receiving DOACs than in patients treated with VKA (p < 0.01). In the VKA group two patients died because of intracranial bleeding. No deaths were recorded in the DOACs group.

Conclusion : Patients with MHI who take DOACs have a significant lower incidence of intracranial bleeding complications than those treated with vitamin k antagonists. This statement is supported by the observation that the hemorrhagic risk, measured according to the chosen scores, was similar between the two groups.

Conclusion (proposition de traduction) : Les patients présentant un traumatisme crânien mineur qui prennent des anticoagulants oraux directs (AOD) présentent une incidence de complications hémorragiques intracrâniennes significativement plus faible que ceux traités avec des antagonistes de la vitamine K (AVK). Cette affirmation est corroborée par l'observation selon laquelle le risque hémorragique, mesuré en fonction des scores choisis, était similaire entre les deux groupes.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage.
Van Ornam J, Pruitt P, Borczuk P. | Am J Emerg Med. 2019 Sep;37(9):1694-1698
DOI: https://doi.org/10.1016/j.ajem.2018.12.012
Keywords: Imaging utilization; Mild intracranial hemorrhage; Traumatic brain injury; Traumatic cranial computerized tomography

Original contribution

Introduction : Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions.

Méthode : This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention.

Résultats : Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305.

Conclusion : RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Conclusion (proposition de traduction) : Répéter un scanner crânien après la découverte d'une hémorragie intracrânienne traumatique avec GCS ≥ 13 entraînant un changement de prise en charge opérationnelle en l'absence d'aggravation neurologique est un événement rare. Un protocole incluant une tomodensitométrie sélective répétitive comprenant des hématomes sous-duraux plus importants en volume ou des patients présentant une coagulopathie (inhibiteurs de la vitamine K et agents antiplaquettaires) pourrait faire l'objet d'une étude ultérieure.

Effect of hypoxia on mortality and disability in traumatic brain injury according to shock status: A cross-sectional analysis.
Seo DE, Shin SD, Song KJ, Ro YS, Hong KJ, Park JH. | Am J Emerg Med. 2019 Sep;37(9):1709-1715
DOI: https://doi.org/10.1016/j.ajem.2018.12.022
Keywords: Disability; Hypoxia; Shock; Survival; Traumatic brain injury

Original contribution

Introduction : This study aimed to test the association between hypoxia level and outcomes according to shock status in traumatic brain injury (TBI) patients.

Méthode : Adult TBI patients transported by emergency medical services in 10 provinces were enrolled. Hypoxia was a main exposure; three groups by oxygen saturation (SaO2, non-hypoxia (≥94%), mild hypoxia (90 ≤ SaO2 < 94%)), and severe hypoxia (<90%). Shock status (

Résultats : Of the 6125 patients, the mortality/disability rates were 49.4%/69.0% in severe hypoxia, 30.7%/46.9% in mild hypoxia, and 18.5%/27.5% in normoxia (p < 0.0001). Mortality/disability rates were 47.1%/57.1% in shock status and 20.5%/31.4% in non-shock status (p < 0.0001). AORs (95% CIs) for worsened disability/mortality compared with normoxia (reference) were 3.23 (2.47-4.21)/2.24 (1.70-2.96) in patients with severe hypoxia and 2.11 (1.63-2.74)/1.84 (1.39-2.45) in those with mild hypoxia. AORs (95% CIs) for worsened disability/mortality was 1.58 (1.20-2.09)/1.33 (1.01-1.76) by severe hypoxia than normoxia in patient with only non-shock status in the interaction analysis.

Conclusion : There was a trend toward worsened outcomes with mild and severe hypoxia in patient with and without shock, however, the only met statistical significance for patients with both severe hypoxia and non-shock status.

Conclusion (proposition de traduction) : On a observé une tendance à l'aggravation de l'hypoxie légère et grave chez les patients avec et sans choc, mais la seule signification statistique était rencontrée chez les patients présentant à la fois une hypoxie grave et un état sans choc.

Utility of applying white blood cell cutoffs to non-diagnostic MRI and ultrasound studies for suspected pediatric appendicitis.
Kennedy TM, Thompson AD, Choudhary AK, Caplan RJ, Schenker KE, DePiero AD. | Am J Emerg Med. 2019 Sep;37(9):1723-1728
DOI: https://doi.org/10.1016/j.ajem.2018.12.029
Keywords: Appendicitis; MRI; Magnetic resonance imaging; Pediatric; Ultrasound

Original contribution

Introduction : Non-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs).

