Bibliographie de Médecine d'Urgence

Mois d'octobre 2019

Academic Emergency Medicine

Risk Factors for Sedation-related Events During Acute Agitation Management in the Emergency Department.
Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE; Sedation for Acute Agitation in Emergency Department Patients: Targeting Adverse Events (SIESTA) Collaborative Study Group.. | Acad Emerg Med. 2019 Oct;26(10):1135-1143
Keywords: Aucun

Original contributions

Introduction : he objective was to describe the incidence, nature, and risk factors for adverse events (AEs) among patients who received parenteral sedation for acute agitation in an emergency department (ED) setting.

Méthode : We undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. We included agitated adult patients who required parenteral sedation from 2014 to 2017 in 12 Australian EDs, excluding those with incomplete information or aged under 18 years. The primary outcome was the number of patients who experienced at least one AE. Multivariable logistic regression was used to determine factors associated with AEs.

Résultats : A total of 904 patients were included in the analyses (62.3% male; median age = 34 years, range = 18 to 95 years). Of these, 144 (15.9%) patients experienced at least one AE. The most common AEs were oxygen desaturation (7.4%), airway obstruction (3.6%), bradycardia (1.9%), hypotension (1.7%), and prolonged QTc interval (1.3%). No deaths or serious AEs were reported. The following factors had an increased adjusted odds ratio (OR) for experiencing an AE: age 65 years and older (OR = 2.8, 95% confidence interval [CI] = 1.2 to 7.2), more than one type of parenteral sedation administered within 60 minutes (OR = 2.1, 95% CI = 1.4 to 3.1), and alcohol intoxication (OR = 1.8, 95% CI = 1.2 to 2.6).

Conclusion : Sedation-related AEs are common, especially respiratory events. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk.

Conclusion (proposition de traduction) : Les événements indésirables liés à la sédation sont courants, en particulier les événements respiratoires.
Les patients âgés, la sédation avec plusieurs sédatifs dans les 60 minutes et l’intoxication alcoolique ont augmenté le risque.

Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study.
Stoecklein HH, Stoecklein H, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown CA; NEAR Investigators. | Acad Emerg Med. 2019 Oct;26(10):1144-1151
Keywords: Aucun

Original contributions

Introduction : Head-up positioning for preoxygenation and ramping for morbidly obese patients are well-accepted techniques, but the effect of head-up positioning with full torso elevation for all intubations is controversial. We compared first-pass success, adverse events, and glottic view between supine (SP) and nonsupine (NSP) positioning for emergency department (ED) patients undergoing orotracheal intubation.

Méthode : We performed a retrospective analysis of prospectively collected data for ED intubations over a 2-year period from 25 participating centers in the National Emergency Airway Registry (NEAR). We compared characteristics and outcomes for adult patients intubated orotracheally in SP and NSP positions with either a direct or video laryngoscope. We report odds ratios (OR) with 95% confidence interval (CI) for categorical variables and interquartile ranges with 95% CI for continuous variables. Our primary outcome was first-attempt intubation success and secondary outcomes were glottic views and peri-intubation adverse events.

Résultats : Of 11,480 total intubations, 5.8% were performed in NSP. The NSP group included significantly more obese patients (OR = 2.2 [95% CI = 1.9-2.6]) and patients with a suspected difficult airway (OR = 1.8 [95% CI = 1.6-2.2]). First-pass success (adjusted OR = 1.1 [95% CI = 0.9-1.4]) and overall rate of grade I glottic views (OR = 1.1 [95% CI = 0.9-1.2]) were similar between groups while NSP had a significantly higher rate of grade I views when direct laryngoscopy was employed (OR = 1.27 [95% CI = 1.04-1.54]). NSP was associated with higher odds of any adverse event (OR = 1.4 [95% CI = 1.1-1.7]).

Conclusion : ED providers utilized SP in most ED intubations but were more likely to use NSP for patients who were obese or in whom they predicted a difficult airway. We found no differences in first-pass success between groups but total adverse events were more likely in NSP. A randomized trial comparing patient positioning during intubation in the ED is warranted.

Conclusion (proposition de traduction) : Les urgentistes utilisaient la position allongée pour la plupart des intubations au services des urgences mais ils étaient plus susceptibles d'utiliser une autre solution que la position allongée chez les patients obèses ou chez ceux, chez qui, ils prédisaient une intubation difficile. Nous n'avons trouvé aucune différence dans le succès de la première tentative entre les groupes, mais le nombre total d'événements indésirables était retrouvé plus souvent chez les patients non allongés.
Un essai randomisé comparant la position du patient lors de l'intubation aux urgences est justifié.

Commentaire : Voir l'article :
• Stoecklein HH, Kelly C, Kaji AH and al. Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study. Acad Emerg Med. 2019 May 22  

Tranexamic Acid for Upper Gastrointestinal Bleeding.
Beyda R, Johari D. | Acad Emerg Med. 2019 Oct;26(10):1181-1182
Keywords: Gastrointestinal Hemorrhage; Hematemesis; Tranexamic Acid

The Brass Tacks: Concise Reviews of Published Evidence

Editorial : Upper gastrointestinal bleeding is common and accounts for at least half of the nearly 500,000 annual U.S. hospitalizations for gastrointestinal bleeding. In the acute setting, severe bleeding is treated with intravenous fluids, blood products, antiulcer therapy, and hemostasis by endoscopy. Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce bleeding. TXA has been proven to be effective in improving patient-centered outcomes after severe hemorrhage due to trauma. The authors of this systematic review sought to evaluate the benefit of TXA administration specifically for upper gastrointestinal bleeding.
The systematic review summarized here identified 8 randomized trials of TXA in 1701 subjects presenting with acute upper gastrointestinal bleeding among patients admitted to the hospital, including some in the intensive care unit. Two comparisons were made: TXA versus placebo and TXA versus antiulcer therapy (cimetidine or lansoprazole). Primary outcomes were mortality and adverse events. Compared to placebo, TXA reduced mortality (relative risk [RR]: 0.60, 95% CI 0.42 to 0.87; ARR: 3.5%; NNT: 30, moderate quality evidence). However, because of a high attrition in several trials the results must be interpreted with caution. About 20% of the studied patients were withdrawn or excluded for reasons such as lack of confirmation of the presence of bleeding, presence of malignancy, terminal illness, or late administration of treatments. Re-analysis including all participants and considering missing patients as treatment failures did not show mortality benefit.
the second comparison, TXA versus antiulcer therapy (cimetidine or lansoprazole), only two trials were included, and no mortality benefit was found. Administration of TXA did not reduce the risk of re-bleeding (RR 0.72, 95% CI 0.50 to 1.03, low quality evidence:) or blood transfusion (RR 1.02, 95% CI 0.94 to 1.11, very low quality evidence:).

Conclusion : We have assigned a color recommendation of Yellow (unclear benefits) to this intervention. Limitations of the reported data, particularly the lost to follow-up and dropout rates, the high risk of bias, and the presence of significant heterogeneity justify this rating. A large pragmatic double-blind controlled trial with a target sample size of 12,000 subjects is currently ongoing. We are hopeful this trial will provide better evidence. Despite TXA’s lack of demonstrated benefit compared to standard treatments with respect to the endpoints of mortality or re-bleeding, given the relative safety, lack of significant adverse events, and low cost of the medication, it may be reasonable to consider TXA in severe upper gastrointestinal bleeding as an adjunct to standard therapy, or if standard therapy fails.

Conclusion (proposition de traduction) : Nous avons attribué à cette intervention une recommandation de couleur Jaune (avantages peu clairs). Les limites des données déclarées, en particulier les taux de perte de suivi et d'abandon, le risque élevé de biais et la présence d'une hétérogénéité importante, justifient cette codification.
Un vaste essai clinique pragmatique à double insu et contrôlé avec un échantillon cible de 12 000 sujets est actuellement en cours. Nous espérons que cet essai fournira de meilleures preuves.
Malgré l'absence d'avantages démontrés de l'acide tranexamique par rapport aux traitements standard en ce qui concerne les critères d'évaluation de la mortalité ou du saignement, étant donné l'innocuité relative, l'absence d'événements indésirables importants et le faible coût du médicament, il peut être raisonnable de considérer l'administration d'acide tranexamique en cas d'hémorragie digestive haute grave comme un complément au traitement standard ou si le traitement standard échoue.

Commentaire : Roberts I, Coats T, Edwards P and al. HALT-IT--tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014 Nov 19;15:450.  .

Single Syringe Administration of Diluted Adenosine.
McDowell M, Mokszycki R, Greenberg A, Hormese M, Lomotan N, Lyons N. | Acad Emerg Med. 2019 Oct 30
Keywords: AVNRT; AVRT; Adenosine; Emergency Department; Supraventricular Tachycardia


Introduction : STUDY HYPOTHESIS: A single-syringe of adenosine diluted in normal saline will be non-inferior to the standard two-syringe method for conversion of supraventricular tachycardia to normal sinus rhythm.
OBJECTIVE : To compare the relative efficacy and safety of a novel route of administration of adenosine to usual care.

Méthode : A single center, prospective, observational study was conducted from November 1, 2016 through February 28, 2018 on patients presenting to the emergency department in supraventricular tachycardia treated with adenosine. Drug was prepared by the pharmacist and method of administration was at the preference of the physician. Adenosine was either prepared as a single-syringe combined with a 0.9% sodium chloride flush to a total of 20ml or as the conventional two separate syringes; adenosine followed immediately by a 20 mL saline flush. Rates of conversion from supraventricular tachycardia to normal sinus rhythm were recorded.

Résultats : A total of 53 patients were included in the analysis. Median number of doses administered in the single-syringe arm was one and three in the two-syringe arm. Conversion to normal sinus rhythm with first dose of adenosine was 73.1% and 40.7% for the single-syringe and conventional method respectively (p=0.0176). Successful conversion, after multiple doses, was 100% in the single-syringe arm and 70.4% in the two-syringe arm (p=0.0043). Adverse effects were minimal in both groups, 0% in the single-syringe arm and 3.85% in the undiluted cohort.

Conclusion : A single-syringe method of adenosine delivery is non-inferior to the conventional two-syringe method. Additionally, no adverse events were observed in the single-syringe method.

Conclusion (proposition de traduction) : La méthode d'administration d'une seule seringue d'adénosine n'est pas inférieure à la méthode conventionnelle à deux seringues. De plus, aucun effet indésirable n'a été observé avec la méthode à une seule seringue.

Annals of Emergency Medicine

Guideline-Based Clinical Assessment Versus Procalcitonin-Guided Antibiotic Use in Pneumonia: A Pragmatic Randomized Trial.
Montassier E, Javaudin F, Moustafa F, Nandjou D, Maignan M, Hardouin JB, Annoot C, Ogielska M, Orer PL, Schotté T, Bouget J, Agha Babaei S, Raynal PA, Eche A, Duc AT, Cojocaru RA, Benaouicha N, Potel G, Batard E, Talan DA.. | Ann Emerg Med . 2019 Oct;74(4):580-591
Keywords: Aucun

Infectious Disease

Introduction : Efforts to reduce unnecessary and unnecessarily long antibiotic treatment for community-acquired pneumonia have been attempted through use of procalcitonin and through guidelines based on serial clinical assessment. Our aim is to compare guideline-based clinical assessment- and procalcitonin algorithm-guided antibiotic use among patients with community-acquired pneumonia.

Méthode : We performed a pragmatic, randomized, multicenter trial from November 2012 to April 2015 at 12 French hospitals. We included emergency department (ED) patients older than 18 years with community-acquired pneumonia. Patients were randomly assigned to either the procalcitonin-guided or clinical assessment group. In accordance with past studies, we hypothesized that serial clinical assessment would be superior to procalcitonin-guided care. The primary outcome was antibiotic duration, and secondary outcomes included rates of antibiotic duration less than or equal to 5 days, and clinical success and combined serious adverse outcomes at 30 days in the intention-to-treat population.

Résultats : Of 370 eligible patients, 285 (77%) were randomly assigned to either clinical assessment- (n=143) or procalcitonin-guided care (n=142). Median age was 67 years (range 18 to 93 years) and 40% of patients were deemed to have Pneumonia Severity Index class IV or V. Procalcitonin algorithm adherence was 76%. Antibiotic duration was not significantly different between clinical assessment- and procalcitonin-guided groups (median 9 versus 10 days, respectively). Clinical success rate was 92% in each group and serious adverse outcome rates were similar (15% versus 20%, respectively).

Conclusion : Guideline-based serial clinical assessment did not reduce antibiotic exposure compared with procalcitonin-guided care among ED patients with community-acquired pneumonia. The strategies were similar in terms of duration of antibiotic use and clinical outcomes.

Conclusion (proposition de traduction) : L'évaluation clinique sérielle basée sur les recommandation n'a pas réduit l'utilisation des antibiotiques comparé à la prise en charge guidée par les taux de procalcitonine parmi les patients des urgences présentant une pneumopathie communautaire acquise. Les stratégies étaient semblables du point de vue de la durée d'utilisation des antibiotiques et des résultats cliniques.

Commentaire : La stratégie de traitement antibiotique basée sur le taux ce la PCT ne permets pas de moins prescrire d'antibiotiques.

Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting.
Cotton DM, Vinson DR, Vazquez-Benitez G, Margaret Warton E, Reed ME, Chettipally UK, Kene MV, Lin JS, Mark DG, Sax DR, McLachlan ID, Rauchwerger AS, Simon LE, Kharbanda AB, Kharbanda E, Ballard DW; Clinical Research on Emergency Services and Treatments (CREST) Network.. | Ann Emerg Med. 2019 Oct;74(4):471-480
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS).

Méthode : We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC.

Résultats : We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS.

Conclusion : The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.

Conclusion (proposition de traduction) : Le pARC a évalué avec précision le risque de diagnostic d'appendicite chez les enfants âgés de 5 ans et plus dans les urgences communautaires et le pARC a surpassé le PAS.

Does Room Air Reduce Mortality Among Term Neonates Requiring Respiratory Support at Birth?.
Long B, April MD. | Ann Emerg Med. 2019 Oct;74(4):509-511
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Meta-analysis authors identified quasi-randomized controlled trials and nonrandomized trials from Ovid MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, and the Cochrane Central Register of Controlled Trials; searched reference lists of the International Liaison Committee on Resuscitation (ILCOR) 2010, 2015 Consensus on Science With Treatment Recommendations, and other systematic reviews on the topic; evaluated trial registries; and searched the first 200 hits of 1 Google Scholar. Authors limited the literature search to studies from 1980 to December 11, 2017.

Méthode : Pairs of independent reviewers independently screened titles and abstracts. They then independently reviewed full-text articles, with final decisions for inclusion made by consensus. Investigators included quasi-randomized controlled trials and observational studies comparing low and high initial oxygen concentration for respiratory support at birth. The authors included studies in which greater than 75% of patients were at greater than 35 weeks’ gestation.

Résultats : Author pairs independently extracted data from included studies. The primary outcome was short-term all-cause mortality (inhospital or up to 30 days postnatal). Secondary outcomes included long-term mortality (1 to 3 years), neurodevelopmental impairment, and hypoxic ischemic encephalopathy. Reviewers used a random-effects model for analysis with pooled unadjusted risk ratios and 95% confidence intervals, and they calculated numbers needed to treat when possible. The authors evaluated risk of bias with the Cochrane Risk of Bias Tool for randomized controlled trials and the Risk of Bias in Non-randomized Studies of Interventions tool for 2,3 observational studies. evaluated heterogeneity with the I2 statistic and assessed evidence certainty for each outcome, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Sensitivity analyses were completed when inclusion of one or more studies was uncertain because of high risk of bias, incongruent allocation, significant heterogeneity, or adjusted and nonadjusted analyses. Subgroup analyses were planned according to gestational ages and specific FiO2 ranges.

Conclusion : Room air is associated with reduced short-term mortality compared with 100% FiO2 for neonates greater than 35 weeks’ gestation who require respiratory support at birth.

Conclusion (proposition de traduction) : L'assistance respiratoire en air ambiant à la naissance est associé à une réduction de la mortalité à court terme comparativement à 100 % de FiO2 chez les nouveau-nés de plus de 35 semaines de gestation qui en ont besoin.

The Reality of Pain Scoring in the Emergency Department: Findings From a Multiple Case Study Design.
Sampson FC, Goodacre SW, O'Cathain A. | Ann Emerg Med. 2019 Oct;74(4):538-548
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Pain Management and Sedation

Introduction : Documentation of pain severity with pain scores is recommended within emergency departments (EDs) to improve consistency of assessment and management of pain. Pain scores are used in treatment guidelines and triage algorithms to determine pain management and in audit and research to evaluate pain management practices. Despite significant debate of their benefits, there has been limited evaluation of their use in practice. We use naturalistic, qualitative methods to understand how pain scores are used in practice and the mechanisms by which pain scoring may influence pain management.

Méthode : We undertook a multiple case study design, using qualitative research in 3 EDs in England (the cases). Case studies incorporated 143 hours of nonparticipant observation, documentary analysis, and semistructured interviews with 36 staff and 19 patients. Data were analyzed with thematic analysis.

Résultats : Analysis identified that ED staff used the pain score for 2 conflicting purposes: as an auditable tool for guiding patient management and as a tool for monitoring patient experience. This led to ED staff's facing conflict between reporting their own judgment of what the pain score ought to be and what the patient said it was. Staff justified recording their own judgment according to concerns of accountability and appropriateness of management decisions. Staff thought that pain scoring had value in raising awareness and prompting action.

Conclusion : In practice, pain scoring may not accurately reflect patient experience. Using pain scoring to determine the appropriateness of triage and treatment decisions reduces its validity as a measure of patient experience. Pain scoring should not be central to audit and systems of accountability for pain management.

Conclusion (proposition de traduction) : Dans la pratique, l'évaluation de la douleur peut ne pas refléter fidèlement l'expérience du patient. Le recours à l'évaluation de la douleur pour déterminer la pertinence des décisions relatives au triage et au traitement réduit sa validité en tant que mesure de l'expérience du patient. L'évaluation de la douleur ne devrait pas être au cœur de la vérification et des systèmes de responsabilisation en matière de gestion de la douleur.

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain.
Dubosh NM, Edlow JA, Goto T, Camargo CA Jr, Hasegawa K. | Ann Emerg Med. 2019 Oct;74(4):549-561
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Serious neurologic conditions can be missed on initial emergency department (ED) visit and discharge diagnosis oftentimes remains a nonspecific symptom. We aim to examine the incidence of potential harm from serious neurologic conditions in ED patients discharged with a nonspecific diagnosis of headache or back pain, identify specific missed conditions, and determine risk factors for potential misdiagnosis-related harm.

Méthode : This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012. We identified adults (≥18 years) discharged from the ED with a diagnosis of atraumatic headache or back pain. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge.

Résultats : There were 2,101,081 ED discharges with a nonspecific diagnosis of headache and 1,381,614 discharges with a nonspecific diagnosis of back pain. Overall, 0.5% of the headache patients and 0.2% of back pain patients had a primary outcome. The most common missed condition for headache was ischemic stroke (18.1%). The most common missed condition for back pain was intraspinal abscess (41%). In both populations, advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy) were associated with higher odds of outcome.

Conclusion : A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or inhospital death within 30 days.

Conclusion (proposition de traduction) : Une petite proportion de patients sortis des urgences avec un diagnostic non spécifique de maux de tête ou de maux de dos sont revenus aux urgences avec une affection neurologique grave ou pour un décès à l'hôpital dans les 30 jours.

