Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs.
Daley JI, Dwyer KH, Grunwald Z, Shaw DL, Stone MB, Schick A, Vrablik M, Kennedy Hall M, Hall J, Liteplo AS, Haney RM, Hun N, Liu R, Moore CL. | Acad Emerg Med. 2019 Nov;26(11):1211-1220
DOI: https://doi.org/10.1111/acem.13774
Keywords: Aucun

EDITOR'S PICK

Introduction : Focused cardiac ultrasound (FOCUS) is insensitive for pulmonary embolism (PE). Theoretically, when a clot is large enough to cause vital sign abnormalities, it is more likely to show signs of right ventricular dysfunction on FOCUS, although this has not been well quantified. A rapid bedside test that could quickly and reliably exclude PE in patients with abnormal vital signs could be of high utility in emergency department (ED) patients. We hypothesized that in patients with tachycardia or hypotension, the sensitivity of FOCUS for PE would increase substantially.

Méthode : We performed a prospective observational multicenter cohort study involving a convenience sample of patients from six urban academic EDs. Patients suspected to have PE with tachycardia (heart rate [HR] ≥ 100 beats/min) or hypotension (systolic blood pressure [sBP] < 90 mm Hg) underwent FOCUS before computed tomography angiography (CTA). FOCUS included assessment for right ventricular dilation, McConnell's sign, septal flattening, tricuspid regurgitation, and tricuspid annular plane systolic excursion. If any of these were abnormal, FOCUS was considered positive, while if all were normal, FOCUS was considered negative. We a priori planned a subgroup analysis of all patients with a HR ≥ 110 beats/min (regardless of their sBP). We then determined the diagnostic test characteristics of FOCUS for PE in the entire patient population and in the predefined subgroup, based on CTA as the criterion standard. Inter-rater reliability of FOCUS was determined by blinded review of images by an emergency physician with fellowship training in ultrasound.

Résultats : A total of 143 subjects were assessed for enrollment and 136 were enrolled; four were excluded because they were non-English-speaking and three because of inability to obtain any FOCUS windows. The mean (±SD) age of enrolled subjects was 56 (±7) years, mean (±SD) HR was 114 (±12) beats/min, and 37 (27.2%) subjects were diagnosed with PE on CTA. In all subjects, FOCUS was 92% (95% confidence interval [CI] = 78% to 98%) sensitive and 64% specific (95% CI = 53% to 73%) for PE. In the subgroup of 98 subjects with a HR ≥ 110 beats/min, FOCUS was 100% sensitive (95% CI = 88% to 100%) and 63% specific (95% CI = 51% to 74%) for PE. There was substantial interobserver agreement for FOCUS (κ = 1.0, 95% CI = 0.31 to 1.0).

Conclusion : A negative FOCUS examination may significantly lower the likelihood of the diagnosis of PE in most patients who are suspected of PE and have abnormal vital signs. This was especially true in those patients with a HR ≥ 110 beats/min. Our results suggest that FOCUS can be an important tool in the initial evaluation of ED patients with suspected PE and abnormal vital signs.

Conclusion (proposition de traduction) : Une échographie cardiaque ciblée négative peut réduire de façon significative la probabilité de diagnostic d'embolie pulmonaire chez la plupart des patients pour lesquels le diagnostic est suspecté et qui ont des signes vitaux anormaux. Ceci était particulièrement vrai chez les patients ayant une fréquence cardiaque ≥ 110 battements/min. Nos résultats suggèrent que l'échographie cardiaque ciblée peut être un outil important dans l'évaluation initiale des patients aux urgences pour lesquels le diagnostic d'embolie pulmonaire est suspecté et qui présentent des signes vitaux anormaux.

Commentaire : Echographie cardiaque ciblée (Focused cardiac ultrasound - FOCUS) :
L'échographie cardiaque focalisée est un examen ciblé du système cardiovasculaire effectué par un médecin en utilisant l'échographie comme complément à l'examen clinique pour reconnaître des signes échographiques spécifiques dans une liste limitée de diagnostics potentiels dans des contextes cliniques spécifiques.
in: Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2013;26:567-81  
Pour mémoire : Dans des conditions de dépistage, on choisira de préférence un test très sensible (ici 100 %), puisque l'objectif est la détection du plus grand nombre possible de sujets porteurs de la maladie. En revanche, on exigera du test de confirmation effectué chez les sujets dont le test de dépistage s'est révélé positif une spécificité très élevée (ici 62 %, ce qui n'est pas le cas), afin de minimiser le risque de faux positifs.
in: Nendaz MR, Perrier A. Sensibilité, spécificité, valeur prédictive positive et valeur prédictive négative d’un test diagnostique. Revue des Maladies Respiratoires. 2004 apr;21(2):390-393  .

Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review.
Gurley KL, Edlow JA. | Acad Emerg Med. 2019 Nov;26(11):1273-1284
DOI: https://doi.org/10.1111/acem.13830
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META‐ANALYSES)

Editorial : Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevent

Conclusion : Patients with posterior circulation cerebrovascular events are often misdiagnosed. Strategies that may decrease misdiagnosis include:
• With any neurologic symptoms, always establish if the onset is abrupt or not because abrupt onset suggests ischemia.
• Be aware of the nonspecific symptoms of posterior circulation ischemia and that variant vascular anatomy can cause nonclassic findings.
• For dizzy patients with an AVS, use a timing and triggers diagnostic approach taking a history as one would with any other chief complaint instead of focusing the history on the response to the question, “What do you mean by dizzy?”
• Perform a brief posterior circulation physical examination that targets the brain stem, cerebellum, and occipital lobes.
• Be aware of the limitations of brain imaging and adopt a nuanced approach that recognizes that initial brain imaging is frequently nondiagnostic.

Conclusion (proposition de traduction) : Les patients se présentant avec un AVC de la circulation postérieure sont souvent mal diagnostiqués. Les stratégies qui peuvent réduire les erreurs diagnostic comprennent :
• Pour tout symptôme neurologique, toujours rechercher si l'apparition est brutale ou non, car une apparition brutale suggère une ischémie.
• Etre conscient des symptômes non spécifiques de l'ischémie de la circulation postérieure, du fait de l'anatomie vasculaire variée qui peut donner des signes cliniques non classiques.
• Pour les patients qui présente un étourdissement avec un syndrome vestibulaire aigu, utilisez une approche diagnostique qui se base sur l'historique et les facteurs déclenchants comme on le ferait avec n'importe quelle autre plainte principale au lieu de se concentrer sur la réponse à la question : « Qu'entendez-vous par étourdissement  ? »
• Effectuez un bref examen clinique de la circulation postérieure qui cible le tronc cérébral, le cervelet et les lobes occipitaux.
• Etre conscient des limites de l'imagerie cérébrale et adoptez une approche nuancée qui reconnaît que l'imagerie cérébrale initiale est souvent non diagnostique.

Commentaire :  
• La revue narrative est une revue de littérature de base, souvent appelée d’ailleurs simplement « revue de littérature ». Elle cherche à identifier les connaissances « portant sur un sujet précis, recueillies à partir de la littérature pertinente sans processus méthodologique systématique, explicite, d’obtention et d’analyse qualitative des articles ». Ce type de recherche se développe suivant un processus itératif.
• Rmq : L’atteinte de la circulation antérieure provoquera le plus souvent un syndrome unilatéral alors qu’une atteinte de la circulation postérieure pourra provoquer un syndrome unilatéral ou bilatéral.
• Étourdissement : La personne peut soudainement perdre l’équilibre ou avoir des difficultés de coordination, surtout en présence d’un ensemble des signes d’un AVC ischémique comme : faiblesse ou une paralysie soudaine d’un côté du corps, ou une sensation d’engourdissement ou de picotement au visage, à un bras, à une jambe ou dans tout un hémicorps, problèmes d’élocution qui sera temporaire ou permanente, problèmes de vision pour la vision d'un œil, perte de champ visuel ou voir double et/ou mal de tête soudain, grave et inhabituel, qui peut s’accompagner de confusion.

Tranexamic Acid for the Treatment of Epistaxis.
Gottlieb M, Koyfman A, Long B. | Acad Emerg Med. 2019 Nov;26(11):1292-1293
DOI: https://doi.org/10.1111/acem.13760
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Epistaxis is a common reason for patients to present to the emergency department (ED), reflecting one of every 200 ED visits in the United States. While many cases of epistaxis are self-limiting, those requiring medical treatment can be associated with significant time and health care costs. Additionally, nasal packing and hemostatic matrices can be painful and require the patient to return for at least one follow-up visit. Therefore, identifying an effective and inexpensive treatment is of particular importance. Tranexamic acid is an antifibrinolytic agent that has been proposed as one potential modality for this.

Conclusion : The existing evidence supports the efficacy of TXA to reduce the risk of rebleeding at 10 days among adult patients. Despite inconsistent reporting of adverse events, the occurrence of such events appears to be unlikely, particularly with topical use. Therefore, we have assigned a color recommendation of green (benefit > harm) to the use of TXA for epistaxis.

Conclusion (proposition de traduction) : Les données de la littérature existantes confirment l'efficacité de l'acide tranexamique pour réduire le risque de récidive de saignement à 10 jours chez les patients adultes. Malgré le manque d'uniformité dans la déclaration des événements indésirables, la survenue de tels événements semble peu probable, particulièrement en ce qui concerne l'utilisation topique. Par conséquent, nous avons attribué une recommandation de couleur verte (avantages > inconvénients) à l'utilisation de l'acide tranexamique dans l'épistaxis.

Factors Predicting Difficult Endotracheal Intubation.
Long B, Koyfman A, Gottlieb M. | Acad Emerg Med. 2019 Nov;26(11):1294-1296
DOI: https://doi.org/10.1111/acem.13824
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Conclusion : In summary, the existing evidence indicates that several findings predict a difficult endotracheal intubation, but their absence cannot reliably exclude this scenario. The most accurate assessment was the upper lip bite test, followed by shorter hyomental distance, retrognathia, impaired neck mobility, modified Mallampati score > 3, and the Wilson score. Future studies should incorporate new airway technology such as video laryngoscopy and include emergency situations.

Conclusion (proposition de traduction) : En résumé, les preuves existantes indiquent que plusieurs résultats prédisent une intubation endotrachéale difficile, mais leur absence ne peut exclure de façon fiable ce scénario.
L'évaluation la plus précise était le test de morsure de la lèvre supérieure, suivi par la distance hyomentale plus courte, la rétrognathie, la mobilité réduite du cou, le score de Mallampati modifié > 3, et le score de Wilson.
Les études futures devraient intégrer les nouvelles technologies des voies respiratoires, comme la vidéolaryngoscopie, et inclure les situations d'urgence.

Commentaire : 
Score de Mallampati modifié : classe 1 : la luette et les loges amygdaliennes sont visibles ; classe 2 : la luette est partiellement visible ; classe 3 : le palais membraneux est visible ; classe 4 : seul le palais osseux est visible.

La valeur seuil de 2 (> 2) prédit une laryngoscopie difficile avec le score de Wilson (étendu du score de 0 à 10).

Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, Pinto R, Simel DL, Wijeysundera DN, Scales DC2. Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA. 2019 Feb 5;321(5):493-503  .