Méthode : A retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of <10.0 and <7.5 × 109/L.

Résultats : Of the 612 patients with MRI studies included, 402 had ultrasound studies performed. MRI with incomplete visualization of a normal appendix without secondary signs of appendicitis had an NPV of 97.9% that changed to 98.1% and 98.2% when combined with WBC cutoffs of <10.0 and <7.5, respectively. Ultrasound studies with incomplete visualization of a normal appendix without secondary signs had an NPV of 85.3% that improved to 94.8% and 96.5% when combined with WBC cutoffs of <10.0 and <7.5, respectively.

Conclusion : In pediatric patients with suspected appendicitis, MRI studies with incomplete visualization of a normal appendix without secondary signs have a high NPV that does not significantly change with the use of these WBC cutoffs. In contrast, combining WBC cutoffs with ultrasound studies with the same interpretation identifies low-risk groups.

Conclusion (proposition de traduction) : Chez les enfants suspectés d'appendicite, les études d'IRM avec visualisation incomplète d'un appendice normal sans signes secondaires ont une valeur prédictive négative élevée qui ne change pas significativement avec l'utilisation de ces seuils de globules blancs. Par contre, la combinaison de ces seuils des globules blancs et des études échographiques avec la même interprétation permet d'identifier les groupes à faible risque.

The Journal of Emergency Medicine

Thoracolumbar Evaluation in the Low-Risk Trauma Patient: A Pilot Study Towards Development of a Clinical Decision Rule to Avoid Unnecessary Imaging in the Emergency Department.
Hercz D, Montrief TD, Kukielski CJ, Supino M. | J Emerg Med. 2019 Sep;57(3):279-289
DOI: https://doi.org/10.1016/j.jemermed.2019.06.010
Keywords: blunt; imaging; rule; spine; thoracolumbar; trauma

Original Contributions

Introduction : Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear.
The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases.

Méthode : Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning.

Résultats : Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65 years. No patients in this cohort with these four findings had a TL spine injury.

Conclusion : In certain lower-risk blunt trauma patients < 65 years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65 years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon.

Conclusion (proposition de traduction) : Chez certains patients à faible risque de traumatisme contondant de plus de 65 ans, un examen ciblé combiné au mécanisme de lésion peut être très sensible (100 %) pour écarter la possibilité d'une lésion thoracolombaire sans avoir recours à une imagerie spécialisée. Toutefois, une validation est nécessaire, étant donné les multiples limites de l'étude.
Instrument potentiel pour dépister les lésions thoraco-lombaires en cas de traumatisme mineur : une lésion thoraco-lombaire est peu probable si les quatre éléments suivants sont tous présents :
1) aucune sensibilité ou déformation de la ligne médiane dorsale ;
2) aucun signe ou symptôme neurologique focal ou altération des fonctions supérieures ;
3) âge < 65 ans ;
4) absence de mécanisme de blessure grave, par exemple, chute plus importante que debout, collision avec un véhicule à moteur, renversement/éjection/piéton ou véhicule non fermé, et agression par une arme à feu.

Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia: A Randomized, Clinical Trial.
Ceylan E, Ozpolat C, Onur O, Akoglu H, Denizbasi A. | J Emerg Med. 2019 Sep;57(3):299-305
DOI: https://doi.org/10.1016/j.jemermed.2019.06.008
Keywords: carotid sinus massage; modified valsalva; standard valsalva; supraventricular tachycardia; vagal maneuver

Original contributions

Introduction : For acute termination of supraventricular tachycardia (SVT), vagal maneuvers, including the standard Valsalva maneuver (sVM), modified Valsalva (mVM) maneuver, and carotid sinus massage (CSM), are first-line interventions. There is no criterion standard technique.
OBJECTIVE : This prospective, randomized study was aimed at analyzing the success rates of these 3 vagal maneuvers as measured by sustaining sinus rhythm at the fifth minute and SVT termination.

Méthode : We conducted this prospective, randomized controlled study in an emergency department (ED). We enrolled all the patients who were admitted to the ED and diagnosed with SVT. We randomly assigned them to 3 groups receiving sVM, mVM, and CSM and recorded the patients' responses to the vagal maneuvers and SVT recurrence after vagal maneuvers.