Commentaire : L'AVC ischémique (18,1 %) était l'affection la plus souvent oubliée à l'origine des céphalées. L'abcès médullaire (41 %) était l'affection la plus souvent oubliée dans les maux de dos.
Dans les deux populations, l'âge avancé, le sexe masculin, la race blanche non hispanique et les comorbidités (p. ex. troubles neurologiques, VIH/sida, malignité) étaient associés à des probabilités de résultat plus élevées.

Do Calcium Antagonists Decrease Mortality or Dependency in Acute Ischemic Stroke?.
Bridwell RE, Long B1, April MD. | Ann Emerg Med. 2019 Oct;74(4):575-577
Keywords: Aucun


Introduction : An information specialist searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, PubMed, Ovid EMBASE,, the World Health Organization International Clinical Trials Registry Platform, EU Clinical Trials Register, Stroke Trials Registry, ISRCTN Registry, and Chinese Clinical Trial Registry. The authors also searched the Chinese Biological Medicine Database, China National Knowledge Infrastructure, Chinese Scientific Periodical Database of VIP information, and Wanfang Data. The Cochrane review authors then evaluated reference lists of identified publications.

Méthode : Two authors independently assessed studies for relevance and resolved disagreements through discussion or involvement of a third author. To aid with trial selection, authors developed an inclusion/ exclusion document, which evaluated general information, trial characteristics, interventions, participants, and outcomes. Investigators included randomized controlled trials of adult patients with presumed or definitive acute ischemic stroke who received a calcium antagonist within 14 days of stroke onset by any route versus placebo or medical treatment alone. Authors also included randomized controlled trials evaluating different doses and routes of administration.

Résultats : Two investigators independently extracted data from included studies. The primary outcomes included all-cause mortality and dependency in activities of daily living as defined by modified Rankin Scale or Oxford Handicap Scale score greater than 3, Glasgow Outcome Coma Scale score less than 4, Barthel Index score less than 60, Toronto Stroke Scale score greater than 3, or Mathew Impairment Scale score equal to 7. Secondary outcomes included death from any cause during scheduled treatment; death from any cause during long-term follow- up with a minimum of 3 months; recurrent stroke during long-term follow up; adverse effects of the drug during the treatment period (eg, reduced renal function, impaired liver function, local infection irritation, nausea); hypotension defined as substantial decrease in blood pressure during the treatment period; and mean systolic blood pressure during the treatment period. Authors calculated risk ratios with 95% confidence intervals for dichotomous data and mean differences with 95% confidence intervals for continuous outcomes. They assessed heterogeneity with the I2 statistic. Two authors assessed risk of bias according to the Cochrane Handbook for Systemic Reviews of Interventions and used the Grading of Recommendations Assessment, Development and evaluation criteria to assess evidencequality. Authorsanalyzed all outcomes and included analyses stratified by route of administration, dose, and interval. They conducted subgroup analyses on drug administration route, dose, and interval to the start of treatment. They planned to conduct sensitivity analysis with the inclusion of only multicenter studies or published trials.

Conclusion : The use of calcium antagonists in acute ischemic stroke does not reduce mortality or dependency in activities of daily living.

Conclusion (proposition de traduction) : L'utilisation des inhibiteur calciques dans les accidents vasculaires cérébraux ischémiques aigus ne réduit ni la mortalité ni la dépendance aux activités de la vie quotidienne.

Commentaire : Les inhibiteur calciques dont il est question dans l'article sont : la nimodipine (Nimotop) et la flunarizine (Sibelium)

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache: Approved by the ACEP Board of Directors June 26, 2019 Clinical Policy Endorsed by the Emergency Nurses Association (July 31, 2019).
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Headache, Godwin SA, Cherkas DS, Panagos PD, Shih RD, Byyny R, Wolf SJ. | Ann Emerg Med. 2019 Oct;74(4):e41-e74
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Editorial : This clinical policy from the American College of Emergency Physicians addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.

Conclusion : A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? Evidence was graded and recommendations were made based on the strength of the available data.

Conclusion (proposition de traduction) : Un sous-comité de rédaction a effectué un examen systématique de la documentation afin de formuler des recommandations fondées sur des données probantes pour répondre aux questions cliniques suivantes :
(1) Chez les patients adultes aux urgences qui présentent une céphalée aiguë, existe-t-il des stratégies de stratification des risques qui permettent de déterminer de façon fiable le besoin du recours à une neuroimagerie ?
(2) Chez les patients adultes des services d'urgence traités pour des céphalées primaires aiguës, les médicaments non-opioïdes sont-ils préférés aux médicaments opioïdes ?
(3) Chez les patients adultes aux urgences qui présentent des céphalées aiguës, une tomodensitométrie normale sans contraste effectuée dans les 6 heures suivant l'apparition des céphalées, exclut-elle la nécessité d'un examen diagnostique plus approfondi pour une hémorragie sous-arachnoïdienne ?
(4) Chez l'adulte hospitalisé aux urgences qui est toujours considéré à risque d'hémorragie sous-arachnoïdienne après une tomodensitométrie sans contraste négative, l'angiographie par tomodensitométrie crânienne est-elle aussi efficace que la ponction lombaire pour écarter en toute sécurité une hémorragie sous-arachnoïdienne ?
Les données probantes ont été notées et des recommandations ont été formulées en fonction de la solidité des données disponibles.

Urine Cultures in Acute Pyelonephritis: Knowing What You Are Up Against.
Liang SY, Durkin MJ. | Ann Emerg Med. 2019 Oct;74(4):596-598
Keywords: Aucun

Clinical Controversies

Editorial : Urine cultures can provide information on the microbiological cause and optimal treatment for patients diagnosed with acute pyelonephritis, but the need for routine cultures for patients with simple, uncomplicated pyelonephritis is unclear. In this Clinical Controversies series our pro and con discussants present opposing viewpoints of the benefits and drawbacks of routine urine cultures among patients with simple, uncomplicated pyelonephritis.

Conclusion : The fundamental questions of what urinary pathogen is responsible for a patient’s infection and what antibiotic can effectively eradicate it with the least disruption to the human microbiome are worthy of asking if we are to be responsible stewards of increasingly finite antibiotic resources and hope to stem the tide of antibiotic resistance. For now, urine culture continues to provide meaningful answers to these questions.

Conclusion (proposition de traduction) : La question fondamentale est de savoir quel agent pathogène urinaire est responsable de l'infection d'un patient et quel antibiotique peut effectivement l'éradiquer avec le moins de d'effet possible sur le microbiome humain méritent d'être posées si nous devons être des gardiens responsables de ressources antibiotiques de plus en plus limitées et espérer enrayer l'augmentation de la résistance aux antibiotiques. Pour l'instant, l'ECBU continue de fournir des réponses significatives à ces questions.

Inhaled Methoxyflurane Provides Greater Analgesia and Faster Onset of Action Versus Standard Analgesia in Patients With Trauma Pain: InMEDIATE: A Randomized Controlled Trial in Emergency Departments.
Borobia AM, Collado SG, Cardona CC, Pueyo RC, Alonso CF, Torres IP, González MC, Casal Codesido JR, Betegón MA, Barcela LA, Andicoechea AO, Testa AF, Colina JT, Dorribo AC, Del Arco Galán C, Martínez Ávila JC, Lugilde ST, Carcas Sansuán AJ; InMEDIATE Investigators Group.. | Ann Emerg Med. 2019 Oct 14
Keywords: Aucun

Article in Press

Introduction : The objective of the InMEDIATE study was to evaluate the change in intensity of traumatic pain over the first 20 min in adult patients treated with methoxyflurane versus standard analgesic treatment in Spain. This the first randomized, active-controlled, multicenter trial of methoxyflurane in the emergency setting in Europe.

Méthode : This was a randomized, controlled study that enrolled adult patients with acute moderate to severe (score ≥4 on the 11-point Numeric Rating Scale) trauma-associated pain in 14 Spanish emergency departments. Patients were randomized 1:1 to methoxyflurane (up to 2×3 mL) or standard analgesic treatment. Coprimary endpoints were the change from baseline in Numeric Rating Scale pain intensity score during the first 20 minutes of treatment and time to first pain relief.

Résultats : Three hundred five patients were randomized (methoxyflurane 156; standard analgesic treatment 149). Most patients in the standard analgesic treatment group (70%) received intravenous first-step analgesics and 9.4% of patients were treated with opioids. Mean decrease from baseline in Numeric Rating Scale pain intensity score was greater for methoxyflurane than standard analgesic treatment at all points, with a significant treatment difference overall up to 20 minutes (repeated-measures model 2.47 versus 1.39; treatment difference 1.00; 95% confidence interval 0.84 to 1.32). Median time to first pain relief was significantly shorter for methoxyflurane than standard analgesic treatment (3 versus 10 minutes). Methoxyflurane achieved better patient and clinician ratings for pain control and comfort of treatment than standard analgesic treatment and exceeded patient and clinician expectations of treatment in, respectively, 77% and 72% of cases compared with 38% and 19% for standard analgesic treatment.

Conclusion : These results support consideration of methoxyflurane as a nonnarcotic, easy-to-administer, rapid-acting, first-line alternative to currently available analgesic treatments for trauma pain.

Conclusion (proposition de traduction) : Ces résultats plaident en faveur de l'utilisation du méthoxyflurane en tant que solution de alternative de première intention, non médicamenteuse, facile à administrer, à action rapide, aux traitements analgésiques actuellement disponibles pour la prise en charge d'une douleur traumatique.

Commentaire : Voir aussi :
• Mercadante S, Voza A, Serra S and al. Analgesic Efficacy, Practicality and Safety of Inhaled Methoxyflurane Versus Standard Analgesic Treatment for Acute Trauma Pain in the Emergency Setting: A Randomised, Open-Label, Active-Controlled, Multicentre Trial in Italy (MEDITA).Adv Ther. 2019 Nov;36(11):3030-3046  .
• A venir, la publication des résultats de l'étude PenASAP : Etude multicentrique française randomisée contrôlée, en double aveugle évaluant l’efficacité et la tolérance du méthoxyflurane inhalé sur le soulagement des douleurs modérées à sévères associées à un traumatisme pour des patients adultes admis aux urgences (présentation en avant-première au congrès Urgences 2019 par : LECOULES, Laurent JACQUIN, Dominique SAVARY, Eric WIEL, Frederic ADNET, Marion DOUPLAT, Patrick DESCHAMPS, Agnès RICARD-HIBON  ).

BMC Emergency Medicine

Early inter-hospital transfer of patients with myocardial infarction without a doctor, paramedic or nurse on board: results from a French regional emergency care network.
Cassan S, Rata M, Vallenet C, Fromage P, Champly F, Broin P, Peribois G, Sierra V, Lutz C, Mangin L, Savary D, Ageron FX, Belle L; SCA-Alp Investigators. | BMC Emerg Med. 2019 Oct 28;19(1):60
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : In France, patients with acute coronary syndromes (ACS) are usually transferred from remote hospitals to percutaneous coronary intervention (PCI) centres in mobile intensive care units (MICUs) with on-board medical staff. They are then returned to the remote hospitals by MICU 48 h after PCI. However, MICU transportation and beds in a PCI centre are in short supply. Therefore, we investigated clinical outcomes among intermediate-risk ACS patients who were transferred in private ambulances without an on-board medic or paramedic; and returned to the remote hospital sooner after PCI.

Méthode : In the French Alps, the RESURCOR network manages 'SCA-Alp' transfers using strict management protocols in ambulances with trained drivers and automatic external defibrillators, but without heart rhythm monitoring. We conducted an observational retrospective study that assessed outcomes (death and emergency return to the PCI centre within 48 h) in patients transferred using SCA-Alp. Our population comprised stabilized patients with ST-segment elevation myocardial infarction (STEMI) who returned to the remote hospital within 24-48 h of PCI, and uncomplicated patients with non-ST-segment elevation myocardial infarction (NSTEMI) within 24-72 h of symptom onset who come from and returned to ('round-trip') the remote hospital on the day of PCI (return < 12 h after PCI).

Résultats : Between 2010 and 2014, 101 STEMI and 490 NSTEMI patients were transferred using SCA-Alp. No adverse events occurred during transportation and no deaths were reported. Two of 591 patients (0.3% [95% confidence interval 0.1-1.4%]) experienced a stent thrombosis within 48 h of PCI that required a second urgent PCI; both were event free at 6-month follow-up.

Conclusion : Inter-hospital transfer using SCA-Alp is associated with low event rates in intermediate-risk ACS patients, allowing a more streamlined use of medical facilities and freeing-up of beds in PCI centres.

Conclusion (proposition de traduction) : Le transfert interhospitalier par le réseau RESURCOR « SCA-Alp », qui gère les transferts, est associé à des taux d'événements (ndlr : indésirables) faibles chez les patients porteur d'un SCA à risque intermédiaire, ce qui permet une utilisation plus rationnelle des installations médicales et la libération de lits dans les centres d'intervention coronarienne percutanée.

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti.
Jachetti A, Massénat RB, Edema N, Woolley SC, Benedetti G, Van Den Bergh R, Trelles M. | BMC Emerg Med. 2019 Oct 18;19(1):56
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA.

Méthode : Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18-65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit.

Résultats : One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group "before" (adjusted odds ratio 0.3, 95%confidence interval 0.1-0.8). They also had a significantly shorter hospital length of stay (p = 0.02).

Conclusion : Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

Conclusion (proposition de traduction) : La mise en œuvre d'un protocole de prise en charge d'une hémorragie massive incluant l'administration précoce d'acide tranexamique a été associée à une réduction de la mortalité et de la durée de séjour à l'hôpital des patients adultes présentants des traumatismes contondants et pénétrants graves dans un contexte où les ressources sont limitées et la disponibilité des produits sanguins limitée.

Clinical Toxicology

Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations' ECMO case registry.
Weiner L, Mazzeffi MA, Hines EQ, Gordon D, Herr DL, Kim HK. | Clin Toxicol (Phila). 2019 Oct 16:1-6
Keywords: Drug-induced cardiogenic shock; Extracorporeal Life Support Organization; cardiac toxicity; extracorporeal membrane oxygenation

Clinical Research

Introduction : Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is increasingly utilized to treat severe or refractory drug-induced cardiovascular shock. There is limited evidence regarding VA-ECMO's clinical utility in poisoning. Therefore, we investigated the clinical benefit of VA-ECMO use in drug-induced cardiovascular shock using the Extracorporeal Life Support Organization (ELSO)'s ECMO case registry

Méthode : The ELSO registry was systematically searched retrospectively, using ICD-9/10 codes for poisoning-related cases from January 1, 2003 to July 30, 2018. All adult cases (age ≥ 18 years) that received VA-ECMO for cardiac support were included. Cardiogenic shock was defined as systolic blood pressure (SBP) <90 mmHg, mean arterial pressure (MAP) <65 mmHg, or requiring infusion of ≥2 vasopressor agents. Study outcomes included survival to discharge (i.e., from the ECMO center), changes in metabolic (acid/base), hemodynamic and ventilatory status, and complications related to ECMO support. Demographic and clinical characteristics of pre-ECMO and 24-h after VA-ECMO cannulation were compared between survivors vs. non-survivors.

Résultats : A total of 113 cases were identified from the ELSO registry; 9 cases were excluded because cardiogenic shock was not related to poisoning, leaving 104 cases for analysis. The median age was 34 years and 53.5% (n = 54) were male. Cardiovascular agents were involved in 47.1% (n = 49) of the cases followed by opioids (n = 9, 6.7%); 34 cases experienced pre-ECMO cardiac arrest. About 92.4% of the cases (n = 85) received vasopressor infusion for hemodynamic support, most frequently norepinephrine (83.7%). Median duration of VA-ECMO was 68 h (interquartile range [IQR]: 48, 113 h); 52.9% (n = 55) of the cases survived to discharge. VA-ECMO significantly improved hemodynamics (MAP, SBP, and DBP), acidemia/acidosis (pH, HCO3 level) and ventilatory parameters (pO2, SpO2, and SvO2). Non-survivors showed persistent acidemia/acidosis at 24-h after VA-ECMO cannulation compared to survivors. Renal replacement therapy (50.9%) and arrhythmia (26.3%) were the most frequently reported complications.

Conclusion : VA-ECMO improved hemodynamic and metabolic parameters in patients with drug-induced cardiogenic shock (DCS).

Conclusion (proposition de traduction) : Technique veino-artérielle (ECMO VA) a amélioré les paramètres hémodynamiques et métaboliques chez les patients présentant un choc cardiogénique induit par les médicaments (DCS).

Critical Care Medicine

Supply Chain Delays in Antimicrobial Administration After the Initial Clinician Order and Mortality in Patients With Sepsis.
Kashiouris MG, Zemore Z, Kimball Z, Stefanou C, Fowler AA, Fisher B, de Wit M, Pedram S, Sessler CN. | Crit Care Med. 2019 Oct;47(10):1388-1395
Keywords: Aucun

Clinical Investigations

Introduction : There is mounting evidence that delays in appropriate antimicrobial administration are responsible for preventable deaths in patients with sepsis. Herein, we examine the association between potentially modifiable antimicrobial administration delays, measured by the time from the first order to the first administration (antimicrobial lead time), and death among people who present with new onset of sepsis.

Méthode :  DESIGN : Observational cohort and case-control study.
SETTING : The emergency department of an academic, tertiary referral center during a 3.5-year period.
PATIENTS : Adult patients with new onset of sepsis or septic shock.

Résultats : We enrolled 4,429 consecutive patients who presented to the emergency department with a new diagnosis of sepsis. We defined 0-1 hour as the gold standard antimicrobial lead time for comparison. Fifty percent of patients had an antimicrobial lead time of more than 1.3 hours. For an antimicrobial lead time of 1-2 hours, the adjusted odds ratio of death at 28 days was 1.28 (95% CI, 1.07-1.54; p = 0.007); for an antimicrobial lead time of 2-3 hours was 1.07 (95% CI, 0.85-1.36; p = 0.6); for an antimicrobial lead time of 3-6 hours was 1.57 (95% CI, 1.26-1.95; p < 0.001); for an antimicrobial lead time of 6-12 hours was 1.36 (95% CI, 0.99-1.86; p = 0.06); and for an antimicrobial lead time of more than 12 hours was 1.85 (95% CI, 1.29-2.65; p = 0.001).

Conclusion : Delays in the first antimicrobial execution, after the initial clinician assessment and first antimicrobial order, are frequent and detrimental. Biases inherent to the retrospective nature of the study apply. Known biologic mechanisms support these findings, which also demonstrate a dose-response effect. In contrast to the elusive nature of sepsis onset and sepsis onset recognition, antimicrobial lead time is an objective, measurable, and modifiable process.

Conclusion (proposition de traduction) : Les retards dans l'exécution de la prescription antimicrobienne, après l'évaluation initiale par le clinicien, sont fréquents et préjudiciables. Les biais inhérents à la nature rétrospective de l'étude s'appliquent. Les mécanismes biologiques connus corroborent ces résultats, qui démontrent également un effet dose-réponse. Contrairement à la nature insaisissable du déclenchement et de la l'identification du sepsis, le délai d'administration des antibiotiques est un processus objectif, mesurable et modifiable.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Tout délai entre la prescription et l’administration d’une antibiothérapie chez les patients en sepsis est délétère  . Rédigé par le Dr Olivier Leroy le 5 décembre 2019.
Bien que cette étude soit rétrospective et uni centrique, ses résultats semblent devoir être pris en compte car il n’y aura jamais d’étude randomisée sur l’impact pronostique d’une antibiothérapie non administrée…
Le circuit d’administration des antibiotiques, peut-être non amélioré par la prescription informatique plutôt qu’orale puis écrite, doit donc être analysé par chacun d’entre nous afin que tout retard soit corrigé.