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).
Mercadante S, Voza A, Serra S, Ruggiano G, Carpinteri G, Gangitano G, Intelligente F, Bonafede E, Sblendido A, Farina A, Soldi A, Fabbri A; MEDITA Study Group. | Adv Ther. 2019 Nov;36(11):3030-3046
DOI: https://doi.org/10.1007/s12325-019-01055-9  | Télécharger l'article au format  
Keywords: Acute pain; Analgesic; Emergency department; Methoxyflurane; Morphine; Non-steroidal anti-inflammatory drug; Paracetamol; Penthrox; Prehospital; Trauma

Original Research

Introduction : Inhaled low-dose methoxyflurane is approved in Europe for emergency relief of moderate-to-severe trauma-related pain in adults, but data versus active comparators are sparse. The phase IIIb Methoxyflurane in Emergency Department in ITAly (MEDITA) trial investigated the analgesic efficacy, practicality and safety of methoxyflurane versus standard analgesic treatment (SAT) for acute trauma pain.

Méthode : This was a randomised, active-controlled, parallel-group, open-label trial conducted in 15 Italian emergency units. Adults with limb trauma and pain score ≥ 4 on numerical rating scale (NRS) were randomised 1:1 to inhaled methoxyflurane 3 mL or SAT [intravenously administered (IV) morphine 0.1 mg/kg for severe pain (NRS ≥ 7); IV paracetamol 1 g or IV ketoprofen 100 mg for moderate pain (NRS 4-6)]. The primary endpoint was overall change in visual analogue scale (VAS) pain intensity from baseline (time of randomisation) to 3, 5 and 10 min. Non-inferiority and superiority of methoxyflurane versus SAT were concluded if the upper 95% confidence interval (CI) for the treatment comparison (methoxyflurane-SAT) was less than 1 and less than 0, respectively.

Résultats : Between 8 February 2018 and 8 February 2019, 272 patients were randomised (136 per treatment group). A total of 270 patients (mean age 51 years; 49% male; 34% with severe pain; mean baseline VAS 67 mm) were treated and analysed for efficacy and safety. Superiority of methoxyflurane was demonstrated for moderate-to-severe pain (adjusted mean treatment difference - 5.94 mm; 95% CI - 8.83, - 3.06 mm), moderate pain (- 5.97 mm; 95% CI - 9.55, - 2.39 mm) and severe pain (- 5.54 mm; 95% CI - 10.49, - 0.59 mm). Median onset of pain relief was 9 min for methoxyflurane and 15 min for SAT. Practicality of methoxyflurane treatment was rated "Excellent", "Very Good" or "Good" by 90% of clinicians vs. 64% for SAT. Adverse events (all non-serious) were reported by 17% of methoxyflurane-treated patients and 3% of SAT-treated patients.

Conclusion : Methoxyflurane provided superior pain relief to SAT in patients with moderate-to-severe trauma pain and may offer a simple, fast, effective non-opioid treatment option.

Conclusion (proposition de traduction) : Le méthoxyflurane (ndlr : Penthrox©) procure un soulagement de la douleur supérieur par rapport au traitement analgésique standard chez les patients souffrant de douleur traumatique modérée à sévère et peut offrir une option de traitement simple, rapide et efficace non opioïde.

Commentaire : Voir aussi :
• Borobia AM, Collado SG, Cardona CC and al. 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. Ann Emerg Med. 2019 Oct 14  .
• 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  ).

Lenglet A, Balen F, Charpentier S, Sourbes A, Arcuset D, Delonglée V, Fort PA, Bounes V, Charriton Dadone B. | Ann Fr Med Urgence. 2019 nov:9;369-374
DOI: https://doi.org/10.3166/afmu-2019-0188
Keywords: Acute coronary syndrome without ST segment elevation; Secondary transportation; Inter-hospital transportation

Article original / Original article

Introduction : Cette étude a pour objectif de connaître l’incidence et la nature des événements indésirables (EI) se produisant lors des transports interhospitaliers (TIH) des patients souffrant d’un syndrome coronarien aigu sans sus-décalage du segment ST (SCA non ST+). L’objectif secondaire est d’étudier les performances pronostiques des différentes évaluations de risque existantes de ces malades (score de GRACE, score de TIMI, grille de Fiancette et niveau de risque de la Société européenne de cardiologie [ESC]) dans la prédiction de ces EI.

Méthode :  Il s’agit d’une étude de cohorte multicentrique rétrospective. Du 1er novembre 2016 au 31 octobre 2017, les patients SCA non ST+ et bénéficiant d’un transport secondaire ont été inclus à partir des fiches de régulation de trois Samu du sud-ouest de la France. Les types d’EI ont été recueillis. Les différents scores ont été calculés pour chaque patient ainsi que leur performance pronostique (sensibilité, spécificité, valeurs prédictives positives [VPP] et négatives [VPN]).

Résultats : Sur un an, 315 patients ont été inclus, et neuf patients (3 % ; IC 95 % : 1,3–5,3) ont présenté un EI. Soixante-dix-huit pour cent des événements recueillis n’ont pas engagé le pronostic vital des patients, et 40 % n’ont pas nécessité d’intervention thérapeutique nécessitant la présence physique d’un médecin. Aucun score n’est retrouvé statistiquement significatif dans la prédiction des EI. Toutefois, la stratification du risque de la ESC semble être la plus simple d’utilisation tout en assurant une valeur prédictive négative de 98 % (IC 95 % : 94–99).

Conclusion : Few AEs occur during transportation of ACS non-ST+ patients. Systematic use of the European Society of Cardiology ischemic risk evaluation process could reduce the over-medicalisation of these patients in favour of interhospital transportation with nursing supervision.

Conclusion (proposition de traduction) : Il y a peu d’EI lors du transport des SCA non ST+. L’utilisation en régulation de l’évaluation du risque ischémique de la ESC pourrait réduire la surmédicalisation de ces malades au bénéfice des TIH.

Risk Factors for Misuse of Prescribed Opioids: A Systematic Review and Meta-Analysis.
Cragg A, Hau JP, Woo SA, Kitchen SA, Liu C, Doyle-Waters MM, Hohl CM. | Ann Emerg Med. 2019 Nov;74(5):634-646
DOI: https://doi.org/10.1016/j.annemergmed.2019.04.019
Keywords: Aucun

Pain Management and Sedation

Introduction : Increasing opioid prescribing has been linked to an epidemic of opioid misuse. Our objective is to synthesize the available evidence about patient-, prescriber-, medication-, and system-level risk factors for developing misuse among patients prescribed opioids for noncancer pain.

Méthode : We performed a systematic search of the scientific and gray literature for studies reporting on risk factors for prescription opioid misuse. Two reviewers independently reviewed titles, abstracts, and full texts; extracted data; and assessed study quality. We excluded studies with greater than 50% cancer patients, palliative patients, and illicit opioid initiation. When possible, we synthesized the effect sizes of dichotomous risk factors and their associations with opioid misuse, using inverse-variance random-effects meta-analysis. We calculated the mean difference between opioid misusers and nonmisusers for continuous risk factors. When studies lacked homogeneity, we synthesized their results qualitatively.

Résultats : Of 9,629 studies, 65 met our inclusion criteria. Among patients with outpatient opioid prescriptions, the following factors were associated with the development of misuse: any current or previous substance use (odds ratio [OR] 3.55; 95% confidence interval [CI] 2.62 to 4.82), any mental health diagnosis (OR 2.45; 95% CI 1.91 to 3.15), younger age (OR 2.19; 95% CI 1.81 to 2.64), and male sex (OR 1.23; 95% CI 1.10 to 1.36).

Conclusion : Although clinicians should endeavor to offer alternative pain management strategies to all patients, those who are younger, are male patients, and report a history of or current substance use or mental health diagnoses were associated with a greater risk of developing opioid misuse. Clinicians should consider prioritizing alternative pain management strategies for these higher-risk patients.

Conclusion (proposition de traduction) : Bien que les cliniciens devraient s'efforcer de proposer des stratégies alternatives de gestion de la douleur à tous les patients, ceux qui sont plus jeunes, sont masculins, et rapportent une histoire ou une consommation actuelle de substances ou un diagnostic d'altération de santé mentale ont été associés à un plus grand risque de développer un mésusage des opioïdes. Les cliniciens devraient envisager de prioriser d'autres stratégies de prise en charge de la douleur pour ces patients à haut risque.

Commentaire : La Haute Autorité de Santé (HAS), Société Française d’Evaluation et de Traitement de la Douleur (SFETD) et l'Observatoire Français des Médicaments Antalgiques (OFMA) recommandent l'utilisation systématique d'outils pour détecter un risque de mésusage avant la première prescription (Opioid Risk-Tool   - ORT) et avant un renouvellement (échelle POMI  ).
• Société Française d’Evaluation et de Traitement de la Douleur. Recommandations pour le bon usage des antalgiques opioïdes forts dans la douleur non cancéreuse   – Février 2016.
• HAS. Prise en charge du patient présentant une lombalgie commune  . Fiche mémo - Mars 2019.
• Société Française d’Etude et de Traitement de la Douleur (SFETD). Utilisation des opioïdes forts dans la douleur chronique non cancéreuse chez l’adulte   - Cahier n° 4, 2019.

Do Antibiotics Improve Outcomes in Patients With Acute Asthma Exacerbations?.
Ganti L, Rosario J. | Ann Emerg Med. 2019 Nov;74(5):711-712
DOI: https://doi.org/10.1016/j.annemergmed.2019.02.033
Keywords: Aucun

Pulmonary

Introduction : Moderate- to low-quality evidence suggests that antibiotics may reduce symptoms and improve pulmonary function but do not improve other outcomes in patients with acute asthma exacerbations.

Méthode : Studies of adults or children presenting to an emergency department (ED), outpatient clinic, or inpatient ward with an asthma exacerbation were included. Exclusion criteria included a diagnosis of pneumonia, chronic obstructive pulmonary disease, or bronchiectasis or already receiving antibiotics for any reason. Other concomitant medications such as steroids or b-agonists were permissible. Randomized trials that compared antibiotic therapy versus control in adults or children with an acute asthma exacerbation were included. There were no limits on route of antibiotic administration (oral or parenteral) or duration.

Résultats : Two authors independently extracted data, using a standardized data collection form. Discrepancies were resolved by consensus or with the addition of a third author. Outcomes included admission to the ICU, duration of symptoms, mortality, length of hospital admission, relapse, peak flow, and adverse events (nausea, diarrhea, and upper abdominal pain). Bias was assessed with the Cochrane Risk of Bias Tool and data were combined, reporting odds ratios for dichotomous outcomes, risk differences for rare events, and mean differences for continuous variables. Heterogeneity was assessed with the I2 statistic.

Conclusion : This review suggests that antibi- otics may improve symptoms and peak expiratory flow but does not alter other identified outcomes. Antibiotics may be considered for select patients, but further work will be needed to best identify those who are most likely to benefit from antibiotics.

Conclusion (proposition de traduction) : Cette revue suggère que les antibiotiques peuvent améliorer les symptômes et le débit expiratoire maximal mais ne modifient pas les autres résultats identifiés. Des antibiotiques peuvent être envisagés pour certains patients, mais des travaux supplémentaires seront nécessaires pour identifier au mieux ceux qui sont les plus susceptibles de bénéficier des antibiotiques.