Résultats : The study was completed with 98 patients. A total of 25 (25.5%) instances of SVT were initially treated successfully with vagal maneuvers. The success rate was 43.7% (14/32 cases) from mVM, 24.2% (8/33) for sVM, and 9.1 % (3/33) for CSM (p < 0.05). At the end of the fifth minute, only 12.2% (12/98) of all patients had sinus rhythm. Sinus rhythm persisted in 28.1% (9/32) of patients in the mVM group, 6.1% (2/33) of patients in the sVM group, and 3% (1/33) in the CSM group at the fifth minute (p < 0.05).

Conclusion : mVM is superior to the CSM maneuver in terminating SVT and maintaining rhythm. We conclude that it is beneficial to use mVM, which is more effective and lacks side effects.

Conclusion (proposition de traduction) : La manœuvre modifiée de Valsalva est supérieure à la manœuvre du massage du sinus carotidien pour mettre fin à la tachycardie supraventriculaire et maintenir le rythme. Nous concluons qu’il est avantageux d’utiliser la manœuvre modifiée de Valsalva, qui est plus efficace et ne présente pas d’effets secondaires.

High Flow Nasal Cannula Oxygen vs. Conventional Oxygen Therapy and Noninvasive Ventilation in Emergency Department Patients: A Systematic Review and Meta-Analysis.
Tinelli V, Cabrini L, Fominskiy E, Franchini S, Ferrante L, Ball L, Pelosi P, Landoni G, Zangrillo A, Secchi A. | J Emerg Med. 2019 Sep;57(3):322-328
DOI: https://doi.org/10.1016/j.jemermed.2019.06.033
Keywords: acute respiratory failure; emergency department; high flow nasal cannula; noninvasive ventilation; oxygen therapy

Clinical Reviews

Introduction : Acute respiratory failure (ARF) is a common cause of presentation to the Emergency Department (ED). High flow nasal cannula (HFNC) has been introduced as an alternative way to administer oxygen. OBJECTIVES: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing HFNC with conventional oxygen therapy (COT) and noninvasive ventilation (NIV) exclusively in the ED setting.

Méthode : Inclusion criteria were: RCTs on adults with ARF admitted to the ED, investigating HFNC vs. COT or other modes of ventilation. Trials that compared HFNC support outside the ED, were published as an abstract, or nonrandomized were excluded.

Résultats : Four RCTs comparing HFNC with COT and one HFNC to NIV met the criteria. Overall, 775 patients were included. The meta-analysis of the studies comparing HFNC and COT showed no differences in intubation requirement, treatment failure, hospitalization, or mortality. Intolerance was significantly higher with HFNC (risk ratio 6.81 95% confidence interval 1.18-39.19; p = 0.03). In the only available RCT comparing HFNC with NIV, no difference was found for intubation rate, treatment failure, tolerance, and dyspnea.

Conclusion : We did not find any benefit of HFNC compared with COT and NIV in terms of intubation requirement, treatment failure, hospitalization, and mortality; COT was better tolerated.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucun bénéfice pour l'oxygénothérapie à haut débit (Optiflow) par rapport à l'oxygénothérapie conventionnelle et à la ventilation non invasive en termes de besoin d'intubation, d'échec thérapeutique, d'hospitalisation et de mortalité ; l'oxygénothérapie conventionnelle était mieux tolérée.

Commentaire : Première revue systématique et méta-analyse sur l'intérêt de l'Optiflow par rapport à l'oxygénothérapie conventionnelle dans le traitement de l'insuffisance respiratoire aiguë aux urgences.

Treatment of Seizures in Children and Adults in the Emergency Medical System of the City of Zurich, Switzerland - Midazolam vs. Diazepam - A Retrospective Analysis.
Theusinger OM, Schenk P, Dette-Oltmann K, Mariotti S, Baulig W. | J Emerg Med. 2019 Sep;57(3):345-353
DOI: https://doi.org/10.1016/j.jemermed.2019.05.036
Keywords: Emergency Medical Services; adults; children; diazepam; epilepsy; midazolam; seizure; status epilepticus

Selected Topics: Prehospital Care

Introduction : Seizures count to critical situations emergency medical systems (EMS) are confronted with.
OBJECTIVES : Evaluation of a modified treatment algorithm (MTAS-EMS) using diazepam and midazolam due to a supply bottleneck of iv lorazepam in 2012.