Emergency Care Journal

Is the nasal route a viable option for relieving acute pain in pediatric emergency medicine? A literature review.
Aleysae NA | Emerg. Care J. 2019 oct;15(3):8320
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : In recent years, the nasal route has increasingly been viewed as an alternative option for the delivery of analgesia, especially when the traditional ways are complicated or time-intensive. However, little is known about the value of this intervention in acute pain management in pediatric emergency medicine.

Méthode : This evidence-based analysis review aims to assess the current evidence regarding the use, safety, and effectiveness of intranasal analgesics in acutely painful conditions encountered in Pediatric Emergency Departments (PEDs). A systemic electronic searching of Cochrane library, PubMed, and EMBASE databases from the beginning of each database until October 2018 was conducted using a maximally sensitive searching strategy. Only randomized controlled trials (RCTs) or quasi-randomized controlled trials that evaluated the use of intranasal analgesia for acute pain in children in the Emergency Department and published between January 1990 and October 2018 were included. The methodological quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria. Risks of bias within each included study were evaluated according to the Cochrane Risk of Bias Tool for RCTs. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses statement.

Résultats : Seven RCTs and one quasi-randomized study met the inclusion criteria. Five studies compared an intranasal analgesic and an alternative intervention, two compared intranasal fentanyl against ketamine, and one compared two different concentrations of intranasal fentanyl. All included trials reported reductions in pain scores, especially within the first 10 to 30 minutes post-intervention; however, pain reduction was maintained to 60 minutes in only one study. No evidence of significant adverse events was associated with the administration of any intranasal analgesic in any of the included studies. This review identified eight articles that discussed the intranasal analgesia as a possible route of analgesia in the PED. While no paper was entirely perfect, the findings support the idea that intranasal analgesia may be an effective analgesic for the treatment of children (3-18 years) with acute moderate to severe pain, and its administration appears to cause minimal adverse effects.

Conclusion : This review identified eight articles that discussed the IN analgesia as a possible route of analgesia in the PED. While no paper was entirely perfect, the findings support that IN analgesia may be an effective analgesic for the treatment of the children (3-18 years) with acute moderate to severe pain, and its administration appears to cause minimal adverse effects.

Conclusion (proposition de traduction) : Cette revue a identifié huit articles qui discutent de l'analgésie intranasale comme voie possible d'analgésie dans le service des urgences pédiatriques. Bien qu'aucun article n'ait été entièrement parfait, les résultats confirment que l'analgésie intranasale peut être un analgésique efficace pour le traitement des enfants (3-18 ans) présentant une douleur aiguë modérée à sévère, et son administration semble causer des effets indésirables minimes.

qSOFA score and LqSOFA score as predictors of outcome in an elderlypopulation with chest infection treated in the Emergency Department. A case series.
Velissaris D, Karamouzos V, Pantzaris ND, Kakoullis L, Pierrakos C, Karanikolas M, Gogos C. | Emerg. Care J. 2019 oct;15(3):8320
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : The objective of this study is to assess the prognostic value regarding 28-day outcome of the quick sequential organ failure assessment (qSOFA) score and the combined score calculated from blood lactate levels + qSOFA (LqSOFA) score in elderly patients initially treated in the Emergency Department (ED) for sepsis due to pneumonia or other chest infections.

Méthode : This is a prospective observational study, conducted at the ED in a Greek University Hospital. Forty-one patients with sepsis due to chest infection were enrolled in the study. All patients were treated in the Resuscitation Room of the ED according to the international treatment protocols for sepsis.

Résultats : The qSOFA score was calculated on admission for all patients, and one point was added in the calculation of the LqSOFA score in patients with blood lactate levels >2 mmol/L. Both the qSOFA and the LqSOFA scores had high sensitivity and specificity in predicting unfavorable outcome in elderly patients with chest infection and sepsis. In the ongoing debate of early diagnosis of sepsis and identification of prognostic indexes of the syndrome, qSOFA score alone or in combination with lactate levels could serve as a reliable predictor of outcome. Large prospective studies are needed to further evaluate the role and prognostic validity of these scores in the ED.

Conclusion : Limitations of our study include the small sample size and the fact that it only includes data from elderly patients treated for respiratory failure in the Resuscitation room of the Emergency Department. The dynamic nature of the sepsis syndrome can make detection of sepsis difficult in the ED setting, and the qSOFA score alone has limitations in predicting outcome due to low sensitivity. The combination of qSOFA score with other clinical parameters and laboratory measurements could possibly identify more patients with sepsis who may benefit from further assessment and interventions in the ED. This clinical study suggests that serum lactate level, a sensitive finding reflecting anaerobic metabolism has comparable validity when added to qSOFA score, and its use in the calculation of prognostic scores already in use could be beneficial in clinical practice by improving specificity of predicting a bad outcome. However, because of the significant limitations of our study, further large prospective clinical studies are warranted to confirm and validate our findings.

Conclusion (proposition de traduction) : Les limites de notre étude comprennent la petite taille de l'échantillon et le fait qu'elle ne comprend que des données provenant de patients âgés traités pour insuffisance respiratoire dans la salle de réanimation du service des urgences. La nature dynamique du syndrome septique peut rendre la détection de la septicémie difficile dans le contexte de l'urgence, et le score qSOFA seul a des limites dans la prédiction des résultats en raison de sa faible sensibilité. La combinaison du score qSOFA avec d'autres paramètres cliniques et des mesures en laboratoire pourrait permettre d'identifier davantage de patients atteints de septicémie qui pourraient bénéficier d'une évaluation et d'interventions plus poussées dans l'urgence. Cette étude clinique suggère que le taux sérique de lactate, résultat sensible reflétant le métabolisme anaérobie, a une validité comparable lorsqu'il est ajouté au score qSOFA, et son utilisation dans le calcul des scores pronostiques déjà utilisés pourrait être bénéfique dans la pratique clinique en améliorant la spécificité de la prévision d'un mauvais résultat. Toutefois, en raison des limites importantes de notre étude, d'autres études cliniques prospectives de grande envergure sont justifiées pour confirmer et valider nos résultats.

Emergency Medicine Journal

Impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest recognition and dispatcher-assisted cardiopulmonary resuscitation.
Chien CY, Chien WC, Tsai LH, Tsai SL, Chen CB, Seak CJ, Chou YS, Ma M, Weng YM, Ng CJ, Lin CY, Tzeng IS, Lin CC, Huang CH. | Emerg Med J. 2019 Oct;36(10):595-600
Keywords: cooperation score; dispatcher-assisted cardiopulmonary resuscitation; emotional content; out-of-hospital cardiac arrest

Original article

Introduction : This study determined the impact of the caller's emotional state and cooperation on out-of-hospital cardiac arrest (OHCA) recognition and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance metrics.

Méthode : This was a retrospective study using data from November 2015 to October 2016 from the emergency medical service dispatching centre in northern Taiwan. Audio recordings of callers contacting the centre regarding adult patients with non-traumatic OHCA were reviewed. The reviewers assigned an emotional content and cooperation score (ECCS) to the callers. ECCS 1-3 callers were graded as cooperative and ECCS 4-5 callers as uncooperative and highly emotional. The relation between ECCS and OHCA recognition, time to key events and DA-CPR delivery were investigated.

Résultats : Of the 367 cases, 336 (91.6%) callers were assigned ECCS 1-3 with a good inter-rater reliability (k=0.63). Dispatchers recognised OHCA in 251 (68.4%) cases. Compared with callers with ECCS 1, callers with ECCS 2 and 3 were more likely to give unambiguous responses about the patient's breathing status (adjusted OR (AOR)=2.6, 95% CI 1.1 to 6.4), leading to a significantly higher rate of OHCA recognition (AOR=2.3, 95% CI 1.1 to 5.0). Thirty-one callers were rated uncooperative (ECCS 4-5) but had shorter median times to OHCA recognition and chest compression (29 and 122 s, respectively) compared with the cooperative caller group (38 and 170 s, respectively). Nevertheless, those with ECCS 4-5 had a significantly lower DA-CPR delivery rate (54.2% vs 85.9%) due to 'caller refused' or 'overly distraught' factors.

Conclusion : The caller's high emotional state is not a barrier to OHCA recognition by dispatchers but may prevent delivery of DA-CPR instruction. However, DA-CPR instruction followed by first chest compression is possible despite the caller's emotional state if dispatchers are able to skilfully reassure the emotional callers.

Conclusion (proposition de traduction) : La charge émotionnelle de l'appelant ne constitue pas un obstacle à la reconnaissance d'un arrêt cardiaque extra-hospitalier par les assistants de régulation, mais peut empêcher la délivrance d'instructions de réanimation cardiopulmonaire assistée par le régulateur. Cependant, l'instruction de réanimation cardiopulmonaire assistée par le régulateur suivie d'une première compression thoracique est possible malgré la charge émotionnelle de l'appelant si les assistants de régulation sont capables de rassurer habilement les appelants avec charge émotionnelle.

Emergency Radiology

CT angiograms of the neck in strangulation victims: incidence of positive findings at a level one trauma center over a 7-year period.
Zuberi OS, Dixon T, Richardson A, Gandhe A, Hadi M, Joshi J. | Emerg Radiol. 2019 Oct;26(5):485-492
Keywords: Angiogram; CTA; Strangled; Strangulation; Trauma; Vascular injury

Original Article

Introduction : To determine the incidence of acute findings diagnosed with computed tomography angiography (CTA) of the neck among emergency department patients presenting with strangulation injury.

Méthode : This institutional review board-approved, HIPAA-compliant retrospective review was performed at our academic urban level 1 trauma center. The PACS database was queried for all consecutive patients who had CTAs of the neck performed for the exam indication of strangulation between January 1, 2009, and April 30, 2016, resulting in 142 included patients. Analysis of the individual cases was then performed, recording any positive results, with clinical findings classified using, when possible, standardized terminology found in the literature. Frequency of acute injury in the CTA neck examinations was determined with the calculation of 95% confidence interval (CI) and positive clinical findings were evaluated by calculation of prevalence. Additionally, two board certified radiologists with training in neuroradiology assessed the cases for vascular injury.

Résultats : There were 142 patients who met inclusion criteria (average age, 32.6 years) and 116 (81.7%) patients were female. CTA of the neck revealed 21 patients to have acute injuries (15.5%, 95% CI 9.5, 21.4) including 6 initially reported vascular injuries (4.2%, 95% CI 0.9, 7.5). Although neck pain (73, 51.4%), loss of consciousness (67, 47.2%), and headache (31, 21.8%) were frequently reported in the ROS, their predictive value of vascular injury was weak (4.1%, 4.5%, and 3.2%, respectively). On physical exam, redness/bruising of the neck (73, 51.4%) and neck tenderness (47, 33.1%) were both the most common and had the highest prevalence (19.2% and 12.8%, respectively), however, when selecting for vascular injuries alone were found to have low predictive yield (vascular injury 4.1% and 2.1%, respectively). The above statistics were based on the initial radiologist report and Emergency Department findings. After retrospective review, 3 Grade 1 BIFFL vascular injuries were identified (2.1%), with one false negative case (0.7%).

Conclusion : Performing CTA of the neck after acute strangulation injury rarely identifies clinically significant findings, with vascular injuries proving exceedingly rare. As positive vascular injury could not be clinically predicted by history and physical examination, prospective validation of a clinical prediction rule in this population is warranted.

Conclusion (proposition de traduction) : L'angioscanner cervical après une strangulation permet rarement d'identifier des résultats cliniquement significatifs, les lésions vasculaires s'avérant extrêmement rares. Comme les antécédents et l'examen physique n'ont pas permis de prédire cliniquement les lésions vasculaires positives, la validation prospective d'une règle de prédiction clinique dans cette population est justifiée.

Blunt chest trauma: classification and management.
Marro A, Chan V, Haas B, Ditkofsky N. | Emerg Radiol. Oct;26(5):557-566
Keywords: AAST; Chest wall; Flail chest; Fracture; Trauma

Review Article

Editorial : Blunt chest wall injuries are a significant cause of mortality and morbidity in trauma patients. Accurate identification and description of chest wall injuries by the radiologist can aid in guiding proper patient management. The American Association for the Surgery of Trauma (AAST) has devised a classification system based on severity. This article describes the features of each injury grade according to the AAST injury scale and discusses the implications for management. Additionally, common mechanisms of blunt chest trauma and multimodal imaging techniques are discussed.

Conclusion : Chest wall injuries are a significant cause of morbidity and mortality in trauma patients. Knowledge of the AAST grading scale and the mechanisms of chest wall injuries are important in facilitating the recognition, de- scription, and classification of these injuries in order to optimize patient management. MDCT is the most sensitive imaging modality for eval- uating chest wall injuries in trauma patients as it provides the highest sensitivity and specificity in the detection and localization of rib fractures. Radiographs should neverthe- less be thoroughly scrutinized for fractures, pleural thick- ening, and subcutaneous emphysema indicative of occult pneumothorax. The role of US has not yet been complete- ly elucidated, but shows promise in recent studies. MRI is not usually used to evaluate traumatic thoracic wall injuries. Chest wall injuries can be managed both operatively and non-operatively depending on patient factors such as adequa- cy of unassisted ventilation and the need operative manage- ment of additional injuries. A thorough description of these injuries should be a part of all imaging reports and is best facilitated by a knowledge of the AAST thoracic wall injury grading scale.

Conclusion (proposition de traduction) : Les lésions de la paroi thoracique sont une cause importante de morbidité et de mortalité chez les patients traumatisés. La connaissance de l'échelle de classification AAST et des mécanismes des lésions de la paroi thoracique est essentielle pour faciliter la reconnaissance, la description et la classification de ces lésions afin d'optimiser la prise en charge du patient.
La TDM est la modalité d'imagerie la plus sensible pour l'évaluation des lésions de la paroi thoracique chez les patients traumatisés, car elle offre la plus grande sensibilité et spécificité pour la détection et la localisation des fractures de côte. Les radiographies doivent néanmoins être examinées minutieusement pour rechercher des fractures, un épaississement de la plèvre et un emphysème sous-cutané révélateur d'un pneumothorax occulte. Le rôle de l'échographie n'a pas encore été complètement élucidé, mais semble être prometteur dans les études récentes. L'IRM n'est généralement pas utilisée pour évaluer les lésions traumatiques à la paroi thoracique. Les lésions de la paroi thoracique peuvent être gérées de manière opératoire ou non opératoire en fonction de facteurs liés au patient, tels que l'adéquation de la ventilation sans assistance et la nécessité d'une prise en charge chirurgicale de lésions supplémentaires. Une description détaillée de ces blessures doit faire partie de tous les compte)rendus d'imagerie et est facilitée par la connaissance de l'échelle de classement des lésions de la paroi thoracique AAST.

European Journal of Emergency Medicine

Effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries: a systematic review.
Considine J, Shaban RZ, Curtis K, Fry M. | Eur J Emerg Med. 2019 Oct;26(5):314-322
Keywords: Aucun

Review Article

Editorial : The aim of this study was to systematically review the literature on the effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries. The review protocol was registered with PROSPERO and CINHAL, MEDLINE and EMBASE were searched for studies comparing nurse-initiated vs physician-initiated X-ray. Because of heterogeneity of patients, providers and outcomes, a meta-analysis was not performed. The 16 included studies were conducted between 1971 and 2018 and involved 8881 participants. There were four randomised trials and 12 observational studies that focussed on X-ray request accuracy (n = 14), emergency department processes (n = 6) and patient outcomes (n = 2). The quality of evidence for each outcome ranged from very low-to-moderate.

Conclusion : Compared with physician-initiated X-ray, nurse-initiated X-ray uses no more resources, is safe and acceptable to patients. Nurse-initiated X-ray did not reduce time to X-ray or waiting time but in some studies, reduced emergency department length of stay and unplanned follow-up.

Conclusion (proposition de traduction) : Comparativement à la radiographie à l'initiative du médecin, la radiographie à l'initiative de l'infirmière n'utilise pas plus de ressources, est sécuritaire et acceptable pour les patients.
La radiographie à l'initiative de l'infirmière n'a pas réduit le temps d'obtention de la radiographie ou le temps d'attente, mais dans certaines études, elle a réduit la durée du séjour au service des urgences et le suivi non planifié.

Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection.
Chen FC, Kung CT, Cheng HH, Cheng CY, Tsai TC, Hsiao SY, Su CM. | Eur J Emerg Med. 2019 Oct;26(5):323-328
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Articles

Introduction : The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality.

Méthode : A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality.

Résultats : Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91).

Conclusion : The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.

Conclusion (proposition de traduction) : Le score qSOFA sestnt plus précis que le score SIRS pour prédire la mortalité à 72 h et permet de mieux prédire la mortalité à 72 h que celle à 28 jours.

Prognostic value of prehospital quick sequential organ failure assessment score among patients with suspected infection.
Vaittinada Ayar P, Delay M, Avondo A, Duchateau FX, Nadiras P, Lapostolle F, Chouihed T, Freund Y. | Eur J Emerg Med. 2019 Oct;26(5):329–333
DOI: Original Articles
Keywords: Aucun

Original Articles

Introduction : After the third international consensus on sepsis released its new definitions, the prognostic value of quick sequential organ failure assessment (qSOFA) score has been confirmed in the emergency department. However, its validity in the prehospital setting remains unknown. The objective of the study was to assess its accuracy for prehospital patients cared by emergency physician-staffed ambulances (services mobiles d’urgence et de réanimation SMUR).

Méthode :  This was a prospective observational multicenter cohort study (N = 6). All consecutive patients with prehospital clinical suspicion of infection by the emergency physician of the SMUR emergency medical service were included. Components of qSOFA were collected, and the patients were followed until hospital discharge. The primary end point was in-hospital mortality, censored at 28 days. Secondary end points included ICU admission longer than 72 h and a composite of ‘death or ICU stay more than 72 h’.

Résultats : We screened 342 patients and included 332 in the analysis. Their mean age was 73 years, 159 (48%) were women, and the most common site of infection was respiratory (73% of cases). qSOFA was at least 2 in 133 (40%) patients. The overall in-hospital mortality was 27%: 41% in patients with qSOFA of at least 2 versus 18% for qSOFA less than 2 (absolute difference 23%; 95% confidence interval: 13–33%, P < 0.001). The overall discrimination for qSOFA was poor, with an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.62–0.74).

Conclusion : In this large multicenter study, prehospital qSOFA presents a strong association with mortality in infected patient, though with poor prognostic performances in our severely ill sample.

Conclusion (proposition de traduction) : Dans cette vaste étude multicentrique, le qSOFA préhospitalier présente une forte association avec la mortalité chez les patients infectés, mais avec des performances pronostiques médiocres dans notre échantillon gravement malade.

Drowning in fresh or salt water: respective influence on respiratory function in a matched cohort study.
Michelet P, Dusart M1 Boiron L, Marmin J, Mokni T, Loundou A, Coulange M, Markarian T. | Eur J Emerg Med. 2019 Oct;26(5):340-344.
Keywords: Aucun

Original articles

Introduction : For the most severe drowned patients, hypoxemia represents one of the major symptoms. As the influence of the type of water (fresh or salt water) on respiratory function is still unclear, the primary endpoint of this multicenter study was to compare hypoxemia according to the type of water.