Are Recanalization Interventions Effective and Safe in the Treatment of Acute Pulmonary Embolism?.
Long B, April MD. | Ann Emerg Med. 2019 Nov;74(5):713-716
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.008
Keywords: Aucun

Pulmonary

Introduction : None of the studied recanalization interventions (full-dose thrombolysis, reduced-dose thrombolysis, and catheter-directed thrombolysis) improve all-cause mortality for patients with acute pulmonary embolism compared with standard anticoagulation; full-dose thrombolysis demonstrates increased risk of major bleeding compared with reduced-dose thrombolysis.

Méthode : One author performed the search and screening of potential articles for initial consideration. Two authors independently reviewed studies for meta-analysis inclusion. Authors included randomized controlled trials reporting mortality outcomes of adults with acute symptomatic pulmonary embolism who received diagnoses through conventional imaging modalities and also received anticoagulant therapy. The intervention consisted of recanalization with full-dose thrombolysis, reduced-dose thrombolysis, or catheter-directed thrombolysis, whereas the comparator was either treatment with a different recanalization procedure or no recanalization procedure.

Résultats : Two authors independently extracted data from included studies and resolved discrepancies by consensus. Primary outcomes included all-cause mortality and major bleeding, whereas secondary outcomes included risk of intracranial hemorrhage and recurrent embolism. Authors abstracted these outcomes according to the intention-to-treat population for the individual trials, calculated pooled odds ratios and 95% confidence intervals (CIs), and assessed outcomes according to the time identified as the primary outcome for the endpoint in each trial. Authors assessed heterogeneity with the estimated between-study variance (s2), Cochran c2 test, and the I2 statistic and risk of bias based on the Cochrane Handbook for Systematic 1 Reviews of Interventions. Because of the limited number of trials directly comparing recanalization interventions, authors performed a network meta-analysis, including randomized controlled trials comparing different therapies with another common treatment.

Conclusion : Results suggest no one recanalization intervention is superior in reducing all-cause mortality, whereas full-dose thrombolytics increase risk of major bleeding. Reduced-dose and catheter-directed thrombolysis may optimize patient outcomes while minimizing the risk of bleeding, although there are few data comparing these interventions with full-dose thrombolysis, and the present meta-analysis did not conclude that these strategies are superior to anticoagulation alone. Further randomized controlled trial data comparing these interventions with anticoagulation alone and full-dose thrombolysis alone are necessary, particularly among patients with intermediate- to high-risk pulmonary embolism.

Conclusion (proposition de traduction) : Les résultats suggèrent qu'aucune intervention de recanalisation n'est plus efficace pour réduire la mortalité toutes causes confondues, alors que les thrombolytiques à pleine dose augmentent le risque de saignement majeur. La thrombolyse à dose réduite et dirigée par cathéter peut optimiser les résultats pour les patients tout en minimisant le risque de saignement, bien qu'il existe peu de données comparant ces interventions à la thrombolyse à dose complète, et la présente méta-analyse n'a pas conclu que ces stratégies soient supérieures à l'anticoagulation seule. D'autres données d'essais contrôlés randomisés comparant ces interventions à l'anticoagulation seule et à la thrombolyse à dose complète seule sont nécessaires, en particulier chez les patients atteints d'embolie pulmonaire à risque intermédiaire à élevé.

Do Antibiotics Improve Patient Outcomes in Acute Exacerbations of Chronic Obstructive Pulmonary Disease?.
Long B, April MD. | Ann Emerg Med. 2019 Nov;74(5):e79-e81
DOI: https://doi.org/10.1016/j.annemergmed.2019.01.004
Keywords: Aucun

Pulmonary

Introduction : For patients with acute chronic obstructive pulmonary disease exacerbation, antibiotics reduce treatment failure for those with mild to moderate exacerbations. Antibiotics reduce mortality and treatment failure for patients with severe exacerbation who are admitted to an ICU, and there may be a benefit for hospitalized patients.

Méthode : Two authors independently assessed studies for relevance and resolved disagreements through consensus. Investigators included randomized controlled trials of adults with acute exacerbation of chronic obstructive pulmonary disease who were followed between 7 days and 1 month and underwent randomization to either antibiotic therapy (oral or intravenous for at least 2 days) or placebo. Authors defined acute chronic obstructive pulmonary disease exacerbation as the worsening of a previously stable condition, with increased dyspnea, cough, or sputum volume, or as change in sputum color.

Résultats : Two investigators independently extracted data from included studies. The primary outcome was treatment failure between 7 days and 1 month, defined as no resolution or deterioration of symptoms after trial medication of any duration, death caused by exacerbation, or additional course of antibiotics or another medication. Secondary outcomes included mortality, adverse events, ICU or hospital admission, length of stay, re-exacerbation within greater than 2 to 6 weeks from the index exacerbation, and time to next exacerbation. Using a fixed-effects model, authors calculated pooled risk ratios for binary events, Peto odds ratios for rare events, and mean differences for continuous outcomes and assessed heterogeneity with c2 and I2 statistics. Two authors assessed risk of bias according to the Cochrane Handbook for Systemic Reviews of Interventions1 and used the Grading of Recommendations Assessment, Development and Evaluation criteria to assess evidence quality. Authors analyzed all outcomes except adverse events in outpatients (whose exacerbations the authors classified as mild to moderate), inpatients (whose exacerbations the authors classified as severe), and ICU patients (whose exacerbations the authors classified as very severe).

Conclusion : According to these results, patients with low to moderate exacerbations and those requiring ICU admission benefit from antibiotics. The effect of antibiotic therapy on mortality, re-exacerbation, and quality of life is unclear. Further randomized controlled trial data are necessary to inform antibiotic effectiveness for patient-centered short- and long- term outcomes, specifically for patients with suspected bacterial infection. Future randomized controlled trials should clearly define exacerbation severity and underlying chronic obstructive pulmonary disease severity.

Conclusion (proposition de traduction) : Selon ces résultats, les patients présentant des exacerbations faibles à modérées et ceux nécessitant une admission en USI bénéficient d'antibiotiques. L'effet de l'antibiothérapie sur la mortalité, la ré-exacerbation et la qualité de vie n'est pas clair. D'autres données d'essais contrôlés randomisés sont nécessaires pour confirmer l'efficacité des antibiotiques pour les résultats à court et à long terme centrés sur le patient, en particulier pour les patients présentant une suspicion d'infection bactérienne. Les futurs essais contrôlés randomisés devraient définir clairement la gravité de l'exacerbation et la gravité de la maladie pulmonaire obstructive chronique sous-jacente.

Comparison of standard and over-the-head method of chest compressions during cardiopulmonary resuscitation - a simulation study.
Ćwiertnia M, Kawecki M, Ilczak T, Mikulska M, Dutka M, Bobiński R. | BMC Emerg Med. 2019 Nov 26;19(1):73
DOI: https://doi.org/10.1186/s12873-019-0292-8  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : Maintaining highly effective cardiopulmonary resuscitation (CPR) can be particularly difficult when artificial ventilation using a bag-valve-mask device, combined with chest compression have to be carried out by one person. The aim of the study is to compare the quality of CPR conducted by one paramedic using chest compression from the patient's side with compression conducted from the 'over-the-head' position.

Méthode : The subject of the study were two methods of CPR - 'standard' (STD) and 'over-the-head' (OTH). The STD method consisted of cycles of 30 chest compressions from the patient's side, and two attempts at artificial ventilation after moving round to behind the patient's head. In the OTH method, both compressions and ventilations were conducted from behind the patient's head.

Résultats : Both CPR methods were conducted by 38 paramedics working in medical response teams. Statistical analysis was conducted on the data collected, giving the following results: the average time of the interruptions between compression cycles (STD 9.184 s, OTH 7.316 s, p < 0.001); the depth of compression 50-60 mm (STD 50.65%, OTH 60.22%, p < 0.001); the rate of compression 100-120/min. (STD 46.39%, OTH 53.78%, p < 0.001); complete chest wall recoil (STD 84.54%, OTH 91.46%, p < 0.001); correct hand position (STD 99.32%, OTH method 99.66%, p < 0.001). A statistically significant difference was demonstrated in the results to the benefit of the OTH method in the above parameters. The remaining parameters showed no significant differences in comparison to reference values.

Conclusion : The higher quality of CPR in the simulated research using the OTH method by a single person justifies the use of this method in a wider range of emergency interventions.

Conclusion (proposition de traduction) : La qualité supérieure de réalisation de la RCP dans cette simulation utilisant la méthode de placement à la tête du patient par une seul secouriste justifie l'utilisation de cette méthode dans un plus large éventail d'interventions d'urgence.

Commentaire : Voir l'analyse de l'article :
• Nasiri E, Nasiri R. A comparison between over-the-head and lateral cardiopulmonary resuscitation with a single rescuer by bag-valve mask. Saudi J Anaesth. 2014 Jan;8(1):30-7  . doi: 10.4103/1658-354X.125923.

POCUS predicts prognosis in cardiac arrest.
Lalande E, Woo MY. | CJEM. 2019 Nov;21(6):689-690
DOI: https://doi.org/10.1017/cem.2019.436  | Télécharger l'article au format  
Keywords: Ultrasound; cardiac arrest; emergency medicine

Commentary

Editorial : Point-of-care ultrasound (POCUS) is a core application of emergency medicine training and is now internationally recognized as a diagnostic tool in resuscitation. The 2015 update of the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) states that POCUS may be used during CPR of cardiac arrest patients, although its usefulness has not been well established. Beckett et al. seeks to define more precisely how best POCUS can contribute to the prognosis assessment of patients in cardiopulmonary arrest. The authors evaluated the prognostic value of POCUS in comparison with electrocardiogram (ECG) but also by combining it with the latter when treating patients in cardiopulmonary arrest.

Conclusion : Cardiac arrest care continues to evolve and with that the role of POCUS. Surely, with the evidence that exists now, POCUS has a role in predicting death when there is no cardiac activity. However, patients with cardiac arrest are complex, and there is no single best test to determine their prognosis. There still remain many questions to be answered. How should we define cardiac activity on POCUS? When should we perform POCUS when trying to evaluate the prognosis of our patient? Does it matter? What is the best combination of tests we should use to determine a patient prognosis while in cardiac arrest? Beckett’s results help us take one step further into answering these important clinical questions. POCUS is essential to the evolution of cardiac arrest care.

Conclusion (proposition de traduction) : Les soins en cas d'arrêt cardiaque continuent d'évoluer et avec cela le rôle de l'échographie au point d'intervention. Sûrement, avec les preuves qui existent maintenant, que l'échographie au point d'intervention a un rôle dans la prévision de la mort quand il n'y a pas d'activité cardiaque. Cependant, les patients en arrêt cardiaque sont complexes et il n'existe pas de meilleur test unique pour déterminer leur pronostic. Il reste encore de nombreuses questions auxquelles il faut répondre. Comment définir l'activité cardiaque sur l'échographie au point d'intervention ? Quand devons-nous effectuer une échographie au point d'intervention lorsque nous essayons d'évaluer le pronostic de notre patient ? Est-ce que cela est utile ? Quelle est la meilleure combinaison de tests à utiliser pour déterminer le pronostic d'un patient en arrêt cardiaque ? Les résultats de Beckett nous aident à franchir une étape supplémentaire pour répondre à ces importantes questions cliniques. L'échographie au point d'intervention est essentiel à l'évolution des soins en cas d'arrêt cardiaque.

Commentaire : Voir sur le sujet :
• Atkinson PR, Beckett N, French J and al. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019 Apr 13;11(4):e4456  .
• Beckett N, Atkinson P, Fraser J and al. Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study. CJEM. 2019 Nov;21(6):739-743  .