Méthode : Retrospective study where data from patients treated for seizures by the EMS of the city of Zurich were analyzed. Effectiveness of the MTAS-EMS and i.v. diazepam in children and adults was compared with respect of cessation of seizure without recurrence over the period until arrival at the hospital. The chi-square and Fisher's exact test were used to compare categorical data. The Student's t-test and Mann Whitney test were used to compare numerical data. p-values < 0.05 are considered significant.

Résultats : Of 584 documented missions, 165 treated patients (126 adults and 39 children) were included. 115 patients (80 adults and 35 children) were treated according the MTAS-EMS. Cessation of seizure was achieved in 85% of the adults and in 97% of the children, if all options of the MTAS-EMS were used. The first dose of nasal midazolam was more successful in children compared to adults (p = 0.012). In adults, the single dose of i.v. diazepam terminated the seizure in 98% (p = 0.001) compared to 57% for the single dose of iv and 64% for nasal midazolam.

Discussion : Le succès thérapeutique du protocole MTAS-EMS est élevé. Cependant, chez l'adulte, la dose unique de diazépam IV est aussi efficace que le MTAS-EMS entièrement utilisé et semble être supérieure à la dose unique IV et au midazolam nasal.

Conclusion : The treatment success of the MTAS-EMS is high. However, in adults the single dose of i.v. diazepam is as successful as the completely used MTAS-EMS and seems to be superior to the single dose iv and nasal midazolam.

Commentaire : Sur le sujet du traitement des crises convulsives par midazolam intranasal, voir :
• Detyniecki K, Van Ess PJ, Sequeira DJ and al. Safety and efficacy of midazolam nasal spray in the outpatient treatment of patients with seizure clusters-a randomized, double-blind, placebo-controlled trial. Epilepsia. 2019 Sep;60(9):1797-1808. doi: 10.1111/epi.15159   (Conclusion : Le midazolam administré en intranasal à dose unique s'est révélé supérieur au placebo pour ce qui est d'assurer un contrôle rapide et persistant des crises convulsives lorsqu'il a été administré à des patients présentant des crises convulsives en consultation externe et a été associé à un profil de tolérance favorable).
• Wheless JW, Meng TC, Van Ess PJ and al. Safety and efficacy of midazolam nasal spray in the outpatient treatment of patients with seizure clusters: An open-label extension trial . Epilepsia. 2019 Sep;60(9):1809-1819. doi: 10.1111/epi.16300  .
• McTague A, Martland T, Appleton R. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev. 2018 Jan 10;1:CD001905. doi: 10.1002/14651858  .

The Lancet

An artificial intelligence-enabled ECG algorithm for the identification of patients with atrial fibrillation during sinus rhythm: a retrospective analysis of outcome prediction.
Attia ZI, Noseworthy PA, Lopez-Jimenez F, Asirvatham SJ, Deshmukh AJ, Gersh BJ, Carter RE, Yao X, Rabinstein AA, Erickson BJ, Kapa S, Friedman PA. | Lancet. 2019 Sep 7;394(10201):861-867
DOI: https://doi.org/10.1016/S0140-6736(19)31721-0
Keywords: Aucun

Articles

Introduction : Atrial fibrillation is frequently asymptomatic and thus underdetected but is associated with stroke, heart failure, and death. Existing screening methods require prolonged monitoring and are limited by cost and low yield. We aimed to develop a rapid, inexpensive, point-of-care means of identifying patients with atrial fibrillation using machine learning.

Méthode : We developed an artificial intelligence (AI)-enabled electrocardiograph (ECG) using a convolutional neural network to detect the electrocardiographic signature of atrial fibrillation present during normal sinus rhythm using standard 10-second, 12-lead ECGs. We included all patients aged 18 years or older with at least one digital, normal sinus rhythm, standard 10-second, 12-lead ECG acquired in the supine position at the Mayo Clinic ECG laboratory between Dec 31, 1993, and July 21, 2017, with rhythm labels validated by trained personnel under cardiologist supervision. We classified patients with at least one ECG with a rhythm of atrial fibrillation or atrial flutter as positive for atrial fibrillation. We allocated ECGs to the training, internal validation, and testing datasets in a 7:1:2 ratio. We calculated the area under the curve (AUC) of the receiver operatoring characteristic curve for the internal validation dataset to select a probability threshold, which we applied to the testing dataset. We evaluated model performance on the testing dataset by calculating the AUC and the accuracy, sensitivity, specificity, and F1 score with two-sided 95% CIs.