Méthode : Medical records of adult patients who experienced a drowning event and were consequently admitted to 10 ICU for acute respiratory failure were analyzed retrospectively using data collected over three consecutive summer periods. From an initial cohort of acute respiratory failure drowned patients, patients were matched by age, sex, Glasgow Coma Scale, and occurrence of cardiac arrest (yes or no).

Résultats : Among an initial cohort of 242 patients, 38 pairs were matched correctly. At the initial assessment, carried out upon ICU admission, hypoxemia was found to be deeper in the fresh water group (PaO2/FiO2: 141 ± 76 vs. 220 ± 122, P < 0.05). However, there was no significant difference in tissue oxygenation (assessed by blood lactate level) between groups. In terms of biology results, sodium levels were higher in the salt water group in the initial assessment (144 ± 6.8 vs. 140 ±5.2 mmol/l, P = 0.004), but no difference was observed later. No difference was recorded in the outcome or length of stay in ICU between groups.

Conclusion : Drowning in fresh water was associated with deeper hypoxemia in the initial assessment. Despite this initial difference, latter respiratory and biological parameters or outcome were similar in both groups.

Conclusion (proposition de traduction) : La noyade en eau douce était associée à une hypoxémie plus profonde lors de l'évaluation initiale. Malgré cette différence initiale, les derniers paramètres respiratoires et biologiques et leurs résultats étaient similaires dans les deux groupes.

Prevalence of pulmonary embolism in emergency department patients with isolated syncope: a prospective cohort study.
Raynal PA1, Cachanado M, Truchot J, Damas-Perrichet C, Feral-Pierssens AL, Goulet H, Deltour S, Boussouar S, Donciu V, Simon T, Freund Y, Philippon AL. | Eur J Emerg Med. 2019 Oct 11
Keywords: Aucun

Original articles

Introduction : Paramount to guide the diagnostic strategy, the prevalence of pulmonary embolism in patients with syncope and no other symptoms is uncertain. We aimed to assess the pulmonary embolism prevalence in patients that present to the emergency department (ED) with syncope and no chest pain nor dyspnea.

Méthode : Multicenter prospective cohort study in seven EDs in France. Adult patients who presented to the ED with syncope (transient loss of consciousness) were included. Patients with chest pain or dyspnea were excluded. Included patients underwent formal work-up for pulmonary embolism, including D-dimer testing and further imaging if positive. Cases of pulmonary embolism were adjudicated by two independent expert radiologists with the review of imaging studies. Secondary objectives included the pulmonary embolism prevalence in the subgroup of patients with cancer, in patients with negative Pulmonary Embolism Rule Out criteria (PERC) score, and according to the clinical probability assessed either by Wells or revised Geneva score.

Résultats : We analyzed 411 patients, in whom 128 (31%) underwent a computed tomographic pulmonary angiogram and 9 (2%) a ventilation-perfusion scan. A pulmonary embolism was confirmed in nine patients (prevalence of 2.2%, 95% confidence interval, 1.1-4.3%), including one subsegmental pulmonary embolism. This prevalence was of 18% (3-52%) in patients with cancer and 0.7% (0.1-4%) in PERC negative patients.

Conclusion : In our sample of patients with isolated syncope, the prevalence of pulmonary embolism was 2.2%. This value is not sufficiently low to negate the requirement for a formal work up in the ED, even in the absence of chest pain or dyspnea. However, the large confidence interval precludes any strong conclusion.

Conclusion (proposition de traduction) : Dans notre échantillon de patients se présentant pour une syncope isolée, la prévalence d'embolie pulmonaire était de 2,2 %. Cette valeur n'est pas suffisamment basse pour supprimer l'obligation d'un bilan formel aux urgences, même en l'absence de douleur thoracique ou de dyspnée. Cependant, le grand intervalle de confiance exclut toute conclusion solide.

Internal and Emergency Medicine

Impact of ‘synchronous’ and ‘asynchronous’ CPR modality on quality bundles and outcome in out-of-hospital cardiac arrest patients.
Sanson G, Ristagno G, Caggegi GD, Patsoura A, Xu 5, Zambon M, Montalbano D, Vukanovic S, Antonaglia V. | Intern Emerg Med. 2019 Oct;14(7):1129-1137
Keywords: Asynchronous CPR; Cardiac arrest; Cerebral performance category; Intubation; Out-of-hospital; Quality metrics; Ventilation


Introduction : During cardiopulmonary resuscitation (CPR), the need to interrupt chest compressions to provide synchronous ventilations prevents blood flow continuity, reducing the possibility to ensure high-quality CPR bundles of care and, thus, having a potentially negative impact on perfusion and patient outcome. Contemporaneous asynchronous chest compressions and ventilations may avoid these potentially negative effects

Méthode : Only a few studies measured the CPR quality metrics during synchronous and asynchronous CPR modality and its relation to patient outcome.

Résultats : A prospective observational study was conducted on 285 consecutive adult patients with out-of-hospital cardiac arrest treated by EMS teams over a 30-month period. Ventilation rate, chest compression fraction (i.e. cardiac arrest time spent delivering uninterrupted chest compressions compared to total cardiac arrest time) and chest compression rate per minute were collected in real time by defibrillators and analysed through a dedicated software (electrical cardiac activity through the ECG, chest compression and ventilations through the transthoracic impedance) during synchronous and asynchronous CPR modalities. During asynchronous CPR modality, higher ventilation rate and chest compression fraction (p  < 0.001), and lower chest compression rate per minute (p < 0.001) were ensured, being all cited metrics more adherent to the high-quality CPR bundles. Ventilation rate provided during the whole CPR was an independent predictor for a good neurological outcome (OR 3.795, p = 0.005).

Conclusion : Asynchronous chest compression and ventilation ensured the most adequate chest compression fraction, uninterrupted chest compression rate and ventilation rate.

Conclusion (proposition de traduction) : La compression et la ventilation thoraciques asynchrones ont assuré la fraction de compression thoracique, le taux de compression thoracique et le taux de ventilation les plus adéquats.

Multimodal oral analgesia for non-severe trauma patients: evaluation of a triage-nurse directed protocol combining methoxyflurane, paracetamol and oxycodone.
Viglino D, Termoz Masson N, Verdetti A, Champel F, Falcon C, Mouthon A, Mabiala Makele P, Collomb Muret R, Maindet Dominici C, Maignan M. | Intern Emerg Med. 2019 Oct;14(7):1139-1145
Keywords: Analgesia; Emergency; Methoxyflurane; Nurse-driven protocol; Trauma


Introduction : Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled methoxyflurane) initiated by triage nurse.

Méthode : We performed a prospective, observational study in an emergency department (Grenoble Alpes University Hospital, France) between December 2017 and April 2018. Adult non-severe trauma patients with a numerical pain rating scale (NRS) score ≥ 4 were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤ 3 at 15 min. Pain intensity was measured for 60 min and during radiography.

Résultats : Data on adverse events and satisfaction were recorded. A total of 200 adult patients were included (median [interquartile range (IQR)] age: 32 [23-49] years; 126 men (63%)). Sixty-six patients (33%) reported an NRS score ≤ 3 at 15 min. The time required to achieve a decrease of at least 2 points in the NRS score was 10 (5-20) min. The median [IQR] pain intensity was 4 [2-5] before radiography and 4 [2-6] during radiography. Adverse events were frequent (n = 128, 64%). No serious adverse events were reported. The patients and caregivers reported good levels of satisfaction.

Conclusion : The administration of a nurse-driven multimodal analgesia protocol (combining paracetamol, oxycodone, and methoxyflurane) was feasible on admission to the emergency department. It rapidly produced long-lasting analgesia in adult trauma patients.

Conclusion (proposition de traduction) : L'administration d'un protocole d'analgésie multimodale initié par une infirmière (combinant le paracétamol, l'oxycodone et le méthoxyflurane) était possible lors de l'admission aux urgences. Il a rapidement produit une analgésie de longue durée chez les patients traumatisés adultes.

Assessment of epinephrine efficacy in out-of-hospital cardiac arrest.
Bonzi M, Peta J, Fusco A, Bosco P; Gruppo di Autoformazione Metodologica (GrAM). | Intern Emerg Med. 2019 Oct;14(7):1155-1157
Keywords: Aucun


Introduction : Epinephrine has been a cornerstone of cardiac resuscitation for over 50 years and continues to be recommended by the recent updates of the advanced life support guidelines. However, there is limited evidence about its effects on survival and neurologic outcomes.
Epinephrine has potentially beneficial effects in cardiac arrest, through its vasoconstrictor activity on arterioles, mediated by α1 and α2 receptors. The augmented vascular tone increases the aortic diastolic pressure, which generates higher coronary perfusion pressures, thereby increasing the probability of return of spontaneous circulation (ROSC). When cardiopulmonary resuscitation (CPR) does not generate coronary perfusion pressure of more than 15 mmHg, ROSC rarely occurs and after more than few minutes’ arterial tone tends to collapse, making vasoconstrictors essential for restoration of cardiac activity.
On the other hand, adrenaline has potentially harmful effects on the heart, mediated by beta-adrenoreceptors, which increase the myocardial oxygen demand and exert a pro-arrhythmogenic effect. This further worsens the mismatch between oxygen delivery and consumption, especially in acute coronary syndromes, thus increasing the risk of recurrent cardiac arrest. In addition, alpha-receptor stimulation causes platelet aggregation, which promotes thrombosis and might worsen acute ischemia. Finally, vasoconstriction induced by epinephrine impairs microvascular blood flow in the cerebral cortex, increasing the severity of cerebral ischemia during CPR and for at least 10 min after ROSC.

Conclusion : The results of this study support guidelines recommendations showing an increased rate of survival among out-of-hospital cardiac arrest patients treated with epinephrine.

Conclusion (proposition de traduction) : Les résultats de cette étude confirment les recommandations des lignes directrices montrant une augmentation du taux de survie chez les patients en arrêt cardiaque extra-hospitalier traités par épinéphrine (adrénaline).

Commentaire : Voir l'analyse de l'article : Perkins GD, Ji C, Deakin CD and al; PARAMEDIC2 Collaborators. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Titre_de_l_article  . Epub 2018 Jul 18.

A meta-analysis of randomized controlled trials: combination of ketamine and propofol versus ketamine alone for procedural sedation and analgesia in children.
Hu Y, Xu W, Cao F. | Intern Emerg Med. 2019 Oct;14(7):1159-1165
Keywords: Analgesia; Ketamine; Ketamine–propofol; Meta-analysis

CE - Systematic reviews and meta-analysis

Introduction : Although ketamine has been used for procedural sedation and analgesia, some researchers have assessed ketamine-propofol as a better alternative because of its reduced adverse events. The goal of this review was to compare adverse events between ketamine-propofol and ketamine for procedural sedation and analgesia in children.

Méthode : We searched the literature from their inception to May 2018 without the restriction of language. We included all randomized controlled trials comparing ketamine-propofol with ketamine for procedural sedation and analgesia in children. The meta-analysis was conducted using the Stata software.

Résultats : A total of six studies involving 693 individuals were included. Pooling of data showed that subjects with ketamine-propofol had similar incidence of respiratory adverse events compared to those with ketamine (RR 1.16, 95% CI 0.68-1.98). However, ketamine-propofol was effective in reducing cardiovascular adverse events compared to ketamine (RR 0.11, 95% CI 0.04-0.31). Ketamine-propofol was also effective in reducing psychomimetic adverse events compared to ketamine (RR 0.39, 95% CI 0.16-0.93). In regard to nausea and vomiting, ketamine-propofol was significantly effective (RR 0.43, 95% CI 0.25-0.74). In addition, we could not demonstrate differences in efficacious sedation between ketamine-propofol and ketamine.

Conclusion : Although our study was not able to demonstrate differences in efficacious sedation between ketamine-propofol and ketamine, we confirmed that ketamine-propofol sedation had a lower frequency of adverse events compared to ketamine sedation in children.

Conclusion (proposition de traduction) : Bien que notre étude n'ait pas pu démontrer de différence d'efficacité de sédation entre la kétamine-propofol et la kétamine, nous avons confirmé que la sédation par la kétamine-propofol avait une survenue de fréquence d'événements indésirables plus faible par rapport à la sédation par la kétamine chez l'enfant.

To enhance the quality of CPR performed by youth layman.
Abelsson A, Nygårdh A. | Int J Emerg Med. 2019 Oct 7;12(1):30
DOI:  | Télécharger l'article au format  
Keywords: CPR; Intervention; Layman; Simulation

Original Research

Introduction : By educating laymen, survival after cardiac arrest can increase in society. It is difficult to reach the entire population with cardiopulmonary resuscitation (CPR) training. However, if 15% of the population knows how to perform CPR, an increase in short- and long-term survival in patients suffering a cardiac arrest could be seen. To educate youth is a way to reach parts of the population. This study aimed to investigate the effect of a 2-h CPR intervention for youth.

Méthode : Data were collected through an intervention utilizing simulation and consisted of a pre- and post-assessment of 50 participants' CPR performance.

Résultats : The participants' compression depths are, after training, within guidelines. However, the compression rate increases from within limits (117) to become too fast (128). The range of the minimum compression rate rises from 70 to 92 which is an improvement. The ventilation volume increases from 112 ml in pre-test to 579 ml in post-test. In the pre-test, 88% of the participants did not succeed in securing an open airway; only six participants succeeded in securing an open airway. In the post-test, 49% of the participants underperform in the ventilation. However, only 12 participants failed in securing an open airway in the post-test. Compression recoil and hand position marginally improved from pre- to post-test.

Conclusion : Educating young people at school is one way to disseminate CPR knowledge in society. In this study, the ventilation of the patient arose as a major weakness. To be able to establish an open airway and ventilate the patient with the correct volume as well as to overcome the psychological barrier to initiate mouth-to-mouth ventilation seems to require more than 2 h training. The training may need to consist of repeated sessions over the year with feedback, to give young people the skills to perform CPR with good quality.

Conclusion (proposition de traduction) : L'éducation des jeunes à l'école est un moyen de diffuser les connaissances en RCP dans la société. Dans cette étude, la ventilation du patient est apparue comme une faiblesse majeure. Pouvoir libérer les voies aériennes et ventiler le patient avec le volume correct ainsi que pour surmonter la barrière psychologique pour initier une ventilation bouche-à-bouche, semble nécessiter plus de 2 h de formation. La formation peut nécessiter des sessions répétées tout au long de l'année avec des débriefing (analyse réflexive (et rétrospective) de leur propre activité), pour donner aux jeunes les compétences nécessaires pour effectuer une RCP de bonne qualité.

Journal of the American College of Cardiology

Dabigatran Reversal With Idarucizumab in Patients With Renal Impairment.
Eikelboom JW, van Ryn J, Reilly P, Hylek EM, Elsaesser A, Glund S, Pollack CV, Weitz JI. | J Am Coll Cardiol. 2019 Oct 8;74(14):1760-1768
DOI:  | Télécharger l'article au format  
Keywords: anticoagulation; bleeding; dabigatran; idarucizumab; kidney disease; surgery


Introduction : Dabigatran and idarucizumab, its reversal agent, are renally cleared.
OBJECTIVES : The purpose of this study was to determine the extent of reversal and outcomes according to baseline renal function in dabigatran-treated nondialysis patients receiving idarucizumab.

Méthode : In 503 patients in RE-VERSE AD (Reversal of Effects of Idarucizumab in Patients on Active Dabigatran), the extent of dabigatran reversal and clinical outcomes were compared according to baseline renal function (creatinine clearance: normal ≥80, mild 50 to <80, moderate 30 to <50, and severe <30 ml/min).

Résultats : Compared with patients with normal renal function, those with impaired renal function were older, were more often women, and had lower body mass indexes, more comorbidities, higher CHADS2 scores, and higher dabigatran plasma levels despite more frequent use of lower-dose dabigatran regimens. Regardless of renal function, median reversal measured by dilute thrombin time was 100% within 4 h of idarucizumab administration, and over 98% of patients achieved this with corresponding undetectable levels of unbound dabigatran. By 12 or 24 h, 56% of patients with severe, 29.1% with moderate, and 9.2% with mild renal impairment had dabigatran levels >20 ng/ml compared with 8.3% of patients with normal renal function at baseline. Time to cessation of bleeding and the proportion with normal hemostasis with procedures were similar regardless of renal function, but patients with severe renal impairment had higher 30- and 90-day mortality rates.

Conclusion : Idarucizumab completely reverses dabigatran in >98% of patients regardless of renal function. Although re-elevation of dabigatran levels within 12 to 24 h is more common with renal impairment, the time to bleeding cessation and the extent of hemostasis during procedures are similar.

Conclusion (proposition de traduction) : L'idarucizumab réverse complètement le dabigatran chez > 98 % des patients, quelle que soit leur fonction rénale. Bien que la ré-élévation des taux de dabigatran dans les 12 à 24 heures soit plus fréquente en cas d'insuffisance rénale, le délai avant l'arrêt du saignement et l'étendue de l'hémostase au cours des procédures sont similaires.

Alteration of Cardiac Performance and Serum B-Type Natriuretic Peptide Level in Healthy Aging.
Yoshida Y, Nakanishi K, Daimon M, Ishiwata J, Sawada N, Hirokawa M, Kaneko H, Nakao T, Mizuno Y, Morita H, Di Tullio MR, Homma S, Komuro I. | J Am Coll Cardiol. 2019 Oct 8;74(14):1789-1800
Keywords: B-type natriuretic peptide; aging; speckle-tracking echocardiography


Introduction : The impact of aging on cardiac function is not fully elucidated. Speckle-tracking echocardiography can unmask subclinical cardiac dysfunction.
OBJECTIVES : This study investigated the impact of healthy aging on left ventricular (LV), right ventricular (RV), and left atrial (LA) performance and their relationship with serum B-type natriuretic peptide (BNP) levels in a sample of the general population without prevalent cardiovascular risk factors and structural heart disease.

Méthode : Speckle-tracking echocardiography was performed to assess LV global longitudinal strain (LVGLS), RV free wall strain, and LA phasic strain in 481 normal weight healthy participants who underwent extensive cardiovascular examination. Elevated BNP was defined as BNP >37.82 pg/ml for men and >50.86 pg/ml for women, which was the 90th percentile of BNP value distribution in the study population.

Résultats : Mean age was 60 ± 12 years (range: 24 to 86 years), and 46% of the participants were men. The earliest alteration of age-related cardiac performance was observed in LA reservoir and conduit strain starting from decade 5, followed by elevated E/e' from decade 6. LVGLS decreased starting from decade 7, whereas there were no significant differences in RV strain, LV ejection fraction, or LV mass index across the decades. In the multivariable linear regression analyses, age was an independent predictor of decreased LVGLS (standardized β = 0.21; p < 0.001) and decreased LA phasic strain (standardized β = -0.40 and -0.61 for reservoir and conduit strain; both p < 0.001). Age and LA strain were significantly associated with elevated BNP values (adjusted odds ratios: 1.10 and 0.93; both p < 0.05, respectively), independent of ventricular morphology and function.

Conclusion : Decreases in LA reservoir and conduit strain are the earliest markers of age-related cardiac remodeling, and LA reservoir strain is an independent predictor of elevated serum BNP level, with both possibly being markers of increased risk of heart failure in older adults.

Conclusion (proposition de traduction) : Les diminutions de taille de l'oreillette gauche et la déformation de l'anneau mitral (ndlr : mesures échographiques) sont les premiers marqueurs du remodelage cardiaque lié à l'âge, et la déformation de la l'oreillette gauche est un prédicteur indépendant du taux sérique élevé de BNP, les deux étant peut-être des marqueurs du risque accru d'insuffisance cardiaque chez les personnes âgées.