How do I manage the emergency airway?.
Mekwan J, Brown CA. | CJEM. 2019 Nov;21(6):706-709
DOI: https://doi.org/10.1017/cem.2019.396
Keywords: Emergency airway; intubation

Just the Facts

Editorial : A 65-year-old male with known chronic obstructive pulmonary disease (COPD) presents to the emergency department (ED) with a 4-day history of progressive dyspnea, productive cough, and fever. His vital signs are p120; BP 98/50; RR 28; Temp 38°C; oxygen saturation 84% room air. He’s looking tired, and you anticipate that he will need intubation. The patient is in a high acuity area, and you prepare your team and ask for additional help from a colleague.
How will you approach airway management, in this case?

Conclusion : KEY POINT:
• Appropriate patient positioning will aid laryngoscopy as well as oxygenation
• A thorough airway assessment can help predict the difficult airway
• Obsessively preoxygenate and use ApOx. This will increase the safe apneic time to allow for intubation
• Correcting abnormal physiology prior to attempting intubation can reduce the risk of secondary compromise and insult.

Conclusion (proposition de traduction) : POINTS CLÉS :
• Un positionnement approprié du patient facilitera la laryngoscopie ainsi que l'oxygénation
• Une évaluation approfondie des voies aériennes peut aider à prévoir les voies aériennes difficiles
• Préoxygénation obsessionnelle et oxygénation d'apnée. Cela augmentera le temps apnéique sécuritaire pour permettre l'intubation
• La correction d'une physiologie anormale avant de tenter l'intubation peut réduire le risque d'échec secondaire et d'événement indésirable.

Does the tonicity or rate of intravenous fluid infusion affect neurologic outcomes in children with diabetic ketoacidosis?.
Packer N, Hunter M, Dowling S. | CJEM. 2019 Nov;21(6):710-712
DOI: https://doi.org/10.1017/cem.2019.378
Keywords: DKA; IV Fluid; Pediatrics

Commentary

Introduction : Prior guidelines for fluid management in pediatric diabetic ketoacidosis (DKA) were based on limited observational data. Rapid fluid administration was thought to cause cerebral injury due to sudden changes in serum. To study the effect of different fluid regimens on neuro- logic outcomes in pediatric DKA.

Méthode : Multicentre randomized, controlled trial (RCT) (2 x 2 factorial design). Children (0–18 years of age) with DKA.Subjects were excluded if:
• GlasgowComaScale(GCS)≤11
• Pregnancy
• Treated DKA
• Conditionimpairingmentalstatus
• Specificintravenoustherapyrequired.

Résultats : In total, 1,389 cases from 1,255 patients were included in the study. Ultimately, 1,361 cases were analysed for the primary outcome. No statistically significant differences were observed between groups for either the primary or secondary outcomes.

Conclusion : This was the first well-designed randomized, controlled trial to study the commonly held belief that rapid intravenous infusion can cause cerebral edema in diabetic ketoacidosis. Although both the lack of physician blinding and the inadequate power to detect between group interaction effects represent significant study limitations, the results of this study have already led to updated clinical practice guidelines.
For pediatric rehydration, it is reasonable to use either 0.45% or 0.9% NaCl and to use a rapid or slow rate of intravenous rehydration (replacing 5%–10% of body weight over 24 -48 hours) as detailed in the study protocol.

Conclusion (proposition de traduction) : Il s'agissait du premier essai contrôlé randomisé bien conçu pour étudier la croyance commune selon laquelle une perfusion intraveineuse rapide peut provoquer un œdème cérébral dans l'acidocétose diabétique. Bien que l'absence d'aveuglement des médecins et le pouvoir insuffisant de détection des effets d'interaction entre les groupes représentent des limites importantes de l'étude, les résultats de cette étude ont déjà conduit à la mise à jour des lignes directrices de pratique clinique.
Pour la réhydratation pédiatrique, il est raisonnable d'utiliser duNaCl soit à 0,45% soit à 0,9% et d'utiliser une vitesse de réhydratation intraveineuse rapide ou lente (remplaçant 5 % à 10 % du poids corporel sur 24 à 48 heures) comme détaillé dans le protocole d'étude.

Does bag-mask ventilation between induction and laryngoscopy reduce the incidence of hypoxemia during intubation of critically ill patients?.
Avery-Cooper G, Seadon S. | CJEM. 2019 Nov;21(6):713-714
DOI: https://doi.org/10.1017/cem.2019.384
Keywords: Emergency medicine; airway management; bag-mask ventilation; critical care

Commentary

Introduction : Hypoxemia is a common complication of tracheal intubation and can lead to cardiac arrest and death. To compare the incidence of hypoxemia during tracheal intubation with or without bag-mask ventilation (BMV) after induction in critically ill patients.

Méthode : Unblinded, parallel-group randomized control trial. Seven academic intensive care units (ICU) across the USA. Adults aged >18 years undergoing rapid-sequence induction (RSI) and tracheal intubation randomized to BMV or no ventilation between induction and laryngoscopy.

Résultats : A total of 401 patients were enrolled, with 199 patients assigned to the BMV group and 202 patients assigned to the no-ventilation group. Further, 198 patients (99.5%) in the BMV group and five patients (2.5%) in the no-ventilation group received BMV prior to initial attempt at laryngoscopy. There was no difference in oxygen saturation at the time of induction between groups. The median lowest oxygen saturation was 96% in the BMV group and 93% in the no-ventilation group (p = 0.01). The mean difference in the lowest oxygen saturation between groups was 4.7% (95% confidence interval [CI] 2.5–6.8). There were more patients with severe hypoxemia (SpO2 < 80%) in the no-ventilation group compared with the BMV group (22.8% v. 10.9%, respectively) with a relative risk of 0.48 (CI 0.30–0.77), and aNumberNeeded toTreat of 9 to prevent one episode of severe hypoxemia. In addition, there were fewer patients in the BMV group who had an oxygen saturation <90% (29.5% v. 40.1%, respectively; relative risk [RR] 0.74) and <70% (4.1% v. 10.2%, respectively; RR 0.41) compared with the no-ventilation group.

Conclusion : In critically ill patients undergoing tracheal intubation in the ICU, BMV between induction and laryngoscopy improves oxygen saturations and reduces the incidence of severe hypoxemia. It is unclear if this result can be generalized to the ED population undergoing tracheal intubation, given potential differences in aspiration risk. Importantly, BMV during RSI should not replace appropriate preoxygenation to prevent hypoxemia. Moreover, the study protocol required a meticulous BMV technique with a two-handed mask seal and avoidance of excessive ventilation that should be replicated. This approach should be avoided in patients at high risk of aspiration. We recommend considering BMV during RSI of the critically ill patient in the ED who is at high risk of desaturation but at low risk of aspiration.

Conclusion (proposition de traduction) : Chez les patients dans un état critique bénéficiant d'une intubation trachéale en USI, la ventilation au masque facial avec ballon, entre l'induction et la laryngoscopie améliore la saturation en oxygène et réduit l'incidence d'hypoxémie sévère. Il n'est pas clair si ce résultat peut être généralisé à la population des services d'urgence bénéficiant d'une intubation trachéale, compte tenu des différences potentielles de risque d'inhalation. Il est important de noter que la ventilation au masque facial avec ballon pendant l'ISR ne doit pas remplacer la préoxygénation appropriée pour prévenir l'hypoxémie. De plus, le protocole de l'étude nécessitait une technique de ventilation méticuleuse avec un masque facial avec ballon avec une application du masque à deux mains et évitant une ventilation excessive qui devrait être reproduite. Cette approche doit être évitée chez les patients à haut risque d'inhalation. Nous recommandons d'envisager une ventilation par masque facial avec ballon pendant l'ISR du patient dans un état critique aux urgences qui présente un risque élevé de désaturation mais un faible risque d'inhalation.

Can we safely use a wait and see approach for patients with recent onset atrial fibrillation?.
Vij S, Burton A, Murray H, Walker M. | CJEM. 2019 Nov;21(6):715-716
DOI: https://doi.org/10.1017/cem.2019.403
Keywords: Emergency medicine; arrhythmia; cardiac disease; evidence-based medicine

Commentary

Introduction : Patients with recent onset, stable, and symptomatic atrial fibrillation in the emergency department (ED) traditionally neccessitate immediate cardioversion, but a portion will convert without any intervention.
Objectives: To determine whether a wait-and-see approach was non-inferior to early cardioversion in patients presenting with recent onset, stable, and symptomatic atrial fibrillation.

Méthode : Primary endpoint included sinus rhythm on electrocardiogram (ECG) at the four-week follow-up visit. Secondary endpoints included length of stay of the primary visit, subsequent visits related to atrial fibrillation, cardiovascular complications, and time to recurrence of atrial fibrillation.

Résultats : A total of 437 patients were randomized: 218 to the delayed cardioversion group, and 219 to the early cardioversion group. In the early cardioversion group, 94% of the patients were in sinus rhythm at the four-week visit, with 16% spontaneously converting and 78% undergoing electrical or chemical cardioversion at their initial ED visit. In the delayed cardioversion group, 91% of the patients were in sinus rhythm at the four-week visit, with 69% having converted spontaneously within 48 hours. Of those in the delayed group, 83% received rate control agents during the initial ED visit. The difference of 2.9% met the pre-specified non-inferiority margin of 10% (95% confidence interval [CI] −8.2 to 2.2, p = 0.005 for non-inferiority). There were no significant differences between the two groups or in terms of cardiovascular complication rates at the four-week visit.

Conclusion : This trial initiates a discussion surrounding our management of symptomatic, recent onset atrial fibrillation. The early cardioversion arm was cardioverted at their initial visit, and the delayed cardioversion arm was rate controlled and reassessed within 48 hours of symptom onset with cardioversion if still in atrial fibrillation. The delayed arm was non-inferior for a primary outcome of sinus rhythm at four weeks. However, this primary outcome may not align with the priorities of physicians or patients, and return visits within 48 hours are not ideal for resources or patient satisfaction. Pending data from this study may help clarify this clinical question.

Conclusion (proposition de traduction) : Cette étude amorce une discussion sur notre prise en charge de la fibrillation atriale symptomatique d'apparition récente. Le groupe de cardioversion précoce a fait l'objet d'une cardioversion lors de la visite initiale, et le groupe de cardioversion retardée a été contrôlé par la fréquence et réévalué dans les 48 heures suivant l'apparition des symptômes avec cardioversion secondairement s'il était encore en fibrillation atriale. Le bras retardé était non inférieur pour le résultat primaire de retour à un rythme sinusal à quatre semaines. Toutefois, ce résultat primaire peut ne pas correspondre aux priorités des médecins ou des patients, et les reconsultations dans les 48 heures ne sont pas idéales pour les ressources ou la satisfaction des patients. Les données en attente de cette étude pourraient aider à clarifier cette question clinique.

Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis.
Netherton S, Milenkovic V, Taylor M, Davis PJ. | CJEM. 2019 Nov;21(6):727-738
DOI: https://doi.org/10.1017/cem.2019.381
Keywords: Emergency medicine; trauma; ultrasound

Original Research

Introduction : Le recours à l’évaluation ciblée par échographie étendue en traumatologie (eFAST : sigle anglais) est pratique courante dans l’évaluation initiale des patients ayant subi un trauma. L’étude avait donc pour but une revue systématique de la documentation publiée sur l'exactitude du diagnostic reposant sur tous les éléments constitutifs de l'eFAST.