Résultats : We included 180 922 patients with 649 931 normal sinus rhythm ECGs for analysis: 454 789 ECGs recorded from 126 526 patients in the training dataset, 64 340 ECGs from 18 116 patients in the internal validation dataset, and 130 802 ECGs from 36 280 patients in the testing dataset. 3051 (8·4%) patients in the testing dataset had verified atrial fibrillation before the normal sinus rhythm ECG tested by the model. A single AI-enabled ECG identified atrial fibrillation with an AUC of 0·87 (95% CI 0·86-0·88), sensitivity of 79·0% (77·5-80·4), specificity of 79·5% (79·0-79·9), F1 score of 39·2% (38·1-40·3), and overall accuracy of 79·4% (79·0-79·9). Including all ECGs acquired during the first month of each patient's window of interest (ie, the study start date or 31 days before the first recorded atrial fibrillation ECG) increased the AUC to 0·90 (0·90-0·91), sensitivity to 82·3% (80·9-83·6), specificity to 83·4% (83·0-83·8), F1 score to 45·4% (44·2-46·5), and overall accuracy to 83·3% (83·0-83·7).

Conclusion : An AI-enabled ECG acquired during normal sinus rhythm permits identification at point of care of individuals with atrial fibrillation.

Conclusion (proposition de traduction) : Un ECG basé sur l'intelligence artificielle, acquis au cours d'un rythme sinusal normal, permet d'identifier les personnes présentant une fibrillation atriale au point d'intervention.

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI): a phase 3, placebo-controlled, randomised trial.
Bhatt DL, Steg PG, Mehta SR, Leiter LA, Simon T, Fox K, Held C, Andersson M, Himmelmann A, Ridderstråle W, Chen J, Song Y, Diaz R, Goto S, James SK, Ray KK, Parkhomenko AN, Kosiborod MN, McGuire DK, Harrington RA; THEMIS Steering Committee and Investigators. | Lancet. 2019 Sep 28;394(10204):1169-1180
DOI: https://doi.org/10.1016/S0140-6736(19)31887-2
Keywords: Aucun

Articles

Introduction : Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor.

Méthode : The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population).

Résultats : Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8-3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74-0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, pinteraction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78-1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75-1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48-2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36-3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74-1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75-0·95, p=0·005, in contrast to patients without PCI where it did not, pinteraction=0·012. Benefit was present irrespective of time from most recent PCI.

Conclusion : In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk.

Conclusion (proposition de traduction) : Chez les patients diabétique présentant une maladie coronarienne stable aux antécédents d’intervention coronaire percutanée antérieure, l’adjonction de ticagrélor à l’aspirine a permis de réduire les décès cardiovasculaires, l’infarctus du myocarde et les accidents vasculaires cérébraux, bien qu’il ait entraîné une augmentation des saignements majeurs. Dans cette vaste population facilement identifiable, le ticagrélor a procuré un bénéfice clinique nettement favorable (supérieur à celui des patients sans antécédent d’intervention coronarienne percutanée).
Cet effet montre qu'une thérapie à long terme avec du ticagrélor en plus de l'aspirine doit être envisagée chez les patients diabétiques et ayant des antécédents d'intervention coronarienne percutanée qui ont toléré le traitement antiplaquettaire, ont un risque ischémique élevé et un risque hémorragique faible.

The New England Journal of Medicine

Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes.
Schüpke S, Neumann FJ, Menichelli M, Mayer K, Bernlochner I, Wöhrle J, Richardt G, Liebetrau C, Witzenbichler B, Antoniucci D, Akin I, Bott-Flügel L, Fischer M, Landmesser U, Katus HA, Sibbing D, Seyfarth M, Janisch M, Boncompagni D, Hilz R, Rottbauer W, Okrojek R, Möllmann H, Hochholzer W, Migliorini A, Cassese S, Mollo P, Xhepa E, Kufner S, Strehle A, Leggewie S, Allali A, Ndrepepa G, Schühlen H, Angiolillo DJ and al.; ISAR-REACT 5 Trial Investigators. | N Engl J Med. 2019 Sep 1
DOI: https://doi.org/10.1056/NEJMoa1908973
Keywords: Aucun

Original article

Introduction : The relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain.