Commentaire : 

Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome.
Lee KK, Ferry AV, Anand A, Strachan FE, Chapman AR, Kimenai DM, Meex SJR, Berry C, Findlay I, Reid A, Cruickshank A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Newby DE, Tuck C, Keerie C, Weir CJ, Shah ASV, Mills NL; High-STEACS Investigators. | J Am Coll Cardiol. 2019 Oct 22;74(16):2032-2043
DOI:  | Télécharger l'article au format  
Keywords: acute coronary syndrome; high-sensitivity cardiac troponin; myocardial infarction; sex-specific threshold


Introduction : Major disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized.
OBJECTIVES : The aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome.

Méthode : Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year.

Résultats : A total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01).

Conclusion : Use of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved.

Conclusion (proposition de traduction) : L'utilisation de seuils spécifiques au sexe a permis d'identifier 5 fois plus de femmes que d'hommes souffrant de lésions myocardique. Malgré cette augmentation, les femmes ont reçu environ la moitié du nombre des traitements pour coronaropathie par rapport aux hommes et les résultats ne se sont pas améliorés.

Commentaire : 

Implanted Monitor Alerting to Reduce Treatment Delay in Patients With Acute Coronary Syndrome Events.
Holmes DR Jr, Krucoff MW, Mullin C, Mikdadi G, Presser D, Wohns D, Kaplan A, Ciuffo A, Eberly AL 3rd, Iteld B, Fischell DR, Fischell T, Keenan D, John MS, Gibson CM. | J Am Coll Cardiol. 2019 Oct 22;74(16):2047-2055
Keywords: implantable cardiac monitor; ischemia monitoring; pre-hospital delay; silent myocardial infarction; supply-side ischemia; symptom-to-door time


Introduction : Increased pre-hospital delay during acute coronary syndrome (ACS) events contributes to worse outcome.
OBJECTIVES : The purpose of this study was to assess the effectiveness of an implanted cardiac monitor with real-time alarms for abnormal ST-segment shifts to reduce pre-hospital delay during ACS events.

Méthode : In the ALERTS (AngeLmed Early Recognition and Treatment of STEMI) pivotal study, subjects at high risk for recurrent ACS events (n = 907) were randomized to control (Alarms OFF) or treatment groups for 6 months, after which alarms were activated in all subjects (Alarms ON). Emergency department (ED) visits with standard-of-care cardiac test results were independently adjudicated as true- or false-positive ACS events. Alarm-to-door (A2D) and symptom-to-door (S2D) times were calculated for true-positive ACS ED visits triggered by 3 possible prompts: alarm only, alarms + symptoms, or symptoms only.

Résultats : The Alarms ON group showed reduced delays, with 55% (95% confidence interval [CI]: 46% to 63%) of ED visits for ACS events <2 h compared with 10% (95% CI: 2% to 27%) in the Alarms OFF group (p < 0.0001). Results were similar when restricted to myocardial infarction (MI) events. Median pre-hospital delay for MI was 12.7 h for Alarms OFF and 1.6 h in Alarms ON subjects (p < 0.0089). Median A2D delay was 1.4 h for asymptomatic MI. Median S2D delay for symptoms-only MI (no alarm) in Alarms ON was 4.3 h.

Conclusion : Intracardiac monitoring with real-time alarms for ST-segment shift that exceeds a subject's self-normative ischemia threshold level significantly reduced the proportion of pre-hospital delays >2 h for ACS events, including asymptomatic MI, compared with symptoms-only ED visits in Alarms OFF.

Conclusion (proposition de traduction) : La surveillance intracardiaque par alarmes en temps réel lors de la détection d'un sus-décalage du segment ST au-dessus du seuil d'ischémie défini pour le patient a réduit de manière significative la proportion de retards préhospitaliers > 2 h pour la prise en charge des syndromes coronariens aigus, y compris les infarctus du myocarde asymptomatiques, comparativement aux consultations au service des urgences pour suspicion clinique seulement, avec les alarmes OFF.

Commentaire : 

Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit.
Jentzer JC, van Diepen S, Barsness GW, Henry TD, Menon V, Rihal CS, Naidu SS, Baran DA. | J Am Coll Cardiol. 2019 Oct 29;74(17):2117-2128
Keywords: cardiac intensive care unit; cardiogenic shock; critical care; mortality; shock


Introduction : A new 5-stage cardiogenic shock (CS) classification scheme was recently proposed by the Society for Cardiovascular Angiography and Intervention (SCAI) for the purpose of risk stratification.
OBJECTIVES : This study sought to apply the SCAI shock classification in a cardiac intensive care unit (CICU) population.

Méthode : The study retrospectively analyzed Mayo Clinic CICU patients admitted between 2007 and 2015. SCAI CS stages A through E were classified retrospectively using CICU admission data based on the presence of hypotension or tachycardia, hypoperfusion, deterioration, and refractory shock. Hospital mortality in each SCAI shock stage was stratified by cardiac arrest (CA).

Résultats : Among the 10,004 unique patients, 43.1% had acute coronary syndrome, 46.1% had heart failure, and 12.1% had CA. The proportion of patients in SCAI CS stages A through E was 46.0%, 30.0%, 15.7%, 7.3%, and 1.0% and unadjusted hospital mortality in these stages was 3.0%, 7.1%, 12.4%, 40.4%, and 67.0% (p < 0.001), respectively. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted odds ratio: 1.53 to 6.80; all p < 0.001) compared with SCAI shock stage A, as was CA (adjusted odds ratio: 3.99; 95% confidence interval: 3.27 to 4.86; p < 0.001). Results were consistent in the subset of patients with acute coronary syndrome or heart failure.

Conclusion : When assessed at the time of CICU admission, the SCAI CS classification, including presence or absence of CA, provided robust hospital mortality risk stratification. This classification system could be implemented as a clinical and research tool to identify, communicate, and predict the risk of death in patients with, and at risk for, CS.

Conclusion (proposition de traduction) : Lorsqu’elle a été évaluée au moment de l’admission en unité de soins intensifs cardiaques, la classification du choc cardiogénique de la Society for Cardiovascular Angiography and Intervention (SCAI), incluant la présence ou non d’un arrêt cardiaque, fournissait une solide stratification du risque de mortalité hospitalière. Ce système de classification pourrait être mis en œuvre en tant qu'outil clinique et de recherche pour identifier, communiquer et prédire le risque de décès chez les patients présentant un risque de choc cardiogénique et risquant d'en subir un.

Commentaire : 

Osteoporotic Fractures in Patients With Atrial Fibrillation Treated With Conventional Versus Direct Anticoagulants.
Binding C, Bjerring Olesen J, Abrahamsen B, Staerk L, Gislason G, Nissen Bonde A. | J Am Coll Cardiol. 2019 Oct 29;74(17):2150-2158
Keywords: atrial fibrillation; direct oral anticoagulants; osteoporosis; osteoporotic fracture; thromboprophylaxis; vitamin k antagonists

Original Investigation

Introduction : Elderly patients in long-term treatment with vitamin K antagonists (VKAs) are at high risk of osteoporotic fractures compared with the background population. It has been speculated that the choice of oral anticoagulant (OAC) may affect the risk of osteoporotic fractures.
OBJECTIVES: The risk of osteoporotic fractures was evaluated among patients with atrial fibrillation treated with VKA or direct oral anticoagulants (DOACs).

Méthode : Patients were identified using the Danish national registries. Patients were included only if they had no prior use of osteoporosis medication and they had undergone 180 days of OAC treatment. Outcomes were hip fracture, major osteoporotic fracture, any fracture, initiation of osteoporosis medication, and a combined endpoint.

Résultats : Overall, 37,350 patients were included. The standardized absolute 2-year risk of any fracture was low among DOAC-treated patients (3.1%; 95% CI: 2.9% to 3.3%) and among VKA-treated patients (3.8%; 95% CI: 3.4% to 4.2%). DOAC was associated with a significantly lower relative risk of any fracture (hazard ratio [HR]: 0.85; 95% CI: 0.74 to 0.97), major osteoporotic fractures (HR: 0.85; 95% CI: 0.72 to 0.99), and initiating osteoporotic medication (HR: 0.82; 95% CI: 0.71 to 0.95). A combined endpoint showed that patients treated with DOAC had a significantly lower relative risk of experiencing any fracture or initiating osteoporosis medication (HR: 0.84; 95% CI: 0.76 to 0.93).

Conclusion : In a nationwide population, the absolute risk of osteoporotic fractures was low among patients with atrial fibrillation on OAC, but DOAC was associated with a significantly lower risk of osteoporotic fractures compared with VKA.

Conclusion (proposition de traduction) : Dans une population nationale, le risque absolu de fractures ostéoporotiques était faible chez les patients atteints de fibrillation auriculaire sous sous anticoagulant oral, mais les anticoagulants oraux directs (AOD) étaient associés à un risque significativement plus faible de fractures ostéoporotiques par rapport aux AVK.

Commentaire : Voir l'analyse de l'article sur le site Medscape : AOD ou AVK, faut-il prendre en compte le risque de fracture ?  . Rédigé par les Dr Marine Cygler, Batya Swift Yasgur MA, LSW, le 31 octobre 2019.

Journal of the American Heart Association

Association Between Occupational Exposure to Pesticides and Cardiovascular Disease Incidence: The Kuakini Honolulu Heart Program.
Berg ZK, Rodriguez B, Davis J, Katz AR, Cooney RV, Masaki K. | J Am Heart Assoc. 2019 Oct;8(19):e012569
DOI:  | Télécharger l'article au format  
Keywords: Honolulu Heart Program; Honolulu‐Asia Aging Study; cardiovascular disease; cerebrovascular accident; coronary heart disease; occupational exposure; pesticide exposure


Introduction : Previously, Kuakini Honolulu Heart Program researchers reported that occupational exposure to pesticides was significantly associated with total mortality. The current study examines occupational exposure to pesticides in relation to incident cardiovascular disease, defined as coronary heart disease or cerebrovascular accident.

Méthode : With the Occupational Safety Health Administration exposure scale used as an estimate of exposure, statistical analyses were performed on a cohort of 7557 Japanese-American men from the Kuakini Honolulu Heart Program. Hazard ratios for cardiovascular disease incidence were calculated for various levels of pesticide exposure using Cox proportional hazards models.

Résultats : In the first 10 years of follow-up, a positive association was observed between age-adjusted cardiovascular disease incidence and high levels of pesticide exposure (hazard ratio=1.46, 95% CI=1.10-1.95, P=0.009). This relationship remained significant after adjustment for other cardiovascular disease risk factors (hazard ratio=1.42, 95% CI=1.05-1.92, P=0.021). No significant association for coronary heart disease or cerebrovascular accident incidence with pesticide exposure was observed when examined separately, possibly due to a smaller number of events

Conclusion : These findings suggest that occupational exposure to pesticides may play a role in the development of cardiovascular diseases. The results are novel, as the association between occupational exposure to pesticides and cardiovascular disease incidence has not been examined previously in this unique cohort.

Conclusion (proposition de traduction) : Ces résultats suggèrent que l'exposition professionnelle aux pesticides pourrait jouer un rôle dans le développement de maladies cardiovasculaires. Les résultats sont nouveaux, car l'association entre l'exposition professionnelle aux pesticides et l'incidence des maladies cardiovasculaires n'a pas été examinée auparavant dans cette cohorte unique.

Médecine & droit

Siranyan V, Toucas 0. | Méd. droit. 2019 October;2019(158):130-136
Keywords: Connected object; Medical device; Medical Software; Mobile medical application

Exercice professionnel

Editorial : Les offres d’applications mobiles et d’objets connectés se multiplient sur internet, dans les magasins de vente de matériel médical mais aussi dans le réseau de la grande distribution. Ces produits de santé ou de bien-être n’ont cependant pas tous, un statut juridique bien déterminé, garant de la sécurité des utilisateurs, patients ou professionnels de santé. Les objets connectés, sources d’innovation et d’espoir, peuvent devenir des compagnons indispensables pour les patients ou les professionnels de santé ; mal utilisés, ils peuvent néanmoins être à l’origine de dommages corporels.

Conclusion (proposition de traduction) : Si l’analyse des mécanismes d’indemnisation des victimes d’accidents médicaux peut se fonder sur une logique européenne, l’examen des particularités des exigences mises à la charge des concepteurs ou fournisseurs d’objets connectés impose un regard international, à l’image du réseau internet qui ne connaît pas de frontières. En outre, l’agence fédérale américaine de sécurité des produits de santé (FDA) expérimente une nouvelle approche pour la régulation des objets connectés, basée sur une certification et un suivi post-commercialisation. En effet, les logiciels médicaux présentent un cycle de vie rapide, sans comparaison avec les autres produits de santé ; leur mise en service oblige à la prise en compte de l’interopérabilité avec d’autres appareils et aux précautions nécessaires à la cybersécurité. Dans un contexte de globalisation des échanges et face à la rapidité des progrès technologiques, les évaluations des produits de santé effectuées par les agences de sécurité sanitaire ou les autorités compétentes devront donc assurer la sécurité des populations, sans ralentir la mise sur le marché de dispositifs médicaux innovants, de plus en plus interconnectés. Ces objectifs communs pourraient en conséquence conduire à une certaine convergence des normes.

Pediatric Emergency Care

Evaluation of the Association of Early Elevated Lactate With Outcomes in Children With Severe Sepsis or Septic Shock.
Gorgis N, Asselin JM, Fontana C, Heidersbach RS, Flori HR, Ward SL. | Pediatr Emerg Care. 2019 Oct;35(10):661-665
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Articles

Introduction : The aim of the study was to assess the association of initial lactate (L0) with mortality in children with severe sepsis.

Méthode : This prospective cohort study included 74 patients younger than 18 years with severe sepsis admitted to the pediatric intensive care unit (PICU) of a tertiary, academic children's hospital with lactate measured within 3 hours of meeting severe sepsis or septic shock. The primary outcome was in-hospital mortality. The secondary outcomes included PICU and hospital length of stay.

Résultats : Although overall mortality was 10.5% (n = 18), patients with L0 measured (n = 72) had a higher mortality (16% vs 6%, P = 0.03) and higher median PRISM-III risk of mortality scores (P = 0.02) than those who did not. Median L0 was no different between nonsurvivors and survivors (3.6 mmol/L [interquartile range, 2.0-9.0] in nonsurvivors vs 2.3 mmol/L [interquartile range, 1.4-3.5] in survivors, P = 0.11). However, L0 was independently associated with PRISM-III score (coefficient, 1.12; 95% confidence interval, 0.4-1.8; P = 0.003) with an increase in mean PRISM-III score of 1.12 U for every 1 mmol/L increase in L0, with L0 accounting for 12% of the variability in PRISM-III scores between patients. There was no association between L0 and PICU or hospital length of stay.

Conclusion : Although our single center study did not demonstrate that an elevated early lactate is associated with mortality in pediatric severe sepsis, L0 did correlate strongly with PRISM-III, the most robust measure of mortality risk in pediatrics. Therefore, early lactate measurement may be important as an early biomarker of disease severity. These data should be validated in a larger, multicenter, prospective study.

Conclusion (proposition de traduction) : Bien que notre étude monocentrique n'ait pas démontré qu'un taux élevé de lactate précoce était associé à la mortalité chez les enfants présentants une septicémie grave, les taux de lactates étaient en corrélation étroite avec PRISM-III, la mesure la plus robuste du risque de mortalité chez les enfants.
Par conséquent, la mesure précoce du lactate peut être importante comme biomarqueur précoce de la gravité de la maladie.
Ces données devraient être validées dans le cadre d'une étude prospective multicentrique plus vaste.

A Comparison of Pediatric Weight Estimation Methods for Emergency Resuscitation.
Samerchua A, Suraseranivongse S, Komoltri C. | Pediatr Emerg Care. 2019 Oct;35(10):705-711
Keywords: Aucun

Original Articles

Introduction : Obtaining accurate pediatric weight is necessary during emergency resuscitation. Although several weight estimation methods exist, the most precise method has not been conclusively determined. This study aimed to evaluate the validity, reliability, and practicality of these tools.

Méthode : A prospective observational study was conducted in healthy Thai children aged 6 months to 12 years. Correlations between estimated and actual weights were tested. Validity was assessed by mean bias (estimated weight minus actual weight) and accuracy (10% error). Practicality was evaluated by time usage and data derived from user questionnaires.

Résultats : Four hundred thirty participants with mean age of 6.7 years and mean weight of 26 kg were enrolled. A strong correlation between estimated weight and actual weight in all methods was demonstrated. Parental estimation was the most accurate tool in all age groups, with the lowest overall mean error (ME) of -0.83 kg and the highest accuracy of 88.7%. The Broselow tape was the second most accurate tool in ages younger than 1 year and 1-to-5-year age groups (ME = 0.23 and 0.50 kg; accuracy = 55.3% and 54.1%, respectively). The Mercy method was the second most accurate tool in the 6-to-10-year and 11-to-12-year age groups (ME = -2.47 and -2.77; accuracy = 54.6% and 67.9%, respectively). The Broselow tape had the highest score for practicality of use.

Conclusion : Parental estimation was the most accurate method in every age group. The next best alternative is the Broselow tape in children aged 5 years or younger and the Mercy method in children aged older than 5 years.

Conclusion (proposition de traduction) : L'estimation parentale était la méthode la plus précise dans chaque groupe d'âge. La deuxième meilleure alternative est la bande Broselow chez les enfants de moins 5 ans et la méthode Mercy chez les enfants de plus de 5 ans.

Ethanol Intoxication of Young Children.
Gaw CE, Osterhoudt KC. | Pediatr Emerg Care. 2019 Oct;35(10):722-730
Keywords: Aucun

CME Review Article

Editorial : Ethanol intoxication of infants and young children can be a challenging diagnosis in the pediatric emergency department, and features of the poisoning may differ in comparison with adolescents. The sources of ethanol exposures in this age are varied and include unintentional, malicious, and iatrogenic etiologies. Young children exposed to ethanol often present with mixed clinical signs and symptoms that may not fit the traditional ethanol or sedative-hypnotic toxidrome. Pediatric ethanol intoxications are often managed supportively, and recovery is usually rapid. The purpose of this review is to describe the sources of ethanol poisoning among children 6 years and younger, highlight presenting symptoms and pharmacokinetic considerations unique to this age group, and review management strategies. In addition, published cases of ethanol poisoning due to ingestion among young infants are compiled for presentation.

Conclusion : -

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 Oct;34(5):489-496
Keywords: ECG; STEMI; paramedic

Original Research

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 d'infarctus du myocarde avec sus-décalage du segment ST réalisés en préhospitalier peuvent être stratifiés avec précision en probabilités élevée, intermédiaire et faible pour l'infarctus du myocarde avec sus-décalage 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 l'interprétation des ECG réalisés en préhospitaliers pourrait entraîner des changements pour le recours aux laboratoires de cathétérisme cardiaque et une diminution des exigences de surlecture des médecins. Cela peut avoir d'importantes répercussions cliniques et qualitatives.