Méthode : Les chercheurs ont effectué une recherche d’études sur les examens de diagnostic ayant pour objets la sensibilité et la spécificité de l'eFAST, dans les bases de données Medline et Embase, depuis leur début respectif jusqu’à octobre 2018. Après le retrait des doubles, il restait 767 documents aux fins de sélection, dont 119 ont été soumis à un examen en texte intégral. Le logiciel Meta-DiScMC a servi à établir la sensibilité et la spécificité globales des études retenues. Quant à la qualité des études, elle a été évaluée à l'aide de l'instrument Quality in Prognostic Studies (QUADAS-2).

Résultats : Au total, 75 études totalisant 24 350 patients et publiées entre 1989 et 2017 répondaient aux critères de sélection. La sensibilité et la spécificité globales ont été calculées pour la détection des pneumothorax (69% et 99% respectivement), des épanchements péricardiques (91% et 94% respectivement) et de liquide libre intra-abdominal (74% et 98% respectivement). Il y a eu également analyse de sous-groupes en vue de la détection de liquide libre intra-abdominal chez les patients hypotendus (sensibilité : 74%; spécificité : 95%), les adultes normotendus (sensibilité : 76%; spécificité : 98%) et les enfants (sensibilité : 71%; spécificité : 95%).

Conclusion : Our systematic review and meta-analysis suggests that e-FAST is a useful bedside tool for ruling in pneumothorax, pericardial effusion, and intra-abdominal free fluid in the trauma setting. Its usefulness as a rule-out tool is not supported by these results.

Conclusion (proposition de traduction) : D'après les résultats de la revue systématique et de la méta-analyse, l'eFAST au chevet se montre utile pour confirmer la présence de pneumothorax, d’épanchement péricardique ou de liquide libre intra-abdominal en traumatologie, mais pas pour en écarter la présence.

Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study.
Beckett N, Atkinson P, Fraser J, Banerjee A, French J, Talbot JA, Stoica G, Lewis D. | CJEM. 2019 Nov;21(6):739-743
DOI: https://doi.org/10.1017/cem.2019.397
Keywords: Cardiac arrest; ECG; POCUS

Original Research

Introduction : On a de plus en plus recours à l’échographie au point d'intervention (EC) durant les manœuvres de réanimation. L’étude visait donc à déterminer si l'association de l'EC et de l’électrocardiogramme (ECG) pour analyse du rythme avait une meilleure valeur prévisionnelle que l'ECG seul quant à l'issue durant les manœuvres de réanimation cardiorespiratoire au service des urgences (SU).

Méthode : Il s'agit d'un examen de dossiers médicaux de patients en état d'arrêt cardiaque qui ont été soumis à une EC au SU. Les principaux critères d’évaluation étaient le retour à la circulation spontanée (RCS), la survie en cours d'hospitalisation et la survie après le congé de l'hôpital.

Résultats : Une EC a été effectuée chez 180 patients; la présence d'activité électrique a été observée à l'ECG initial chez 45 d'entre eux (25,0%; 19,2–31,8%) et à l'EC initiale chez 21 d'entre eux (11,7%; 7,7–17,2%). Quarante-sept patients (26,1%; 20,2–33,0%) ont connu un RCS, 18 (10,0%; 6,3–15,3%) ont survécu à l'hospitalisation et 3 (1,7%; 0,3–5,0%) ont survécu au congé de l'hôpital. L'ECG a révélé une sensibilité de 82,7% (intervalle de confiance à 95% : 75,2%−88,7%) et une spécificité de 46,8% (32,1–61,9%) à l’égard de la valeur prévisionnelle du non-retour à la circulation spontanée. Dans l'ensemble, l'EC avait une sensibilité supérieure (96,2%; [(91,4–98,8%]) mais une spécificité comparable (34,0%; [(20,9–49,3%]) à celles de l'ECG. Chez les patients présentant une asystole à l'ECG, l'EC avait une sensibilité de 98,18% (93,59–99,78%) et une spécificité de 16,00,% (4,54–36,08%). Quant aux patients ayant une activité électrique sans pouls, l'EC avait une sensibilité de 86,96% (66,41–97,22%) et une spécificité de 54,55% (32,21–75,61%). Des résultats comparables ont été obtenus en ce qui concerne la survie en cours d'hospitalisation ainsi qu'après le congé de l'hôpital. Enfin, seulement 0,8% (0,0–4,7%) des patients présentant une asystole à l'ECG et un arrêt des contractions du cœur à l'EC ont survécu au congé de l'hôpital.

Conclusion : The absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

Conclusion (proposition de traduction) : L'absence d'activité électrique cardiaque à l'échographie au point d'intervention seule ou à l'association de l'ECG et de l'échographie au point d'intervention a une meilleure valeur prévisionnelle que l'ECG seul. Aucun test n'a prédit de manière fiable la survie.

How is quality of cardiopulmonary resuscitation being assessed? A national survey of Canadian emergency medicine physicians.
Wright N, Lin Y, Cheng A. | CJEM. 2019 Nov;21(6):744-748
DOI: https://doi.org/10.1017/cem.2019.382
Keywords: Cardiac arrest; emergency medicine; resuscitation

Original Research

Introduction : Il est crucial d'effectuer des manœuvres de réanimation cardiopulmonaire (RCP) de qualité dans le traitement des arrêts cardiaques; pourtant, rares sont les fournisseurs de soins qui respectent les lignes directrices recommandées. Les rétroactions en temps réel améliorent l'efficacité des manœuvres de RCP. Toutefois, on ne sait pas comment les urgentologues au Canada évaluent la qualité des RCP durant les arrêts cardiaques et s'ils utilisent des dispositifs de rétroaction. L’étude visait donc à établir la manière dont les urgentologues évaluent la qualité des RCP et à faire ressortir de possibles obstacles à l'utilisation de la rétroaction technologique.

Méthode : Il s'agit d'une enquête transversale menée par l'Association canadienne des médecins d'urgence, parmi les urgentologues traitants et les résidents dans le domaine. Les chercheurs ont d'abord résumé les réponses, puis analysé les données à l'aide de statistiques descriptives.

Résultats : Le taux de réponse a atteint 19 % (323/1735). La méthode d’évaluation la plus courante de la qualité des manœuvres de RCP reposait sur l'observation visuelle (41,2 %) faite au pied du lit par les chefs d’équipe (67,4 %). Suivaient la vérification du pouls en temps réel (29,7 %) et les valeurs de CO2 en fin d'expiration (21,7 %). Enfin, seuls 12 % des médecins avaient recours à la rétroaction technologique sur la RCP. Les obstacles évoqués le plus souvent étaient le manque de dispositifs, le manque d'expérience d'utilisation de ces appareils et le manque de lignes directrices sur leur emploi ou de données probantes à l'appui.

Conclusion : La plupart des urgentistes au Canada qui ont participé à l'enquête évaluent la qualité des manœuvres de RCP en se tenant au pied du lit et en se fondant sur l'observation visuelle et la palpation, deux méthodes connues pour leur inexactitude. Les autres, soit une minorité, ont recours à des mesures objectives comme l'EtCO₂ ou à des dispositifs de rétroaction, et le plus grand obstacle perçu est le manque d'appareils.

Conclusion (proposition de traduction) : Most Canadian emergency physicians that responded to our survey, assess quality of CPR by standing at the foot of the bed and utilize visual observation and palpation methods which are known to be inaccurate. A minority utilize objective measurements such as ETCO2 or feedback devices, with the greatest barrier being lack of availability.

Computed tomography for diagnosis of acute appendicitis in adults.
Rud B, Vejborg TS, Rappeport ED, Reitsma JB, Wille-Jørgensen P. | Cochrane Database Syst Rev. 2019 Nov 19;2019(11)
DOI: https://doi.org/10.1002/14651858.CD009977.pub2
Keywords: Aucun

Diagnostic

Introduction : Diagnosing acute appendicitis (appendicitis) based on clinical evaluation, blood testing, and urinalysis can be difficult. Therefore, in persons with suspected appendicitis, abdominopelvic computed tomography (CT) is often used as an add-on test following the initial evaluation to reduce remaining diagnostic uncertainty. The aim of using CT is to assist the clinician in discriminating between persons who need surgery with appendicectomy and persons who do not.
OBJECTIVES: Primary objective Our primary objective was to evaluate the accuracy of CT for diagnosing appendicitis in adults with suspected appendicitis. Secondary objectives Our secondary objectives were to compare the accuracy of contrast-enhanced versus non-contrast-enhanced CT, to compare the accuracy of low-dose versus standard-dose CT, and to explore the influence of CT-scanner generation, radiologist experience, degree of clinical suspicion of appendicitis, and aspects of methodological quality on diagnostic accuracy.

Méthode : We searched MEDLINE, Embase, and Science Citation Index until 16 June 2017. We also searched references lists. We did not exclude studies on the basis of language or publication status.
SELECTION CRITERIA: We included prospective studies that compared results of CT versus outcomes of a reference standard in adults (> 14 years of age) with suspected appendicitis. We excluded studies recruiting only pregnant women; studies in persons with abdominal pain at any location and with no particular suspicion of appendicitis; studies in which all participants had undergone ultrasonography (US) before CT and the decision to perform CT depended on the US outcome; studies using a case-control design; studies with fewer than 10 participants; and studies that did not report the numbers of true-positives, false-positives, false-negatives, and true-negatives. Two review authors independently screened and selected studies for inclusion.
DATA COLLECTION AND ANALYSIS: Two review authors independently collected the data from each study and evaluated methodological quality according to the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate random-effects model to obtain summary estimates of sensitivity and specificity.

Résultats : We identified 64 studies including 71 separate study populations with a total of 10,280 participants (4583 with and 5697 without acute appendicitis). Estimates of sensitivity ranged from 0.72 to 1.0 and estimates of specificity ranged from 0.5 to 1.0 across the 71 study populations. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.93 to 0.96), and summary specificity was 0.94 (95% CI 0.92 to 0.95). At the median prevalence of appendicitis (0.43), the probability of having appendicitis following a positive CT result was 0.92 (95% CI 0.90 to 0.94), and the probability of having appendicitis following a negative CT result was 0.04 (95% CI 0.03 to 0.05). In subgroup analyses according to contrast enhancement, summary sensitivity was higher for CT with intravenous contrast (0.96, 95% CI 0.92 to 0.98), CT with rectal contrast (0.97, 95% CI 0.93 to 0.99), and CT with intravenous and oral contrast enhancement (0.96, 95% CI 0.93 to 0.98) than for unenhanced CT (0.91, 95% CI 0.87 to 0.93). Summary sensitivity of CT with oral contrast enhancement (0.89, 95% CI 0.81 to 0.94) and unenhanced CT was similar. Results show practically no differences in summary specificity, which varied from 0.93 (95% CI 0.90 to 0.95) to 0.95 (95% CI 0.90 to 0.98) between subgroups. Summary sensitivity for low-dose CT (0.94, 95% 0.90 to 0.97) was similar to summary sensitivity for standard-dose or unspecified-dose CT (0.95, 95% 0.93 to 0.96); summary specificity did not differ between low-dose and standard-dose or unspecified-dose CT. No studies had high methodological quality as evaluated by the QUADAS-2 tool. Major methodological problems were poor reference standards and partial verification primarily due to inadequate and incomplete follow-up in persons who did not have surgery.