Méthode : In this multicenter, randomized, open-label trial, we randomly assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. A major secondary end point (the safety end point) was bleeding.

Résultats : A total of 4018 patients underwent randomization. A primary-end point event occurred in 184 of 2012 patients (9.3%) in the ticagrelor group and in 137 of 2006 patients (6.9%) in the prasugrel group (hazard ratio, 1.36; 95% confidence interval [CI], 1.09 to 1.70; P = 0.006). The respective incidences of the individual components of the primary end point in the ticagrelor group and the prasugrel group were as follows: death, 4.5% and 3.7%; myocardial infarction, 4.8% and 3.0%; and stroke, 1.1% and 1.0%. Definite or probable stent thrombosis occurred in 1.3% of patients assigned to ticagrelor and 1.0% of patients assigned to prasugrel, and definite stent thrombosis occurred in 1.1% and 0.6%, respectively. Major bleeding (as defined by the Bleeding Academic Research Consortium scale) was observed in 5.4% of patients in the ticagrelor group and in 4.8% of patients in the prasugrel group (hazard ratio, 1.12; 95% CI, 0.83 to 1.51; P = 0.46).

Conclusion : Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups.

Conclusion (proposition de traduction) : Chez les patients présentant un syndrome coronarien aigu avec ou sans surélévation du segment ST, l'incidence de décès, d'infarctus du myocarde ou d'accident vasculaire cérébral était significativement plus basse chez ceux recevant du prasugrel que chez ceux recevant du ticagrélor, et l'incidence d'hémorragie majeure n'était pas significativement différent entre les deux groupes.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Syndrome coronarien aigu : le prasugrel l'emporte sur le ticagrélor  . Rédigé par le Dr Jean-Claude Lemaire le 2 septembre 2019.

Antithrombotic Therapy for Atrial Fibrillation with Stable Coronary Disease.
Yasuda S, Kaikita K, Akao M, Ako J, Matoba T, Nakamura M, Miyauchi K, Hagiwara N, Kimura K, Hirayama A, Matsui K, Ogawa H; AFIRE Investigators. | N Engl J Med. 2019 Sep 19;381(12):1103-1113
DOI: https://doi.org/10.1056/NEJMoa1904143
Keywords: Aucun

Original articles

Introduction : There are limited data from randomized trials evaluating the use of antithrombotic therapy in patients with atrial fibrillation and stable coronary artery disease.

Méthode : In a multicenter, open-label trial conducted in Japan, we randomly assigned 2236 patients with atrial fibrillation who had undergone percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG) more than 1 year earlier or who had angiographically confirmed coronary artery disease not requiring revascularization to receive monotherapy with rivaroxaban (a non-vitamin K antagonist oral anticoagulant) or combination therapy with rivaroxaban plus a single antiplatelet agent. The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause; this end point was analyzed for noninferiority with a noninferiority margin of 1.46. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis; this end point was analyzed for superiority.

Résultats : The trial was stopped early because of increased mortality in the combination-therapy group. Rivaroxaban monotherapy was noninferior to combination therapy for the primary efficacy end point, with event rates of 4.14% and 5.75% per patient-year, respectively (hazard ratio, 0.72; 95% confidence interval [CI], 0.55 to 0.95; P<0.001 for noninferiority). Rivaroxaban monotherapy was superior to combination therapy for the primary safety end point, with event rates of 1.62% and 2.76% per patient-year, respectively (hazard ratio, 0.59; 95% CI, 0.39 to 0.89; P = 0.01 for superiority).

Conclusion : As antithrombotic therapy, rivaroxaban monotherapy was noninferior to combination therapy for efficacy and superior for safety in patients with atrial fibrillation and stable coronary artery disease.

Conclusion (proposition de traduction) : En tant que traitement antithrombotique, la monothérapie par rivaroxaban n'a pas été inférieure à la thérapie d'association en ce qui concerne l'efficacité et la sécurité en supériorité chez les patients présentant une fibrillation atriale et une maladie coronarienne stable.


Mois de septembre 2019