A Comparison of Venous versus Capillary Blood Samples when Measuring Blood Glucose Using a Point-of-Care, Capillary-Based Glucometer.
Topping J, Reardon M, Coleman J, Hunter B, Shojima-Perera H, Thyer L, Simpson P. | Prehosp Disaster Med. 2019 Oct;34(5):506-509
Keywords: blood glucose level; capillary; prehospital; venous

Original Research

Introduction : Blood glucose level (BGL) is routinely assessed by paramedics in the out-of-hospital setting. Most commonly, BGL is measured using a blood sample of capillary origin analyzed by a hand-held, point-of-care glucometer. In some clinical circumstances, the capillary sample may be replaced by blood of venous origin. Given most point-of-care glucometers are engineered to analyze capillary blood samples, the use of venous blood instead of capillary may lead to inaccurate or misleading measurements.

Méthode : The aim of this prospective study was to compare mean difference in BGL between venous and capillary blood from healthy volunteers when measured using a capillary-based, hand-held, point-of-care glucometer.

Résultats : Using a prospective observational comparison design, 36 healthy participants provided paired samples of blood, one venous and the other capillary, taken near simultaneously. The BGL values were similar between the two groups. The capillary group had a range of 4.3mmol/l, with the lowest value being 4.4mmol/l and 8.7mmol/l the highest. The venous group had a range of 2.7mmol/l, with the lowest value being 4.1mmol/l and 7.0mmol/l the highest.For the primary research question, the mean BGL for the venous sample group was 5.3mmol/l (SD = 0.6), compared to 5.6mmol/l (SD = 0.8) for the capillary group. This represented a statistically significant difference of 0.3mmol/l (P = .04), but it did not reach the a priori established point of clinical significance (1.0mmol/l). Pearson's correlation coefficient for capillary versus venous indicated moderate correlation (r = 0.42).

Conclusion : In healthy, non-fasted people in a non-clinical setting, a statistically significant, but not clinically significant, difference was found between venous- and capillary-derived BGL when measured using a point-of-care, capillary-based glucometer. Correlation between the two was moderate. In this context, using venous samples in a capillary-based glucometer is reasonable providing the venous sample can be gathered without exposure of the clinician to risk of needle-stick injury. In clinical settings where physiological derangement or acute illness is present, capillary sampling would remain the optimal approach.

Conclusion (proposition de traduction) : Chez des personnes en bonne santé, non à jeun, dans un contexte non clinique, une différence statistiquement significative, mais non cliniquement significative, a été observée entre la glycémie d'origine veineuse et capillaire, mesurée au moyen d'un glucomètre capillaire au point d'intervention. La corrélation entre les deux était modérée. Dans ce contexte, l'utilisation d'échantillons veineux avec un glucomètre capillaire est raisonnable à condition que l'échantillon veineux puisse être prélevé sans exposer le clinicien au risque de blessure par piqûre d'aiguille. Dans les milieux cliniques où il existe un dérangement physiologique ou une maladie aiguë, l'échantillonnage capillaire demeurerait l'approche optimale.

The Effect of Prehospital Epinephrine in Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.
Ng KT, Teoh WY. | Prehosp Disaster Med. 2019 Oct;34(5):532-539
Keywords: cardiac arrest; emergency medicine; epinephrine; first aid; resuscitation

Comprehensive Review

Introduction : Epinephrine has been recommended for out-of-hospital cardiac arrest (OHCA) resuscitation for nearly one century, but its efficacy and safety remain unclear in the literature. The primary aim of this review was to determine whether epinephrine increases the return of spontaneous circulation in OHCA patients.

Méthode : A systematic review and meta-analysis were conducted using the following databases: MEDLINE, EMBASE, and CENTRAL, from their inception until October 2018. All the randomized controlled trials (RCTs) were included. Observational studies, case reports, case series, and non-systematic reviews were excluded.

Résultats : Two trials including 8,548 patients were eligible for inclusion in the data synthesis. In patients who received epinephrine during OHCA, the incidence of return of spontaneous circulation was increased, with an odds ratio (95%CI) of 4.25 (3.79-4.75), P <.001, high-quality of evidence. The number of patients transported to hospital was increased in patients who had prehospital epinephrine, with an odds ratio (95%CI) of 2.31 (2.11-2.53), P <.001, high-quality of evidence. The prehospital use of epinephrine was associated with an increased survival to hospital discharge, the odds ratio (95%CI) being 1.43 (1.10-1.87), P = .008, moderate-quality of evidence. No significant effect was noted on the favorable neurologic state of patient at hospital discharge, with an odds ratio (95%CI) of 1.21 (0.90-1.64), P = .21, moderate-quality of evidence.

Conclusion : This meta-analysis suggests that the prehospital use of epinephrine increases return of spontaneous circulation, transport of patients to hospital, and survival to hospital discharge for OHCA. However, no significant effects on favorable neurologic function at hospital discharge were demonstrated. The general quality of evidence ranged from moderate to high.

Conclusion (proposition de traduction) : Cette méta-analyse suggère que l'utilisation préhospitalière d'épinéphrine (adrénaline) augmente le taux de récupération d'activité cardiaque spontanée, le nombre de patients transporté à l'hôpital et la survie à la sortie de l'hôpital dans l'arrêt cardiaque extra-hospitalier. Cependant, aucun effet significatif sur la fonction neurologique favorable à la sortie de l'hôpital n'a été démontré. La qualité générale des preuves variait de modérée à élevée.

Prehospital Emergency Care

Maximum Value of End-Tidal Carbon Dioxide Concentrations during Resuscitation as an Indicator of Return of Spontaneous Circulation in out-of-Hospital Cardiac Arrest.
Javaudin F, Her S, Le Bastard Q, De Carvalho H, Le Conte P, Baert V, Hubert H, Montassier E, Lascarrou JB, Leclère B; GR-RéAC. | Prehosp Emerg Care. 2019 Oct 31:1-7
Keywords: capnography; cardiopulmonary resuscitation; out-of-hospital cardiac arrest; return of spontaneous circulation; traumatology


Introduction : The end-tidal carbon dioxide (ETCO2) concentration during resuscitation (CPR) of an out-of-hospital cardiac arrest (OHCA) has an increasingly well-known prognostic value. Nevertheless, few studies have investigated its maximum value in different etiologies.

Méthode : It was a retrospective, observational, multicentre study from the French OHCA Registry. All adult OHCA with a known maximum value of ETCO2 during CPR were included. The primary end-point was to determine the area under the receiver operating characteristic curve (AUROC) of the maximum value of ETCO2 during resuscitation for the return of spontaneous circulation (ROSC)

Résultats : Of the 53,048 eligible subjects from 2011 to 2018, ETCO2 was known in 32,249 subjects (61%). Among them, there were 9.2% of traumatic OHCA, 37.7% of suspected cardiac etiology and 16.4% of suspected respiratory etiology. The AUROC of maximum value of ETCO2 during CPR to achieve ROSC was 0.887 95CI [0.875-0.898] in traumatic OHCA, 0.772 95CI [0.765-0.780] in suspected cardiac etiology and 0.802 95CI [0.791-0.812] in suspected respiratory etiology. The threshold with no survivors at d-30 was <10 mmHg for traumatic etiologies and <6 mmHg for suspected cardiac and respiratory causes. The probability of ROSC increased with the value of ETCO2 in the 3 etiologies studied.

Conclusion : The maximum value of ETCO2 during OHCA resuscitation was strongly associated with ROSC, especially in the case of a traumatic cause. This suggests that a single elevated ETCO2 value, regardless of time, could help to predict the outcome.

Conclusion (proposition de traduction) : La valeur maximale d'ETCO2 pendant la réanimation d'un arrêt cardiaque extra-hospitalier était fortement associée au retour d'activité cardiaque spontanée (RACS), surtout dans le cas d'une cause traumatique. Cela donne à penser qu'une seule valeur élevée d'ETCO2, peu importe l'heure, pourrait aider à prédire le résultat.

Prevalence and Predictors of Post-Intubation Hypotension in Prehospital Trauma Care.
Elmer J, Brown F, Martin-Gill C, Guyette FX. | Prehosp Emerg Care. 2019 Oct 22:1-9
Keywords: prehospital; airway; hypotension; resuscitation; trauma


Introduction : Prehospital care of severe trauma patients often involves endotracheal intubation (ETI), which has complications. The frequency and predictors of post-ETI hypotension and cardiac arrest are not well defined in this population. We sought to derive and validate a scoring system that predicts post-ETI hypotension in prehospital patients and to describe the impact of hypotension on outcome.

Méthode : We performed an observational cohort study including normotensive adult trauma patients requiring ETI, treated from 2001 to 2018 by critical care transport providers in a regional air medical transport system. We divided eligible patients into a derivation cohort (2001-2010) and validation cohort (2011-2018) for analysis. We identified predictors of new systolic hypotension (<90 mmHg) or cardiac arrest within 15 minutes of ETI then developed and validated a scoring system that stratified patients into low, moderate and high risk.

Résultats : We included 4,866 subjects, 3,127 in the derivation and 1,739 in the validation cohort. Post-ETI hypotension occurred in 11% and 21%, respectively; 5% of each cohort experienced post-ETI cardiac arrest. Major independent predictors of post-ETI hypotension were age, pre-ETI systolic blood pressure and pre-ETI oxygen saturation. We developed a well-calibrated scoring system based on these major and several minor risk factors. Applying our system, 890 (33%) derivation patients and 550 (37%) validation patients were higher risk for post-ETI adverse outcomes. Of these, 21% and 33% respectively experienced post-ETI hypotension and 6% and 4%, respectively suffered post-ETI cardiac arrest.

Conclusion : Patients at high risk for post-ETI hypotension or arrest are common and identifiable in prehospital trauma care.

Conclusion (proposition de traduction) : Les patients à haut risque d'hypotension ou d'arrêt cardiaque après une intubation endotrachéale sont courants et identifiables dans les soins préhospitaliers en traumatologie.

Association Between Post-Resuscitation Coronary Angiography With and Without Intervention and Neurological Outcomes After Out-of-Hospital Cardiac Arrest.
Kim KH, Park JH, Ro YS, Shin SD, Song KJ, Hong KJ, Jeong J, Lee KW, Hong WP. | Prehosp Emerg Care. 2019 Oct 11:1-9
Keywords: electrocardiogram; out-of-hospital cardiac arrest; post-resuscitation care


Introduction : This study aimed to investigate the association between coronary angiography (CAG) with and without percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest (OHCA) and neurological recovery and to determine the influence of primary electrocardiogram or patient age on the effects of CAG.

Méthode : Adult patients with OHCA with cardiac etiology who were admitted to PCI-capable hospitals from 2016 to 2017 were enrolled in this study from the nationwide OHCA registry of Korea. Coronary intervention was categorized into three groups: No CAG, CAG without PCI, and CAG with PCI. The endpoint was good neurological recovery. Multivariable logistic regression and interaction analyses (intervention × electrocardiogram and intervention × age) were conducted by calculating adjusted odds ratios (aORs) and 95% confidence intervals (CI).

Résultats : Of a total of 6,802 eligible OHCA patients, 1,218 (17.9%) underwent CAG without PCI and 1,136 (16.7%) underwent CAG with PCI. The CAG without PCI and CAG with PCI groups were more likely to have good neurological recovery than the No CAG group (57.4% vs. 61.6% vs. 16.3%; 3.39 [2.83-4.06] for CAG without PCI and 3.32 [2.74-4.01] for CAG with PCI). Interaction analysis showed that although the effect size differed according to patient characteristics, both CAG groups were associated with an increased likelihood of good neurological recovery, regardless of primary electrocardiogram and age group. In younger patients, CAG with PCI had greater outcome benefits than CAG without PCI (8.54 [4.31-16.95] vs. 4.10 [2.69-6.24]), whereas CAG without PCI had a larger effect size than CAG with PCI in elderly patients (4.46 [2.59-7.68] vs. 2.92 [1.80-4.73]) (p value for interaction 0.02).

Conclusion : Post-resuscitation CAG with and without PCI are associated with better neurological recovery in patients with OHCA, regardless of primary electrocardiogram and patient age.

Conclusion (proposition de traduction) : L'angiographie coronaire après réanimation cardio-pulmonaire, avec ou sans intervention coronaire percutanée, est associée à une meilleure récupération neurologique chez les patients en arrêt cardiaque extra-hospitaliers, quels que soient l'électrocardiogramme primaire et l'âge du patient.

Temporal Trends in the Incidence, Characteristics, and Outcomes of Hanging-Related Out-of-Hospital Cardiac Arrest.
Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K. | Prehosp Emerg Care. 2019 Oct 11:1-9
Keywords: cardiopulmonary resuscitation; emergency medical services; hanging; out-of-hospital cardiac arrest; quality of life


Introduction : The aim of this study was to describe temporal trends in the incidence, characteristics, and outcomes of hanging-related out-of-hospital cardiac arrest (OHCA).

Méthode : A retrospective study of all hanging-related OHCA in Victoria, Australia, between 2000 and 2017 was conducted. Trends in incidence, characteristics, and outcomes were assessed using linear regression and a non-parametric test for trend, as appropriate. Predictors of survival to hospital discharge were identified using multivariable logistic regression.

Résultats : Between 2000 and 2017, emergency medical services (EMS)-attended 3,891 cases of hanging-related OHCA, of which 876 cases (23%) received an attempted resuscitation. The overall incidence rate of EMS-attended cases was 3.8 cases per 100,000 person-years increasing from 2.3 cases per 100,000 person-years in 2000 to 4.7 cases in 2017 (p for trend <0.001). Incidence rates increased approximately two-fold in young adults (18-44 years) and three-fold in middle aged adults (45-64 years). Despite improvement in the rate of bystander cardiopulmonary resuscitation (from 49% in 2000-2005 to 75% in 2012-2017), the survival to hospital discharge rate remained unchanged (3% overall). Among adult survivors with 12-month follow-up (n = 10), five patients responded to telephone interviews. Of those, three (60%) reported severe functional disability. Five patients responded to telephone interviews, of which 3 patients reported severe functional disability. An initial shockable rhythm (OR 23.17, 95% CI: 5.75, 93.36) or pulseless electrical activity (OR 13.14, 95% CI: 4.79, 36.03) were associated with survival.

Conclusion : The incidence of hanging-related OHCA doubled over the 18 year period with no change to survival rates. New preventative strategies are needed to reduce the community burden of these events.

Conclusion (proposition de traduction) : L'incidence des arrêts cardiaques extra-hospitaliers liés à une pendaison a doublé au cours de la période des derniers 18 ans sans changement des taux de survie. De nouvelles stratégies préventives sont nécessaires pour réduire la charge de ces événements pour la collectivité.


Novel technologies for heart rate assessment during neonatal resuscitation at birth - A systematic review.
Johnson PA, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM. | Resuscitation. 2019 Oct;143:196-207
Keywords: Delivery room; Heart rate assessment; Infants; Neonatal resuscitation; Newborn


Introduction : 6.5-9 million newborns worldwide require resuscitation at birth annually. During neonatal resuscitation, inaccurate or slow heart rate (HR) assessments may significantly increase risk of infant mortality or morbidity. Therefore fast, accurate, and effective HR assessment tools are critical for neonatal resuscitation.
OBJECTIVES : To systematically review the literature about accuracy, latency, and efficacy of technologies for HR assessment during neonatal resuscitation.

Méthode : Adhering to PRISMA guidelines, PubMed, EMBASE, and Google Scholar databases were systematically searched to identify studies related to technologies for HR assessment, which could be used to guide neonatal resuscitation.

Résultats : Forty-six studies evaluating HR assessment technologies for neonatal resuscitation were identified. In total, 16 studies (3/16 randomized trials and 13/16 observational studies) compared two or more HR assessment technologies to measure accuracy, latency, and efficacy. Of the trials, 1/3 had a low risk of bias while 2/3 had high risks. All observational studies had high risks of bias. Most studies considered infants not requiring resuscitation, constituting indirect evidence and lower certainty in the context of neonatal resuscitation. Two trials reported faster times to HR assessment using electrocardiogram with a mean(SD) 66(20) versus 114(39) s and a median(IQR) 24(19-39) versus 48(36-69) s (both p < 0.001), compared to pulse oximetry.

Conclusion : While electrocardiography is faster to assess HR at birth and more reliable to detect HR changes compared to other recommended technologies, practice should not exclusively rely on ECG. While novel technologies could support HR assessment, no studies validate their clinical efficacy during neonatal resuscitation.

Conclusion (proposition de traduction) : Bien que l'électrocardiogramme soit plus rapide pour évaluer la fréquence cardiaque à la naissance et plus fiable pour détecter les modifications de la fréquence cardiaque par rapport aux autres technologies recommandées, la pratique ne devrait pas reposer exclusivement sur l’ECG. Bien que de nouvelles technologies puissent soutenir l’évaluation de la fréquence cardiaque, aucune étude n’a validé leur efficacité clinique lors de la réanimation néonatale.

The performance of a new shock advisory algorithm to reduce interruptions during CPR.
Hu Y, Tang H, Liu C, Jing D, Zhu H, Zhang Y, Yu X, Zhang G, Xu J. | Resuscitation. 2019 Oct;143:1-9
Keywords: Algorithm; CPR; Cardiac arrest; Rhythm analysis

Clinical Papers

Introduction : To explore a new algorithm and strategy for rhythm analysis during chest compressions (CCs), and to improve the efficiency of cardiopulmonary resuscitation (CPR) by minimizing interruptions.

Méthode : The clinical data and ECG of patients with sudden cardiac arrest (CA) from three hospitals in China were collected with Philips MRx monitor/defibrillators. The length of each analyzed ECG segment was 23 s, the first 11.5 s was selected to contain CPR compressions, the next 5 s had no compressions, and the last 6.5 s had no requirement. Three experienced emergency doctors annotated the ECG segments without compression artifacts. A two-step analysis through CPR (ATC) algorithm was applied to the selected data. The first step was analysis during chest compressions. If a shockable rhythm was not detected, compression-free analysis followed. The results of the ATC algorithm were compared with the annotations by the physicians, to determine the sensitivity and specificity of the algorithm.

Résultats : In total 166 CA patients were included with 100 out-of-hospital cardiac arrest (OHCA) patients and 66 in-hospital cardiac arrest (IHCA) patients. A total of 1578 ECG segments were analyzed, including 115 (7.3%) shockable rhythms, 1278 (81.0%) non-shockable rhythms, and 185 (11.7%) intermediate/unknown rhythms. The specificity of all non-shockable rhythms was 99.8% at the end of chest compressions, and 99.5% after analysis without compression artifact. 70.5% of ventricular fibrillation (VF) rhythms were detected by the end of chest compressions. After the CC-free analysis, 93.6% of VF was identified.

Conclusion : The ATC algorithm achieved sensitivity of 93.6% and specificity of 99.5% after the two-step analysis, and 70.5% of the patients with shockable rhythms did not require CC-free analysis. Such an approach has the potential to substantially reduce CC interruptions when identifying shockable rhythms.

Conclusion (proposition de traduction) : L'analyse à l'aide de l'algorithme de RCP a permis d'obtenir une sensibilité de 93,6 % et une spécificité de 99,5 % après l'analyse en deux étapes, et 70,5 % des patients présentant des rythmes choquables n'ont pas nécessité une analyse sans compression thoracique. Une telle approche peut potentiellement réduire considérablement les interruptions des compressions thoraciques lors de l'identification des rythmes choquables.

Modulating effects of immediate neuroprognosis on early coronary angiography and targeted temperature management following out-of-hospital cardiac arrest: A retrospective cohort study.
Wang CH, Tsai MS, Chang WT, Yu PH, Wu YW, Huang CH, Chen WJ. | Resuscitation. 2019 Oct;143:42-49
Keywords: Coronary angiography; Coronary intervention; Neuroprognosis; Out-of-hospital cardiac arrest; Percutaneous; Targeted temperature management

Clinical Papers

Introduction : The simplified cardiac arrest hospital prognosis (sCAHP) score is a validated tool for predicting neurological outcomes after out-of-hospital cardiac arrest (OHCA). We used the sCAHP score to evaluate whether the effects of early coronary angiography (CAG) and targeted temperature management (TTM) for OHCA were modulated by immediate neuroprognosis.