Conclusion : The sensitivity and specificity of CT for diagnosing appendicitis in adults are high. Unenhanced standard-dose CT appears to have lower sensitivity than standard-dose CT with intravenous, rectal, or oral and intravenous contrast enhancement. Use of different types of contrast enhancement or no enhancement does not appear to affect specificity. Differences in sensitivity and specificity between low-dose and standard-dose CT appear to be negligible. The results of this review should be interpreted with caution for two reasons. First, these results are based on studies of low methodological quality. Second, the comparisons between types of contrast enhancement and radiation dose may be unreliable because they are based on indirect comparisons that may be confounded by other factors.

Conclusion (proposition de traduction) : La sensibilité et la spécificité de la TDM pour le diagnostic de l'appendicite chez l'adulte sont élevées. La TDM à dose standard non injectée semble avoir une sensibilité plus faible que la TDM à dose standard avec administration du contraste par voie intraveineuse, rectale ou orale et intraveineuse. L'utilisation de différents types de contraste ou l'absence de contraste ne semble pas affecter la spécificité. Les différences de sensibilité et de spécificité entre les TDM à faible dose et à dose normale semblent négligeables. Les résultats de cette revue doivent être interprétés avec prudence pour deux raisons. Premièrement, ces résultats sont basés sur des études de faible qualité méthodologique. Deuxièmement, les comparaisons entre les types de contrastes et la dose de radiation peuvent ne pas être fiables parce qu'elles sont fondées sur des comparaisons indirectes qui peuvent être confondues par d'autres facteurs.

Commentaire : Voir la traduction du résumé proposée par la bibliothèque Cochrane : Quelle est la précision de la tomodensitométrie pour le diagnostic de l'appendicite aiguë chez l'adulte ?  . Rédigé par le Dr Jean-Charles Vinet et Cochrane France.

Beneficial effects of early empirical administration of appropriate antimicrobials on survival and defervescence in adults with community-onset bacteremia.
Lee CC, Lee CH, Yang CY, Hsieh CC, Tang HJ, Ko WC. | Crit Care. 2019 Nov 20;23(1):363
DOI: https://doi.org/10.1186/s13054-019-2632-1  | Télécharger l'article au format  
Keywords: Antimicrobial therapy; Bloodstream infection; Community-onset; Empirical; Febrile; Mortality

Research

Introduction : Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. The effects of early administration of appropriate antimicrobials on the prognosis and timing of defervescence of bacteremic patients remain under debate.

Méthode : In a 6-year retrospective, multicenter cohort, adults with community-onset bacteremia at the emergency departments (EDs) were analyzed. The period from ED arrival to appropriate antimicrobial administration and that from appropriate antimicrobial administration to defervescence was regarded as the time-to-appropriate antibiotic (TtAa) and time-to-defervescence (TtD), respectively. The primary study outcome was 30-day mortality after ED arrival. The effects of TtAa on 30-day mortality and delayed defervescence were examined after adjustment for independent predictors of mortality, which were recognized by a multivariate regression analysis.

Résultats : Of the total 3194 patients, a TtAa-related trend in the 30-day crude (γ = 0.919, P = 0.01) and sepsis-related (γ = 0.909, P = 0.01) mortality rate was evidenced. Each hour of TtAa delay was associated with an average increase in the 30-day crude mortality rate of 0.3% (adjusted odds ratio [AOR], 1.003; P < 0.001) in the entire cohort and 0.4% (AOR, 1.004; P < 0.001) in critically ill patients, respectively, after adjustment of independent predictors of 30-day crude mortality. Of 2469 febrile patients, a TtAa-related trend in the TtD (γ = 0.965, P = 0.002) was exhibited. Each hour of TtAa delay was associated with an average 0.7% increase (AOR, 1.007; P < 0.001) in delayed defervescence (TtD of ≥ 7 days) after adjustment of independent determinants of delayed defervescence. Notably, the adverse impact of the inappropriateness of empirical antimicrobial therapy (TtAa > 24 h) on the TtD was noted, regardless of bacteremia severity, bacteremia sources, or causative microorganisms.

Conclusion : The delay in the TtAa was associated with an increasing risk of delayed defervescence and 30-day mortality for adults with community-onset bacteremia, especially for critically ill patients. Thus, for severe bacteremia episodes, early administration of appropriate empirical antimicrobials should be recommended.

Conclusion (proposition de traduction) : Le délai d’administration d’une antibiothérapie appropriée était associé avec une défervescence thermique retardé et une surmortalité à 30 jours chez les adultes présentant une bactériémie communautaire, en particulier pour les patients réanimatoires. Ainsi, pour les épisodes de bactériémie sévère, l'administration précoce d'antibiotiques probabilistes appropriés doit être recommandée.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Une antibiothérapie précoce et appropriée est indispensable chez les patients présentant une bactériémie communautaire  . Rédigé par le Dr Olivier Leroy, le 16 décembre 2019.

The impact of closing emergency departments on mortality in emergencies: an observational study.
Knowles E, Shephard N, Stone T, Mason S2, Nicholl J. | Emerg Med J. 2019 Nov;36(11):645-651
DOI: https://doi.org/10.1136/emermed-2018-208146  | Télécharger l'article au format  
Keywords: death/mortality; emergency care systems; emergency departments

Original article

Introduction : In England the demand for emergency care is increasing, while there is also a staffing shortage. This has implications for quality of care and patient safety. One solution may be to concentrate resources on fewer sites by closing or downgrading emergency departments (EDs). Our aim was to quantify the impact of such reorganisation on population mortality.

Méthode : We undertook a controlled interrupted time series analysis to detect the impact of closing or downgrading five EDs, which occurred due to concerns regarding sustainability. We obtained mortality data from 2007 to 2014 using national databases. To establish ED resident catchment populations, estimated journey times by road were supplied by the Department for Transport. Other major changes in the emergency and urgent care system were determined by analysis of annual NHS Trust reports in each geographical area studied. Our main outcome measures were mortality and case fatality for a set of 16 serious emergency conditions.

Résultats : For residents in the areas affected by closure, journey time to the nearest ED increased (median change 9 min, range 0-25 min). We found no statistically reliable evidence of a change in overall mortality following reorganisation of ED care in any of the five areas or overall (+2.5% more deaths per month on average; 95% CI -5.2% to +10.2%; p=0.52). There was some evidence to suggest that, on average across the five areas, there was a small increase in case fatality, an indicator of the 'risk of death' (+2.3%, 95% CI +0.9% to+3.6%; p<0.001), but this may have arisen due to changes in hospital admissions.

Conclusion : We found no evidence that reorganisation of emergency care was associated with a change in population mortality in the five areas studied. Further research should establish the economic consequences and impact on patient experience and neighbouring hospitals.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune preuve que la réorganisation de l'offre de soins d'urgence était associée à un changement dans la mortalité de la population dans les cinq régions étudiées. De nouvelles recherches devraient établir les conséquences économiques et l'impact sur l'expérience des patients et les hôpitaux voisins.

Let the kids play: gamification as a CPR training methodology in secondary school students. A quasi-experimental manikin simulation study.
Otero-Agra M, Barcala-Furelos R, Besada-Saavedra I, Peixoto-Pino L, Martínez-Isasi S, Rodríguez-Núñez A. | Emerg Med J. 2019 Nov;36(11):653-659.
DOI: https://doi.org/10.1136/emermed-2018-208108
Keywords: CPR; feedback; gamification; secondary school education; teenagers

CPR AND FIRST AID

Introduction : Gamification is a non-evaluation and competition-based training methodology with high emotional involvement. The goal of this study was to evaluate gamification methodology as compared with other existing methodologies when teaching cardiopulmonary resuscitation (CPR) to secondary school students.

Méthode : 489 secondary school students from two high schools in Spain participated in this randomised-block quasi-experimental study in February 2018. The students were classified into different groups. Each group received CPR training with a different methodology: GAM (gamification-based training as a compulsory but non-tested academic activity to learn by playing in teams, with instructor and visual feedback); EVA (training based on subsequent evaluation as a motivational incentive, with instructor and visual feedback); VFC (visual feedback complementary, training based on a non-compulsory and non-tested academic activity, with instructor and visual feedback); TC (traditional complementary, training based on a non-compulsory and non-tested academic activity, with instructor feedback). After a week, each student performed a 2 min hands-only CPR test and quality of CPR was assessed. Visual feedback in training and CPR variables in test were provided by the QCPR Instructor App using a Little Anne manikin, both from Laerdal (Norway).

Résultats : GAM (89.56%; 95% CI 86.71 to 92.42) methodology resulted in significantly higher scores for CPR quality than VFC and TC (81.96%; 95% CI 78.04% to 85.88% and 64.11%; 95% CI 58.23 to 69.99). GAM (61.77%; 95% CI 56.09 to 67.45) methodology also resulted in significantly higher scores for correct rate than VFC and TC (48.41%; 95% CI 41.15% to 55.67% and 17.28%; 95% CI 10.94 to 23.62). 93.4% of GAM methodology participants obtained >50 mm of compression mean depth which was a significantly higher proportion than among students in VFC and TC (78.0% and 71.9%). No differences between GAM and EVA were found. A confidence level of 95% has been assigned to all values.

Conclusion : GAM methodology resulted in higher CPR quality than non-tested methods of academic training with instructor feedback or visual feedback. Gamification should be considered as an alternative teaching method for Basic Life Support (BLS) in younger individuals.

Conclusion (proposition de traduction) : La méthodologie basée sur la ludification (GAM) a abouti à une qualité de RCP meilleure que les méthodes non testées de formation académique avec rétroaction de l'instructeur ou rétroaction visuelle. La ludification doit être considérée comme une méthode d'enseignement alternative pour l'apprentissage des Gestes Elémentaires de Survie (GES = Basic Life Support [BLS] en anglais) chez les jeunes.

Commentaire : La ludification, couramment désignée par l'anglicisme « gamification », est l'utilisation des mécanismes du jeu dans d’autres domaines, en particulier des sites web, des situations d'apprentissage, des situations de travail ou des réseaux sociaux. Son but est d’augmenter l’acceptabilité et l’usage de ces applications en s’appuyant sur la prédisposition humaine au jeu. Wikipédia  .

Public perception towards bystander cardiopulmonary resuscitation.
Becker TK, Gul SS, Cohen SA, Maciel CB, Baron-Lee J, Murphy TW, Youn TS, Tyndall JA, Gibbons C, Hart L, Alviar CL; Florida Cardiac Arrest Resource Team. | Emerg Med J. 2019 Nov;36(11):660-665
DOI: https://doi.org/10.1136/emermed-2018-208234
Keywords: Cardiopulmonary Resuscitation; Heart Arrest; Out-of-Hospital Cardiac Arrest; Rescue Work; Social Perception

CPR AND FIRST AID

Introduction : Bystander cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA) improves survival and neurological outcomes. Nonetheless, many OHCA patients do not receive bystander CPR during a witnessed arrest. Our aim was to identify potential barriers to bystander CPR

Méthode : Participants at CPR training events conducted in the USA between February and May 2018 answered a 14-question survey prior to training. Respondents were asked about their overall comfort level performing CPR, and about potential concerns specific to performing CPR on a middle-aged female, a geriatric male, and male and female adolescent patients. Open-ended responses were analysed qualitatively by categorising responses into themes

Résultats : Of the 677 participants, 582 (86.0%) completed the survey, with 509 (88.1%) between 18 and 29 years of age, 341 (58.6%) without prior CPR training and 556 (96.0%) without prior CPR experience. Across all four scenarios of patients in cardiac arrest, less than 65% of respondents reported that they would be 'Extremely Likely' (20.6%-29.1%) or 'Moderately Likely' (26.9%-34.8%) to initiate CPR. The leading concerns were 'causing injury to patient' for geriatric (n=193, 63.1%), female (n=51, 20.5%) and adolescent (n=148, 50.9%) patients. Lack of appropriate skills was the second leading concern when the victim was a geriatric (n=41, 13.4%) or adolescent (n=68, 23.4%) patient, whereas for female patients, 35 (14.1%) were concerned about exposing the patient or the patient's breasts interfering with performance of CPR and 15 (6.0%) were concerned about being accused of sexual assault. Significant differences were observed in race, ethnicity and age regarding the likelihood of starting to perform CPR on female and adolescent patients

Conclusion : Participants at CPR training events have multiple concerns and fears related to performing bystander CPR. Causing additional harm and lack of skills were among the leading reservations reported. These findings should be considered for improved CPR training and public education

Conclusion (proposition de traduction) : Les participants aux formations en RCP ont de multiples préoccupations et craintes liées à la pratique de la RCP par des témoins. Les principales réserves exprimées portaient sur la possibilité de causer des dommages supplémentaires et sur le manque de compétences. Ces conclusions devraient être prises en compte pour améliorer la formation à la RCP et l'éducation du public

'The (second) year of first aid': a 15-month follow-up after a 3-day first aid programme.
Bánfai B, Pandur A, Schiszler B, Pek E, Radnai B, Csonka H, Betlehem J. | Emerg Med J. 2019 Nov;36(11):666-669.
DOI: https://doi.org/10.1136/emermed-2018-208110
Keywords: education; first responders; resuscitation

CPR AND FIRST AID

Introduction : First aid education in early childhood can be an effective method to increase the number of trained bystanders. Our aim was to evaluate the long-term effects of a 3-day first aid programme for all primary school-age groups (7-14 years old).

Méthode : This study was a 15-month follow-up of our previous investigation. Five-hundred and twenty-four primary school children were involved in this study. Measurements were made on the following topics: adult basic life support, using an automated external defibrillator (AED), handling an unconscious patient, managing bleeding and calling the ambulance. Data collection was made with a self-made questionnaire and skill test.

Résultats : Knowledge and skills were significantly higher after 15 months than before training (p<0.01). However, these results were significantly worse than immediately and 4 months after training (p<0.01). Based on the questionnaire, more than three-quarters knew the emergency phone number 15 months after training. Approximately two-thirds of the children could use the correct hand position in cardiopulmonary resuscitation, the correct compression-ventilation ratio and an AED, and half of them could perform correct recovery position at 15 months. Correct assessment of breathing was similar in a situation game than before training. Self-efficacy improved significantly after training (p<0.01) and remained improved after 4 and 15 months when compared with before training (p<0.01).

Conclusion : Participants could remember some aspects of first aid long term. However, knowledge and skills had declined after 15 months, so refresher training would be recommended. Self-efficacy towards first aid improved after training and remained high after 15 months.

Conclusion (proposition de traduction) : Les participants ont pu se souvenir de certains aspects des premiers secours à long terme. Cependant, les connaissances et les compétences ayant diminué après 15 mois, une formation de recyclage serait recommandée. L'auto-efficacité en matière de premiers secours s'est améliorée après la formation et est restée élevée après 15 mois.

Should we resuscitate elderly patients with blunt traumatic cardiac arrest? Analysis of National Trauma Registry Data in Japan.
Norii T, Matsushima K, Miskimins RJ, Crandall CS. | Emerg Med J. 2019 Nov;36(11):670-677
DOI: https://doi.org/10.1136/emermed-2019-208690
Keywords: cardiac arrest; epidemiology; geriatrics; major trauma management; trauma

CRITICAL CARE

Introduction : Recent studies suggest that survival after traumatic cardiac arrest (TCA) has been improving. Many elderly adults enjoy active lifestyles, which occasionally result in TCA. The epidemiology and efficacy of resuscitative procedures on blunt TCA in elderly patients are largely unknown. Our primary aim was to compare the survival to discharge following blunt TCA between non-elderly adult (ages 18-59 years) and elderly patients (age ≥60 years).

Méthode : We analysed 2004-2015 observational cohort data from a nationwide trauma registry in Japan. We included all adult patients (18 years and older) who experienced blunt TCA. We excluded patients missing data for age, survival, mechanism of injury or initial vital signs. Resuscitative procedures included thoracotomy and resuscitative endovascular balloon occlusion of the aorta. We compared survival for elderly patients (age ≥60 years old) to younger adults.

Résultats : Of 8347 patients with blunt TCA, 3547 (42.5%) were elderly. Survival differed significantly by age: 164/4800 (3.4%) of younger adults survived whereas 188/3547 (5.3%) of elderly patients survived (p<0.001). Survival increased but Injury Severity Scores (ISSs) declined with increasing patient age. The efficacy of resuscitative procedures did not vary by age. In logistic regression models, increasing age was independently associated with better survival.

Conclusion : In a cohort of patients with blunt TCA, survival increased with increasing patient age. A number of patients with low ISS in the elderly group raises the possibility that this improved survival is due to preceding or concomitant medical cardiac arrest in the older cohort. Clinicians should be cautious about applying TCA algorithms to elderly patients and should not be discouraged from resuscitating TCA because of patient age.

Conclusion (proposition de traduction) : Dans une cohorte de patients en arrêt cardiaque traumatique, la survie augmentait avec l'âge du patient.
Un certain nombre de patients avec un ISS faible dans le groupe des personnes âgées soulève la possibilité que cette amélioration de la survie soit due à un arrêt cardiaque médical antérieur ou concomitant dans la cohorte plus âgée.
Les cliniciens doivent être prudents quant à l'application d'algorithmes d'arrêt cardiaque traumatique aux patients âgés et ne doivent pas être découragés de réanimer un arrêt cardiaque traumatique en raison de l'âge du patient.

Predicting sudden cardiac death in a general population using an electrocardiographic risk score.
Holkeri A, Eranti A, Haukilahti MAE, Kerola T, Kenttä TV, Tikkanen JT, Anttonen O, Noponen K, Seppänen T, Rissanen H, Heliövaara M, Knekt P, Junttila MJ, Huikuri HV, Aro AL. | Heart. 2019 Nov 15. pii: heartjnl-2019-315437
DOI: https://doi.org/10.1136/heartjnl-2019-315437
Keywords: ECG; electrocardiography; epidemiology

Arrhythmias and sudden death

Introduction : We investigated whether combining several ECG abnormalities would identify general population subjects with a high sudden cardiac death (SCD) risk.

Méthode : In a sample of 6830 participants (mean age 51.2±13.9 years; 45.5% male) in the Mini-Finland Health Survey, a general population cohort representative of the Finnish adults aged ≥30 years conducted in 1978-1980, we examined their ECGs, following subjects for 24.3±10.4 years. We analysed the association between individual ECG abnormalities and 10-year SCD risk and developed a risk score using five ECG abnormalities independently associated with SCD risk: heart rate >80 beats per minute, PR duration >220 ms, QRS duration >110 ms, left ventricular hypertrophy and T-wave inversion. We validated the score using an external general population cohort of 10 617 subjects (mean age 44.0±8.5 years; 52.7% male).

Résultats : No ECG abnormalities were present in 4563 subjects (66.8%), while 96 subjects (1.4%) had ≥3 ECG abnormalities. After adjusting for clinical factors, the SCD risk increased progressively with each additional ECG abnormality. Subjects with ≥3 ECG abnormalities had an HR of 10.23 (95% CI 5.29 to 19.80) for SCD compared with those without abnormalities. The risk score similarly predicted SCD risk in the validation cohort, in which subjects with ≥3 ECG abnormalities had HR 10.82 (95% CI 3.23 to 36.25) for SCD compared with those without abnormalities.

Conclusion : The ECG risk score successfully identified general population subjects with a high SCD risk. Combining ECG risk markers may improve the risk stratification for SCD.

Conclusion (proposition de traduction) : Le score de risque ECG a réussi à identifier les sujets dans la population générale présentant un risque élevé de mort subite d'origine cardiaque. La combinaison de marqueurs de risque ECG peut améliorer la stratification du risque de mort subite d'origine cardiaque.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Un score ECG pour déterminer le risque de mort subite d'origine cardiaque  . Rédigé par le Dr Jean-Claude Lemaire le 16 décembre 2019.

Real-world efficacy and safety of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation.
Violi F, Pastori D. | Intern Emerg Med. 2019 Nov;14(8):1199-1201
DOI: https://doi.org/10.1007/s11739-019-02135-y
Keywords: Aucun

IM - COMMENTARY

Editorial : The INSIghT investigators performed a real-world prospec- tive observational cohort study to investigate the safety and efficacy of non-vitamin K antagonist oral anticoagu- lants (NOACs) in 632 patients with atrial fibrillation (AF) according to the presence of chronic kidney disease (CKD), defined by a creatinine clearance (CrCl) < 60 ml/min [1]. Patients with CKD (n = 219) were at higher thromboembolic risk, as they were older, more likely to be women, hyperten- sive and diabetic. Among NOACs, apixaban was the most commonly used anticoagulant in CKD patients, followed by dabigatran and rivaroxaban. No patients on edoxaban were included.

Conclusion : In conclusion, patients with AF and CKD represent a high-risk subset of patients that would require a structured and careful monitoring. The use of NOACs in this popula- tion is increasing, and NOACs are becoming a safe alterna- tive to warfarin also in patients with very low renal function.

Conclusion (proposition de traduction) : En conclusion, les patients présentant une fibrillation auriculaire et une Insuffisance Rénale Chronique représentent un sous-ensemble de patients à haut risque qui nécessiteraient une surveillance structurée et attentive. L'utilisation des AOD dans cette population est en augmentation et les AOD deviennent une alternative sûre à la warfarine également chez les patients à très faible fonction rénale.

Real-world 2-year outcome of atrial fibrillation treatment with dabigatran, apixaban, and rivaroxaban in patients with and without chronic kidney disease.
Godino C, Melillo F, Rubino F, Arrigoni L, Cappelletti A, Mazzone P, Mattiello P, Della Bella P, Colombo A, Salerno A, Cera M, Margonato A; INSIghT investigators. | Intern Emerg Med. 2019 Nov;14(8):1259-1270
DOI: https://doi.org/10.1007/s11739-019-02100-9
Keywords: Chronic kidney disease; Direct oral anticoagulant; Non-valvular atrial fibrillation

IM - ORIGINAL

Introduction : Patients with non-valvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) are at increased risk of stroke and bleeding.

Méthode : Although direct oral anticoagulant (DOAC) trials excluded patients with severe CKD, a growing portion of CKD patients have been starting DOACs and limited data from real-world outcome in this high-risk setting are available.