Méthode : This was a single-centre retrospective observational study. Consecutive OHCA patients were screened between 2011 and 2017. Multivariate logistic regression analysis and generalised additive models (GAMs) were used to examine the associations between independent variables and outcomes. Early CAG was defined as CAG performed within 24 h after return of spontaneous circulation (ROSC).

Résultats : A total of 412 patients were included in the study, and 94 (22.8%) patients had neurologically intact survival. The GAM plot identified a sCAHP score of 185 as the cut-off point to differentiate high-risk (sCAHP score ≧185) from low-risk (sCAHP score <185) patients. Regression models indicated that early CAG was significantly associated with favourable neurological [odds ratio (OR) 4.43, 95% confidence interval (CI) 2.28-8.60, p < 0.001] and survival outcomes (OR 3.47, 95% CI 1.93-6.25, p < 0.001), independent of the sCAHP score. Although TTM was associated with favourable neurological outcome only in low-risk patients (OR 2.13, 95% CI 1.10-4.13, p = 0.02), TTM was associated with improved survival for all patients (OR 2.66, 95% CI 1.54-4.59, p < 0.001), independent of the sCAHP score.

Conclusion : Early CAG and TTM should be considered for all OHCA patients as suggested by guidelines, irrespective of the immediately predicted neuroprognosis after ROSC.

Conclusion (proposition de traduction) : L'angiographie coronarienne précoce et la gestion ciblée de la température doivent être envisagées pour tous les patients en arrêt cardiaque cardiaques en dehors de l'hôpital, comme le suggèrent les directives, indépendamment du pronostic neurologique immédiatement après le retour à une activité cardiaque spontanée (RACS).

Trends in survival from out-of-hospital cardiac arrests defibrillated by paramedics, first responders and bystanders.
Nehme Z, Andrew E, Bernard S, Haskins B, Smith K. | Resuscitation. 2019 Oct;143:85-91
Keywords: Defibrillation; Emergency medical service; Out-of-hospital cardiac arrest; Public access defibrillation; Resuscitation

Clinical papers

Introduction : Although survival from out-of-hospital cardiac arrest (OHCA) is increasing, little is known about the long-term trends in survival for patients defibrillated by first responders and bystanders.

Méthode : Between 2000 and 2017, we included adult non-traumatic OHCA with an initial shockable rhythm from the Victorian Ambulance Cardiac Arrest Registry. Adjusted logistic regression analyses were used to assess trends in survival to hospital discharge according to whether the patient was initially shocked by paramedics, first responders or bystanders.

Résultats : Of the 10,451 initial shockable arrests, 796 (7.6%) and 526 (5.0%) were initially shocked by first responders and bystanders, respectively. Between 2000-02 and 2015-17, the proportion of cases initially shocked by first responders and bystanders increased from 3.8% to 8.2% and from 2.0% to 11.2%, respectively. Over the same period, survival to hospital discharge increased from 11.6% to 28.8% for cases initially shocked by paramedics, from 10.5% to 37.8% for cases initially shocked by first responders, and from 6.7% to 55.5% for cases initially shocked by bystanders (p trend <0.001 for all). In the adjusted analyses, patients initially shocked by first responders (AOR 1.40, 95% CI: 1.18, 1.67; p < 0.001) and bystanders (AOR 2.11, 95% CI: 1.72, 2.59; p < 0.001) were more likely to survive to hospital discharge than those initially shocked by paramedics. The odds of survival increased year-on-year by 8.1% for patients shocked by paramedics (p < 0.001), 6.1% for patients shocked by first responders (p = 0.004), and 11.8% for patients shocked by bystanders (p < 0.001).

Conclusion : OHCA patients initially defibrillated by bystanders yielded the largest improvements in survival over time.

Conclusion (proposition de traduction) : Les patients en arrêt cardiaque extrahospitalier initialement défibrillés par des tiers ont présenté les améliorations les plus importantes en termes de survie dans le temps.

Optimal timing to measure optic nerve sheath diameter as a prognostic predictor in post-cardiac arrest patients treated with targeted temperature management.
Park JS, Cho Y, You Y, Min JH, Jeong W, Ahn HJ, Kang C, Yoo I, Ryu S, Lee J, Kim SW, Cho SU, Oh SK, Lee J, Lee IH. | Resuscitation. 2019 Oct;143:173-179
Keywords: Cardiac arrest; Optic nerve; Prognostication

Clinical papers

Introduction : We evaluated the optimal timing of optic nerve sheath diameter (ONSD) measurement to predict neurologic outcome in post-cardiac arrest patients treated with target temperature management (TTM).

Méthode : This was a prospective single-centre observational study from April 2018 to March 2019. Good outcome was defined as the Glasgow-Pittsburgh cerebral performance categories (CPC) 1 or 2, and poor outcome as a CPC between 3 and 5. ONSD was measured initially after return of spontaneous circulation (ROSC) (ONSDinitial), at 24 h (ONSD24), 48 h (ONSD48), and 72 h (ONSD72) using ultrasonography. The receiver operating characteristic (ROC) curves and DeLong method were used to compare the values for predicting neurologic outcomes.

Résultats : Out of the 36 patients enrolled, 18 had a good outcome. ONSD24, ONSD48, and ONSD72 were higher in the poor outcome group. The area under ROC curve of ONSD24 was 0.91 (95% confidence interval 0.77-0.98) in predicting poor neurologic outcomes. With a cut off value of 4.90 mm, ONSD24 had a sensitivity of 83.3% and a specificity of 94.4% in predicting poor neurologic outcomes.

Conclusion : Our findings demonstrate ONSD24 as a valuable tool to predict the neurologic outcome in post-cardiac arrest patients treated with TTM. Therefore, we recommend performing ONSD measurement using ultrasonography at 24 h after ROSC, rather than immediately after ROSC, to predict neurologic outcome in post-cardiac arrest patients treated with TTM.

Conclusion (proposition de traduction) : Nos résultats démontrent que le diamètre de la gaine du nerf optique mesuré à 24 ans est un outil précieux pour prédire le résultat neurologique chez les patients après un arrêt cardiaque traités pavec un contrôle de la température cible. Par conséquent, nous recommandons d'effectuer une mesure du diamètre de la gaine du nerf optique par échographie 24 heures après le retour à une circulation spontanée (RACS), plutôt qu'immédiatement après le retour à une circulation spontanée (RACS), pour prédire le résultat neurologique chez les patients après un arrêt cardiaque et traités par contrôle de la température cible.

Gender differences in utilization of coronary angiography and angiographic findings after out-of-hospital cardiac arrest: A registry study.
Lindgren E, Covaciu L, Smekal D, Lagedal R, Nordberg P, Elfwén L, Svensson L, Jonsson M, James S, Rubertsson S. | Resuscitation. 2019 Oct;143:189-195
Keywords: CPR; Cardiac arrest; Coronary angiography; Gender differences; Out-of-hospital cardiac arrest; Percutaneous coronary intervention; Registry study; Ventricular fibrillation

Clinical papers

Introduction : We investigated the impact of gender in performance and findings of early coronary angiography (CAG) and percutaneous coronary intervention (PCI), comorbidity and outcome in a large population of out-of-hospital cardiac arrest (OHCA) patients with an initially shockable rhythm.

Méthode : Retrospective cohort study. Data retrieved 2008-2013 from the Swedish Register for Cardio-Pulmonary Resuscitation, Swedeheart Registry and National Patient Register.

Résultats : We identified 1498 patients of whom 78% were men. Men and women had the same pathology on the first registered electrocardiogram (ECG): 30% vs. 29% had ST-elevation and 10% vs. 9% had left bundle branch block (LBBB) (P = 0.97). Proportions of performed CAG did not differ between genders. Among patients without ST-elevation/LBBB men more often had at least one significant stenosis, 78% vs. 54% (P = 0.001), more multi-vessel disease (P = 0.01), had normal coronary angiography less often, 22% vs. 46% and PCI more often, 59% vs. 42% (P = 0.03). Among patients without ST-elevation/LBBB on the initial ECG, more men had previously known ischaemic heart disease, 27% vs. 19% (P = 0.02) and a presumed cardiac origin of the cardiac arrest, 86% vs. 72% (P < 0.001). Multivariable analysis showed no association between gender and evaluation by early CAG. In men and women, 1-year survival was 56% vs. 50% (P = 0.22) in patients with ST-elevation/LBBB and 48% vs. 51% (P = 0.50) in patients without.

Conclusion : Despite no gender differences in ECG findings indicating an early CAG, men had more severe coronary artery disease while women more frequently had normal coronary angiography. However, this did not influence 1-year survival.

Conclusion (proposition de traduction) : Malgré l'absence de différence entre les sexes dans les résultats de l'ECG indiquant la réalisation d'une angiographie coronarienne précoce, les hommes présentaient une coronaropathie plus grave alors que les femmes présentaient plus fréquemment une angiographie coronaire normale. Cependant, cela n'influençait pas la survie à 1 an.

Shorter defibrillation interval promotes successful defibrillation and resuscitation outcomes.
Roh YI, Jung WJ, Hwang SO, Kim S, Kim HS, Kim JH, Kim TY, Kang HS, Lee JS, Cha KC. | Resuscitation. 2019 Oct;143:100-105
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Electric defibrillation


Introduction : Current cardiopulmonary resuscitation guidelines recommend performing defibrillation every 2 min during resuscitation. This study aimed to compare the rate of successful defibrillation using 1- and 2-min defibrillation intervals.

Méthode : Twenty-six pigs were randomly assigned to 1- or 2-min interval groups. After inducing ventricular fibrillation (VF), we observed pigs for 2 min. Thereafter, basic life support was initiated with a 30:2 compression-to-ventilation ratio for 8 min. Defibrillation was performed with an energy of 2 J/kg at 10 min after VF and was repeated every 1 or 2 min according to randomization. Advanced cardiac life support, including continuous chest compression with ventilation every 6 s and intravenous injection of 1 mg epinephrine every 3 min, was performed until the return of spontaneous circulation (ROSC) or until 20 min after VF induction. Haemodynamic parameters and baseline arterial blood gas profiles were compared between groups. ROSC, 24 -h survival, and the neurologic deficit score (NDS) were evaluated at 24 h.

Résultats : Haemodynamic parameters during resuscitation and baseline arterial blood gas profiles did not differ between groups. ROSC was more frequently observed in the 1-min interval group (p = 0.047). Time to ROSC was not different between groups (p = 0.054). The 24 -h survival was higher (p = 0.047) and NDS at 24 h was lower (92 ± 175) in the 1-min interval group than in the 2-min interval group (272 ± 190) (p = 0.028).

Conclusion : Defibrillation success and resuscitation outcomes were superior when using a 1-min defibrillation interval in animal models of cardiac arrest.

Conclusion (proposition de traduction) : Le succès de la défibrillation et les résultats de la réanimation étaient supérieurs lorsqu’on utilisait un intervalle de défibrillation d’une minute dans des modèles animaux d’arrêt cardiaque

Frailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation.
Wharton C, King E, MacDuff A. | Resuscitation. 2019 Oct;143:208-211
Keywords: Cardiopulmonary resuscitation (CPR); Outcome

Short papers

Introduction : To assess whether frailty was associated with cardio-pulmonary resuscitation (CPR) outcome in a UK setting.

Méthode : Retrospective review of prospectively collected data on in-hospital cardio-respiratory arrests between 1/1/17 and 31/12/17. Clinical Frailty Scale (CFS) scores were assigned from notes review, patients with CFS scores ≥6 signified moderate or greater frailty.

Résultats : There were 179 in-hospital cardiac arrest cases where the CFS could be calculated. The median age on admission was 74 (mean 71, range 27-102), 110 patients were male and 69 female. The initial rhythm was non-shockable in 64% of cases. In 49% of cases return of spontaneous circulation (ROSC) was achieved, 22% of the study population survived to hospital discharge. Moderate or greater frailty was present in 31.3% of patients. Return of spontaneous circulation (ROSC) was achieved in 56.1% of patients with a CFS score of 1-5 and 32.1% with scores 6-9 (p < 0.001). Survival to hospital discharge was also associated with frailty, being seen in 31.7% of CFS 1-5 patients but only in 1.8% of CFS 6-9 patients (p < 0.001). In multivariable analysis adjusting for age, presenting rhythm and admitting specialty the effect of frailty on survival to discharge remained significant (p = 0.044).

Conclusion : Patients with moderate or greater frailty as determined by CFS score are unlikely to survive to hospital discharge even if ROSC occurs following CPR. This should be considered when making resuscitation status and ceiling of care decisions in this patient group.

Conclusion (proposition de traduction) : Les patients présentant une fragilité modérée ou plus importante, telle que déterminée par le score de l'échelle de fragilité clinique, ont peu de chances de survivre jusqu'à la sortie de l'hôpital, même si une récupération d'activité cardiaque spontanée (RACS) est obtenue après la RCP. Il faut en tenir compte au moment de prendre des décisions concernant le statut réanimatoire et les objectifs de soins dans ce groupe de patients.

The Journal of Emergency Medicine

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center.
Barnes BC, Kamat PP, McCracken CM, Santore MT, Mallory MD, Simon HK, Sulton CD. | J Emerg Med. 2019 Oct;57(4):429-436
Keywords: analgesics; cervical spine immobilization; pediatric trauma; radiologic imaging; sedatives

Original Contributions

Introduction : Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS.
OBJECTIVE : To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization.

Méthode : Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded.

Résultats : A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed.

Conclusion : Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

Conclusion (proposition de traduction) : Seulement 50 % des patientes dont la colonne cervicale était immobilisée et non intubée avaient besoin d'un seul sédatif ou analgésique pour leur imagerie radiologique. Le succès de la procédure a été élevé, avec peu d'effets indésirables.

Analgesic Effect of Nitrous Oxide/Oxygen Mixture for Traumatic Pain in the Emergency Department: A Randomized, Double-Blind Study.
Gao LL, Yu JQ, Liu Q, Gao HX, Dai YL, Zhang JJ, Wang YL, Zhang TT, Yang JJ, Li YX. | J Emerg Med. 2019 Oct;57(4):444-452
Keywords: acute pain; analgesia; nitrous oxide; trauma

Original Contributions

Introduction : Acute pain is the most common complaint in Emergency Department (ED) admissions, and options for analgesia are limited. Nitrous oxide/oxygen possesses many properties showing it may be an ideal analgesic in the ED. OBJECTIVES: The aim of this study is to evaluate the safety and analgesic effect of the fixed nitrous oxide/oxygen mixture for trauma patients in the ED.

Méthode : We enrolled 60 patients in this double-blind, randomized study. The treatment group received conventional pain treatment plus a mixture of 65% nitrous oxide/oxygen. The control group received the conventional pain treatment plus oxygen. Primary outcome was the reduction in pain intensity at 5 and 15 min after the start of intervention. Secondary outcomes include adverse events, physiological parameters, and satisfaction from both patients and health care professionals.

Résultats : Initial pain scores for the nitrous oxide/oxygen group (6.0 [5.0-8.0]) and the oxygen group (6.75 [5.0-9.0]) were comparable (p = 0.57). The mean numerical rating scale scores at 5 min were 3.4 ± 1.8 and 7.0 ± 1.8 for nitrous oxide/oxygen and oxygen, respectively (p < 0.01). The mean pain intensity at 15 min in the treatment group was 3.0 ± 1.9, compared with 6.3 ± 2.2 in the control group (p < 0.01). Both patients' (8.0 [7.0-9.0] vs. 4.0 [2.0-6.0], p < 0.01) and physicians' (8.5 [8.0-9.0] vs. 4.0 [3.0-6.0], p < 0.01) satisfaction scores in the treatment group were significantly higher than the oxygen group. No serious adverse events were observed.

Conclusion : This study gives supporting evidence for the safety and effectiveness of using self-administered nitrous oxide/oxygen mixture in the ED for moderate-to-severe traumatic pain.

Conclusion (proposition de traduction) : Cette étude fournit des preuves à l'appui de l'innocuité et de l'efficacité du mélange équimoléculaire oxygène/protoxyde d’azote auto-administré aux urgences en cas de douleur traumatique modérée à sévère.

Clinical Scores and Formal Triage for Screening of Sepsis and Adverse Outcomes on Arrival in an Emergency Department All-Comer Cohort.
Nieves Ortega R, Rosin C, Bingisser R, Nickel CH. | J Emerg Med. 2019 Oct;57(4):453-460.e2
Keywords: ESI; NEWS; SIRS; SOFA; qSOFA; screening; sepsis; triage

Original Contributions

Introduction : Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown.
OBJECTIVES : Our aim was to compare the performance of qSOFA, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), and formal triage with the Emergency Severity Index (ESI) algorithm to identify patients with sepsis and predict adverse outcomes on arrival in an emergency department (ED) all-comer cohort.

Méthode : We included all patients presenting consecutively to the ED during a 3-week period. We used vital signs recorded at triage to calculate the study scores. Two independent assessors retrospectively assigned the primary outcome of sepsis according to Third International Consensus Definitions for Sepsis and Septic Shock criteria in a chart review process.

Résultats : There were 2523 cases included in the analysis and 39 (1.6%) had the primary outcome of sepsis. The area under the curve for sepsis was 0.79 (95% confidence interval [CI] 0.71-0.86) for qSOFA, 0.81 (95% CI 0.73-0.87) for SIRS, 0.85 (95% CI 0.77-0.92) for NEWS, and 0.77 (95% CI 0.70-0.83) for ESI.

Conclusion : qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.

Conclusion (proposition de traduction) : Le qSOFA offrait une spécificité élevée pour la prédiction du sepsis et des effets indésirables. Cependant, sa faible sensibilité ne permet pas une utilisation généralisée comme outil de dépistage du sepsis. Le score NEWS a surpassé le qSOFA en matière de prévision des effets indésirables et de dépistage du sepsis.

Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection.
Anderson J, Furnival RA, Zhang L, Lunos SA, Sadiq Z, Strutt JR, Kaila R, Hendrickson MA. | J Emerg Med. 2019 Oct;57(4):461-468
Keywords: constipation; efficacy; enema; pink lady

Original Contributions

Introduction : Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection.
OBJECTIVE : Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate.

Méthode : We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus.

Résultats : There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain.

Conclusion : There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

Conclusion (proposition de traduction) : Il n'y avait pas de différence significative dans la production de selles rapportée produite par le phosphate de sodium, la mousse de savon et les lavements Pink lady chez les enfants traités dans un service d'urgence. Des études complémentaires via des essais contrôlés randomisés seraient utiles pour guider la sélection de la solution de lavement.

Can Systemic Thrombolysis Improve Prognosis of Cardiac Arrest Patients During Cardiopulmonary Resuscitation? A Systematic Review and Meta-Analysis.
Wang Y, Wang M, Ni Y, Liang B, Liang Z. | J Emerg Med. 2019 Oct;57(4):478-487
Keywords: acute myocardial infarction; cardiac arrest; cardiopulmonary resuscitation; pulmonary embolism; thrombolysis

Clinical Reviews in Emergency Medicine

Introduction : Cardiac arrests are caused in most cases by thromboembolic diseases, such as acute myocardial infarction (AMI) and pulmonary embolism (PE).
OBJECTIVE : We aimed to ascertain the associations of thrombolytic therapy with potential benefits among cardiac arrest patients during cardiopulmonary resuscitation (CPR).

Méthode : We searched PubMed, Embase, and Cochrane databases for studies that evaluated systemic thrombolysis in cardiac arrest patients. The primary outcome was survival to hospital discharge, and secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival rate, hospital admission rate, and bleeding complications.

Résultats : Nine studies with a total of 4384 cardiac arrest patients were pooled in the meta-analysis, including 1084 patients receiving systemic thrombolysis and 3300 patients receiving traditional treatments. Compared with conventional therapies, the use of systemic thrombolysis did not significantly improve survival to hospital discharge (13.5% vs. 10.8%; risk ratio [RR] 1.13; 95% confidence interval [CI] 0.92-1.39; p = 0.24, I2 = 35%), ROSC (50.9% vs. 44.3%; RR 1.29; 95% CI 1.00-1.66; p = 0.05, I2 = 73%), and 24-h survival (28.1% vs. 25.6%; RR 1.25; 95% CI 0.88-1.77; p = 0.22, I2 = 63%). We observed higher hospital admission rates for patients receiving systemic thrombolysis (43.4% vs. 30.6%; RR 1.53; 95% CI 1.04-2.24; p = 0.03, I2 = 87%). In addition, higher risk of bleeding was observed in the thrombolysis group (8.8% vs. 5.0%; RR 1.65; 95% CI 1.16-2.35; p = 0.005, I2 = 7%).

Conclusion : Systemic thrombolysis during CPR did not improve hospital discharge rate, ROSC, and 24-h survival for cardiac arrest patients. Patients receiving thrombolytic therapy have a higher risk of bleeding. More high-quality studies are needed to confirm our results.

Conclusion (proposition de traduction) : La thrombolyse systémique au cours de la RCP n'a pas amélioré le taux de sortie de l'hôpital, la RACS et la survie à 24 h pour les patients en arrêt cardiaque. Les patients recevant un traitement thrombolytique ont un risque plus élevé de saignement. Plus d'études de haute qualité sont nécessaires pour confirmer nos résultats.

Mandated 30-minute Scene Time Interval Correlates With Improved Return of Spontaneous Circulation at Emergency Department Arrival: A Before and After Study.
Eastin C, Karim S, Hawthorn C, Webb MH4, Waheed MA, Buford A, Hutchison M, Mason C, Sexton K. | J Emerg Med. 2019 Oct;57(4):527-534
Keywords: out-of-hospital cardiac arrest; return of spontaneous circulation; scene time interval

Selected Topics: Prehospital Care

Introduction : Conflicting ideas exist about whether or not Emergency Medical Service (EMS) personnel should treat a cardiac arrest on scene or transport immediately. OBJECTIVE: Our aim was to examine patient outcomes before and after an urban EMS system implemented a protocol change mandating a 30-min scene time interval (STI) for out-of-hospital cardiac arrest (OHCA).

Méthode : This was a retrospective, single-center, observational study of OHCA patients before and after an EMS protocol change mandating resuscitation on scene. Data were retrieved from an EMS cardiac arrest database for all adults with non-traumatic OHCA between January 2015 and August 2016. Descriptive statistics were used to summarize the study population, and a regression model was used to determine the associations of the protocol with the return of spontaneous circulation (ROSC).

Résultats : A total of 633 patients were included in the study population, which was primarily male (61.3%) with a mean age of 65 years. After the 30-min STI was implemented, ROSC from OHCA increased to 40.1% of cases compared to 27.3% before the protocol change (p = 0.001; 95% confidence interval [CI] 0.053-0.203). The STI increased from 19 min 23 s to 29 min 40 s in the pre and post periods, respectively (p < 0.001). Regression indicated that the protocol change was independently associated with an improved chance of ROSC (OR 1.81; 95% CI 1.23-2.64).

Conclusion : A protocol change mandating a 30-min STI in OHCA correlated with increased STI and increased ROSC. While increased ROSC may not always equate with positive neurologic outcome, logistic regression indicated that the protocol change was independently associated with improved ROSC at emergency department arrival.

Conclusion (proposition de traduction) : Un changement de protocole prescrivant un intervalle de 30 minutes entre les lieux de l'arrêt cardiaque à l'extérieur de l'hôpital est corrélé à un intervalle de temps plus long entre les lieux de l'accident et à une récupération d'activité cardiaque spontanée (RACS). Bien qu'une récupération d'activité cardiaque spontanée (RACS) ne soit pas toujours synonyme d'un résultat neurologique positif, la régression logistique a indiqué que le changement de protocole était indépendamment associé à une meilleur récupération d'activité cardiaque spontanée (RACS) à l'arrivée au service des urgences.

The Lancet

Identifying optimal doses of heart failure medications in men compared with women: a prospective, observational, cohort study.
Santema BT, Ouwerkerk W, Tromp J, Sama IE, Ravera A, Regitz-Zagrosek V, Hillege H, Samani NJ, Zannad F, Dickstein K, Lang CC, Cleland JG, Ter Maaten JM, Metra M, Anker SD, van der Harst P, Ng LL, van der Meer P, van Veldhuisen DJ, Meyer S, Lam CSP; ASIAN-HF investigators, Voors AA. | Lancet. 2019 Oct 5;394(10205):1254-1263
Keywords: Aucun


Introduction : Guideline-recommended doses of angiotensin-converting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), and β blockers are similar for men and women with heart failure with reduced ejection fraction (HFrEF), even though there are known sex differences in pharmacokinetics of these drugs. We hypothesised that there might be sex differences in the optimal dose of ACE inhibitors or ARBs and β blockers in patients with HFrEF.

Méthode : We did a post-hoc analysis of BIOSTAT-CHF, a prospective study in 11 European countries of patients with heart failure in whom initiation and up-titration of ACE inhibitors or ARBs and β blockers was encouraged by protocol. We included only patients with left ventricular ejection fraction less than 40%, and excluded those who died within the first 3 months. Primary outcome was a composite of time to all-cause mortality or hospitalisation for heart failure. Findings were validated in ASIAN-HF, an independent cohort of 3539 men and 961 women with HFrEF.

Résultats : Among 1308 men and 402 women with HFrEF from BIOSTAT-CHF, women were older (74 [12] years vs 70 [12] years, p<0·0001) and had lower bodyweights (72 [16] kg vs 85 [18] kg, p<0·0001) and heights (162 [7] cm vs 174 [8] cm, p<0·0001) than did men, although body-mass index did not differ significantly. A similar number of men and women reached guideline-recommended target doses of ACE inhibitors or ARBs (99 [25%] vs 304 [23%], p=0·61) and β blockers (57 [14%] vs 168 [13%], p=0·54). In men, the lowest hazards of death or hospitalisation for heart failure occurred at 100% of the recommended dose of ACE inhibitors or ARBs and β blockers, but women showed approximately 30% lower risk at only 50% of the recommended doses, with no further decrease in risk at higher dose levels. These sex differences were still present after adjusting for clinical covariates, including age and body surface area. In the ASIAN-HF registry, similar patterns were observed for both ACE inhibitors or ARBs and β blockers, with women having approximately 30% lower risk at 50% of the recommended doses, with no further benefit at higher dose levels.

Conclusion : This study suggests that women with HFrEF might need lower doses of ACE inhibitors or ARBs and β blockers than men, and brings into question what the true optimal medical therapy is for women versus men.

Conclusion (proposition de traduction) : Cette étude suggère que les femmes atteintes d'insuffisance cardiaque avec une fraction d'éjection altérée pourraient avoir besoin de doses plus faibles d'inhibiteurs de l'enzyme de conversion de l'angiotensine ou d'inhibiteurs des récepteurs de l'angiotensine et de β bloqueurs que les hommes, ce qui remet en question la véritable thérapie médicale optimale pour les femmes comparativement aux hommes.

Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial.
The CRASH-3 trial collaborators | Lancet. 2019 October 14
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : L’acide tranexamique réduit les saignements chirurgicaux et diminue la mortalité chez les patients présentant des saignements extra-crâniens traumatiques. Les saignements intracrâniens sont fréquents après un traumatisme cranio-cérébral (TCC) et peuvent entraîner une hernie cérébrale et la mort. Nous avons évalué les effets de l’acide tranexamique chez les patients ayant subi un TCC.

Méthode : Cet essai randomisé a été réalisé dans 175 hôpitaux dans 29 pays. Le premier patient a été sélectionné en juillet 2012 et le dernier en janvier 2019. Les patients admissibles étaient des adultes atteints d’un TCC dans les trois heures suivant la lésion et qui présentaient un score ≤ 12 sur l’échelle de coma Glasgow (GCS) ou tout saignement intracrânien à la TDM et aucun saignement extra-crânien significatif. Au départ, la période d’admissibilité était de 8 heures, mais en 2016, le protocole a été modifié pour limiter ce délai à 3 heures après une blessure. Ce changement ne permettait pas de connaitre les données de l’essai, en raison de preuves externes selon lesquelles il est peu probable qu’un traitement différé soit efficace. Nous avons randomisé les patients pour qu’ils reçoivent de l’acide tranexamique (dose de charge de 1 g sur 10 min puis perfusion de 1 g sur 8 h) ou un placebo correspondant. Les patients ont reçu un kit de traitement numéroté provenant d’une boîte contenant huit kits identiques, dont seul le numéro était différent. L’essai s’est déroulé en triple aveugle (patients, soignants et chercheurs). Le principal résultat a été le décès suite à un traumatisme crânien à l’hôpital dans les 28 jours suivant la lésion chez les patients traités dans les trois heures suivant la blessure. Parmi les résultats secondaires, mentionnons les décès par traumatisme crânien précoce, les décès pour toute cause et la mortalité par cause, l’invalidité, les événements vasculaires occlusifs, les crises, les complications et les événements indésirables. Nous avons préspécifié une analyse de sensibilité qui excluait les patients ayant un score GCS de 3 et ceux dont les pupilles bilatérales n’étaient pas réactives au départ. Toutes les analyses ont été faites dans l’intention de traiter le patient.

Résultats : Entre juillet 2012 et janvier 2019, nous avons randomisé 12 737 patients atteints de TCC chez qui nous avons administré de l’acide tranexamique ou un placebo, dont 9 202 patients ont été traités dans les 3 heures suivant la lésion. Parmi les patients traités tôt, le risque de décès par traumatisme crânien était de 18,5 % dans le groupe traité avec de l’acide tranexamique contre 19,8 % dans le groupe placebo (855 contre 892 événements, risque relatif = 0,94, IC 95 % 0,86-1,02). Dans l’analyse de sensibilité préspécifiée qui excluait les patients ayant un score GCS de 3 ou des pupilles non réactives bilatérales au départ, les résultats étaient de 12,5 % dans le groupe sous acide tranexamique et de 14,0 % dans le groupe placebo (485 contre 525 événements, risque relatif = 0,89, IC 95 % 0,80-1,00). On a observé une réduction du risque de décès par traumatisme crânien lié à l’acide tranexamique dans les traumatismes crâniens légers à modérés (RR = 0,78 95 % CI 0,64-0,95), mais dans les traumatismes crâniens graves (RR = 0,99, 95 % CI 0,91-1,07), il n’y avait aucune preuve claire de réduction (valeur p pour hétérogénéité 0,030). Le traitement précoce était plus efficace pour les traumatismes crâniens légers et modérés (p = 0,005), mais il n’y avait pas d’impact évident du temps de traitement pour les traumatismes crâniens graves (p = 0,73). Le risque d’invalidité, d’événements vasculaires occlusifs et de crises convulsives était semblable dans les deux groupes. Il n’y a pas eu d’effet bénéfique ou nuisible apparent parmi les personnes randomisées 3 heures après la lésion.

Conclusion : Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.

Conclusion (proposition de traduction) : Cet essai montre que l’acide tranexamique est sans danger pour les patients ayant subi un traumatisme crânien et que le traitement dans les trois heures suivant la blessure réduit le nombre de décès par traumatisme crânien. Les patients doivent être traités dès que possible après une lésion.

Commentaire : Voir l'article :
Roberts I, Belli A, Brenner A, Chaudhri R, Fawole B, Harris T, Jooma R, Mahmood A, Shokunbi T, Shakur H; CRASH-3 trial collaborators. Tranexamic acid for significant traumatic brain injury (The CRASH-3 trial): Statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Version 2. Wellcome Open Res. 2018 Sep 26 [revised 2018 Jan 1];3:86  .

The New England Journal of Medicine

Conservative Oxygen Therapy during Mechanical Ventilation in the ICU.
ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Mackle D, Bellomo R, Bailey M, Beasley R, Deane A, Eastwood G, Finfer S, Freebairn R, King V, Linke N, Litton E, McArthur C, McGuinness S, Panwar R, Young P. | N Engl J Med. 2019 Oct 14
Keywords: Aucun

Original article

Introduction : Patients who are undergoing mechanical ventilation in the intensive care unit (ICU) often receive a high fraction of inspired oxygen (Fio2) and have a high arterial oxygen tension. The conservative use of oxygen may reduce oxygen exposure, diminish lung and systemic oxidative injury, and thereby increase the number of ventilator-free days (days alive and free from mechanical ventilation).

Méthode : We randomly assigned 1000 adult patients who were anticipated to require mechanical ventilation beyond the day after recruitment in the ICU to receive conservative or usual oxygen therapy. In the two groups, the default lower limit for oxygen saturation as measured by pulse oximetry (Spo2) was 90%. In the conservative-oxygen group, the upper limit of the Spo2 alarm was set to sound when the level reached 97%, and the Fio2 was decreased to 0.21 if the Spo2 was above the acceptable lower limit. In the usual-oxygen group, there were no specific measures limiting the Fio2 or the Spo2. The primary outcome was the number of ventilator-free days from randomization until day 28.

Résultats : The number of ventilator-free days did not differ significantly between the conservative-oxygen group and the usual-oxygen group, with a median duration of 21.3 days (interquartile range, 0 to 26.3) and 22.1 days (interquartile range, 0 to 26.2), respectively, for an absolute difference of -0.3 days (95% confidence interval [CI], -2.1 to 1.6; P = 0.80). The conservative-oxygen group spent more time in the ICU with an Fio2 of 0.21 than the usual-oxygen group, with a median duration of 29 hours (interquartile range, 5 to 78) and 1 hour (interquartile range, 0 to 17), respectively (absolute difference, 28 hours; 95% CI, 22 to 34); the conservative-oxygen group spent less time with an Spo2 exceeding 96%, with a duration of 27 hours (interquartile range, 11 to 63.5) and 49 hours (interquartile range, 22 to 112), respectively (absolute difference, 22 hours; 95% CI, 14 to 30). At 180 days, mortality was 35.7% in the conservative-oxygen group and 34.5% in the usual-oxygen group, for an unadjusted odds ratio of 1.05 (95% CI, 0.81 to 1.37).

Conclusion : In adults undergoing mechanical ventilation in the ICU, the use of conservative oxygen therapy, as compared with usual oxygen therapy, did not significantly affect the number of ventilator-free days.

Conclusion (proposition de traduction) : Chez l'adulte bénéficiant d'une ventilation mécanique en USI, le recours à une oxygénation conservative, par rapport à une oxygénothérapie habituelle, n'a pas eu d'incidence significative sur le nombre de jours sans respirateur.

Commentaire : Voir, sur le sujet, les articles :
• Panwar R, Hardie M, Bellomo R and al. Conservative versus Liberal Oxygenation Targets for Mechanically Ventilated Patients. A Pilot Multicenter Randomized Controlled Trial. Am J Respir Crit Care Med. 2016 Jan 1;193(1):43-51   - L’objectif principal de cette étude pilote était d’évaluer la faisabilité et la sécurité d’une stratégie de délivrance de l’oxygène dite conservative – ciblant une SpO2 entre 88 et 92 % – en comparaison à une stratégie dite libérale – ciblant une SpO2 ≥ 96 %.
Et l'analyse de l'article sur le site de la SRLF : Vers moins d’oxygène pour mieux respirer ?  . Rédigé par le Dr Guillaume Carteaux, le 18/08/2016.
• Girardis M, Busani S, Damiani E and al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589  .
• Aggarwal NR, Brower RG, Hager DN and al. Oxygen Exposure Resulting in Arterial Oxygen Tensions Above the Protocol Goal Was Associated With Worse Clinical Outcomes in Acute Respiratory Distress Syndrome. Crit Care Med. 2018 Apr;46(4):517-524   (chez des patients en SDRA).
Et l'analyse de l'article sur le site de la SRLF : L’oxygène dans le SDRA : avec modération ?  . Rédigé par le Dr Hadrien Winiszewski et le Pr Gilles Capellier, le 01/08/2019.
• Chu DK, Kim LH, Young PJ and al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705  .

Rivaroxaban in Patients with Heart Failure, Sinus Rhythm, and Coronary Disease.
Zannad F, Anker SD, Byra WM, Cleland JGF, Fu M, Gheorghiade M, Lam CSP, Mehra MR, Neaton JD, Nessel CC, Spiro TE, van Veldhuisen DJ, Greenberg B; COMMANDER HF Investigators. | N Engl J Med. 2018 Oct 4;379(14):1332-1342
Keywords: Aucun

Original articles

Introduction : Heart failure is associated with activation of thrombin-related pathways, which predicts a poor prognosis. We hypothesized that treatment with rivaroxaban, a factor Xa inhibitor, could reduce thrombin generation and improve outcomes for patients with worsening chronic heart failure and underlying coronary artery disease.

Méthode : In this double-blind, randomized trial, 5022 patients who had chronic heart failure, a left ventricular ejection fraction of 40% or less, coronary artery disease, and elevated plasma concentrations of natriuretic peptides and who did not have atrial fibrillation were randomly assigned to receive rivaroxaban at a dose of 2.5 mg twice daily or placebo in addition to standard care after treatment for an episode of worsening heart failure. The primary efficacy outcome was the composite of death from any cause, myocardial infarction, or stroke. The principal safety outcome was fatal bleeding or bleeding into a critical space with a potential for causing permanent disability.

Résultats : Over a median follow-up period of 21.1 months, the primary end point occurred in 626 (25.0%) of 2507 patients assigned to rivaroxaban and in 658 (26.2%) of 2515 patients assigned to placebo (hazard ratio, 0.94; 95% confidence interval [CI], 0.84 to 1.05; P=0.27). No significant difference in all-cause mortality was noted between the rivaroxaban group and the placebo group (21.8% and 22.1%, respectively; hazard ratio, 0.98; 95% CI, 0.87 to 1.10). The principal safety outcome occurred in 18 patients who took rivaroxaban and in 23 who took placebo (hazard ratio, 0.80; 95% CI, 0.43 to 1.49; P=0.48).

Conclusion : Rivaroxaban at a dose of 2.5 mg twice daily was not associated with a significantly lower rate of death, myocardial infarction, or stroke than placebo among patients with worsening chronic heart failure, reduced left ventricular ejection fraction, coronary artery disease, and no atrial fibrillation.

Conclusion (proposition de traduction) : Le rivaroxaban à la dose de 2,5 mg deux fois par jour n'a pas été associé à un taux significativement plus faible de décès, d'infarctus du myocarde ou d'accident vasculaire cérébral que le placebo chez les patients atteints d'insuffisance cardiaque chronique qui s'aggravent, de fraction d'éjection ventriculaire gauche réduite, de maladie coronarienne et sans fibrillation auriculaire.

Mois d'octobre 2019