Résultats : The INSigHT registry included 632 consecutive NVAF patients that started apixaban (256 patients, 41%), dabigatran (245, 39%) and rivaroxaban (131, 20%) between 2012 and 2015. Based on creatinine clearance, two sub-cohorts were defined: (1) non-CKD group (CrCl 60-89 mL/min, 413 patients) and (2) CKD group (15-59 ml/min, 219). Compared to non-CKD patients, those with CKD, were at higher ischemic (CHA2DS2-VASc 4.5 vs 2.9, p < 0.001) and hemorrhagic risk (HAS-BLED 2.4 vs 1.8, p < 0.001). At 2-year follow-up, the overall ISTH-major bleeding and thromboembolic event rates were 5.2% and 2.3% and no significant difference between non-CKD and CKD patients for both efficacy and safety endpoints were observed. In non-CKD patients, the 2-year ISTH-major bleeding rates were higher in rivaroxaban group (HR 2.9, 95% CI 1.1-7.3; p = 0.047) while dabigatran showed non-significant excess in thromboembolic events (HR 4.3, 95% CI 0.9-20.8; p = 0.068). In CKD patients, a significantly higher rate of thromboembolic events was observed in rivaroxaban (HR 6.3, 95% CI 1.1-38.1; p = 0.044).

Conclusion : This real-world, non-insurance database registry shows remarkable 2-year safety and efficacy profile of DOACs even in patients with moderate to severe CKD. Head to head differences between DOACs are exploratory, hypothesis generating and warrant further investigation in larger studies.

Conclusion (proposition de traduction) : Ce registre de base de données réel, non assuré, présente un profil remarquable de sécurité et d'efficacité des AOD sur deux ans, même chez les patients atteints d'une IRC modérée à sévère. Les différences entre les AOD sont exploratoires, génèrent des hypothèses et justifient des recherches plus approfondies dans le cadre d'études plus importantes.

Prognostic value of serial lactate levels in septic patients with and without shock.
Innocenti F, Meo F, Giacomelli I, Tozzi C, Ralli ML, Donnini C, Tassinari I, Caldi F, Zanobetti M, Pini R. | Intern Emerg Med. 2019 Nov;14(8):1321-1330
DOI: https://doi.org/10.1007/s11739-019-02196-z
Keywords: Lactate; Lactate clearance; Prognosis; Septic shock

EM - ORIGINAL

Introduction : To analyze the prognostic value of lactate levels for day-7 and in-hospital mortality, in septic patients with and without shock.

Méthode : In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis of sepsis.

Résultats : actate dosage was performed at ED-HDU admission (T0), after 2 h (T2), 6 h (T6) and 24 h (T24); lactate clearance was calculated at T2 and T6 [T2: ((LAC T0-LAC T2/LAC T0)*100)]; T6: [(LAC T0-LAC T6/LAC T0)*100]. The end-points were day-7 and in-hospital mortality. At every evaluation, the lactate level was higher in patients with shock than in those without (T0 3.8 ± 3.8 vs 2.4 ± 2.1; T6 2.9 ± 3.2 vs 1.6 ± 1.1; T24 3.0 ± 4.4 vs 1.4 ± 0.9 meq/L, all p < 0.001). Among patients with shock, an analysis for repeated measures confirmed a more marked lactate level reduction in survivors compared with non-survivors, both by day-7 and in-hospital mortality (p = 0.057 and p = 0.006). A Kaplan-MeIer analysis confirmed a significantly better day-7 survival in patients with T6 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) and T24 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) lactate ≤ 2 meq/L, compared with patients with higher levels. A T6 lactate clearance > 10% was more frequent among in-hospital survivors in the whole study population (57% vs 39%) and in patients with shock (74% vs 46%, all p < 0.05).

Conclusion : Higher lactate levels and decreased clearance were associated with an increased short-term and intermediate-term mortality regardless of the presence of shock.

Conclusion (proposition de traduction) : Des niveaux de lactate plus élevés et une clairance réduite ont été associés à une augmentation de la mortalité à court terme et à moyen terme, indépendamment de la présence d'un choc.

Triage and flow management in sepsis.
Pires HHG, Neves FF, Pazin-Filho A. | Int J Emerg Med. 2019 Nov 21;12(1):36
DOI: https://doi.org/10.1186/s12245-019-0252-9  | Télécharger l'article au format  
Keywords: Clinical pathways; Health care rationing; Healthcare systems; Sepsis; Triage

Original Research

Introduction : Sepsis is a major public health problem, with a growing incidence and mortality rates still close to 30% in severe cases. The speed and adequacy of the treatment administered in the first hours of sepsis, particularly access to intensive care, are important to reduce mortality. This study compared the triage strategies and intensive care rationing between septic patients and patients with other indications of intensive care. This study included all patients with signs for intensive care, enrolled in the intensive care management system of a Brazilian tertiary public emergency hospital, from January 1, 2010, to December 31, 2016. The intensivist periodically evaluated the requests, prioritizing them according to a semi-quantitative scale. Demographic data, Charlson Comorbidity Index (CCI), Sequential Organ Failure Assessment (SOFA), and quick SOFA (qSOFA), as well as surgical interventions, were used as possible confounding factors in the construction of incremental logistic regression models for prioritization and admission to intensive care outcomes.

Résultats : The study analyzed 9195 ICU requests; septic patients accounted for 1076 cases (11.7%), 293 (27.2%) of which were regarded as priority 1. Priority 1 septic patients were more frequently hospitalized in the ICU than nonseptic patients (52.2% vs. 34.9%, p <  0.01). Septic patients waited longer for the vacancy, with a median delay time of 43.9 h (interquartile range 18.2-108.0), whereas nonseptic patients waited 32.5 h (interquartile range 11.5-75.8)-p <  0.01. Overall mortality was significantly higher in the septic group than in the group of patients with other indications for intensive care (72.3% vs. 39.8%, p <  0.01). This trend became more evident after the multivariate analysis, and the mortality odds ratio was almost three times higher in septic patients (2.7, 2.3-3.1).

Conclusion : Septic patients had a lower priority for ICU admission and longer waiting times for an ICU vacancy than patients with other critical conditions. Overall, this implied a 2.7-fold increased risk of mortality in septic patients.

Conclusion (proposition de traduction) : Les patients septiques avaient une priorisation inférieure pour l'admission en soins intensifs et des temps d'attente plus longs pour une place aux soins intensifs que les patients souffrant d'autres pathologies en situation critique. Dans l'ensemble, cela impliquait un risque de surmortalité multiplié par 2,7 chez les patients septiques.

Triage and flow management in sepsis.
Pires HHG, Neves FF, Pazin-Filho A. | Int J Emerg Med. 2019 Nov 21;12(1):36
DOI: https://doi.org/10.1186/s12245-019-0252-9  | Télécharger l'article au format  
Keywords: Clinical pathways; Health care rationing; Healthcare systems; Sepsis; Triage

Original research

Introduction : Sepsis is a major public health problem, with a growing incidence and mortality rates still close to 30% in severe cases. The speed and adequacy of the treatment administered in the first hours of sepsis, particularly access to intensive care, are important to reduce mortality. This study compared the triage strategies and intensive care rationing between septic patients and patients with other indications of intensive care. This study included all patients with signs for intensive care, enrolled in the intensive care management system of a Brazilian tertiary public emergency hospital, from January 1, 2010, to December 31, 2016. The intensivist periodically evaluated the requests, prioritizing them according to a semi-quantitative scale. Demographic data, Charlson Comorbidity Index (CCI), Sequential Organ Failure Assessment (SOFA), and quick SOFA (qSOFA), as well as surgical interventions, were used as possible confounding factors in the construction of incremental logistic regression models for prioritization and admission to intensive care outcomes.

Résultats : The study analyzed 9195 ICU requests; septic patients accounted for 1076 cases (11.7%), 293 (27.2%) of which were regarded as priority 1. Priority 1 septic patients were more frequently hospitalized in the ICU than nonseptic patients (52.2% vs. 34.9%, p <  0.01). Septic patients waited longer for the vacancy, with a median delay time of 43.9 h (interquartile range 18.2-108.0), whereas nonseptic patients waited 32.5 h (interquartile range 11.5-75.8)-p <  0.01. Overall mortality was significantly higher in the septic group than in the group of patients with other indications for intensive care (72.3% vs. 39.8%, p <  0.01). This trend became more evident after the multivariate analysis, and the mortality odds ratio was almost three times higher in septic patients (2.7, 2.3-3.1).

Conclusion : Septic patients had a lower priority for ICU admission and longer waiting times for an ICU vacancy than patients with other critical conditions. Overall, this implied a 2.7-fold increased risk of mortality in septic patients.

Conclusion (proposition de traduction) : Les patients septiques avaient une priorité inférieure pour l'admission en soins intensifs et des temps d'attente plus longs pour une disponibilité de place aux soins intensifs que les patients souffrant d'autres situations critiques. Dans l'ensemble, cela impliquait un risque de mortalité multiplié par 2,7 chez les patients septiques.

Cardiac arrest in obstetrics.
Fischer C | JEUR. 2019 Dec;31:151—157
DOI: https://doi.org/10.1016/j.jeurea.2019.08.013
Keywords: Cardiac arrest; Pregnancy; Delivery; Cesarean section

Republication de

Editorial : La fréquence de l’arrêt cardiaque au cours de la grossesse est de l’ordre de 1/12 000. Les principales causes sont l’hémorragie de la délivrance et l’embolie amniotique. La réanimation de l’arrêt cardiaque a certaines particularité : déplacement manuel de l’utérus gravide et surtout réalisation rapide et prioritaire de la césarienne sur place après 20–24 semaines d’aménorrhée.

Conclusion (proposition de traduction) : La survenue intra-hospitalière d’un arrêt cardiaque maternel est un événement rare face auquel les équipes soignantes doivent se préparer et organiser le maintien de leurs compétences dans le cadre de programmes de formation et de simulation. Les manœuvres de ressuscitation doivent être coordonnées et multidisciplinaires ; les particularités sont liées à la compression aorto-cave par l’utérus gravide qui nécessite une latéro-déviation utérine manuelle au cours du MCE et à un risque d’hypoxie précoce qui doit conduire à une oxygénation rapide. Pour les premières minutes, et quel que soit le terme, les objectifs de la prise en charge visent uniquement à restaurer une activité cardiaque spontanée maternelle et suivent les algorithmes de la RCP de l’adulte. En cas d’échec de la réanimation initiale, et après 20 SA, la césarienne pratiquée sur place sans interrompre le massage cardiaque, dans le but de lever la compression aorto-cave, permet d’améliorer le pronostic maternel. Après 24 SA, elle peut permettre également le sauvetage fœtal. La règle des 4 minutes conditionne le pronostic neurologique maternel.

Sex-Related Differences in Heart Failure After ST-Segment Elevation Myocardial Infarction.
Edina Cenko, Mihaela van der Schaar, Jinsung Yoon, Olivia Manfrini, Zorana Vasiljevic, Marija Vavlukis, Sasko Kedev, Davor Miličić, Lina Badimon, Raffaele Bugiardini . | J Am Coll Cardiol . 2019 Nov;74(19):2379-2389
DOI: https://doi.org/10.1016/j.jacc.2019.08.1047
Keywords: ST-segment elevation myocardial infarction; heart failure; outcomes; sex differ

ORIGINAL INVESTIGATIONS

Introduction : ST-segment elevation myocardial infarction (STEMI) complicated by symptoms of acute de novo heart failure is associated with excess mortality. Whether development of heart failure and its outcomes differ by sex is unknown.
Objectives: This study sought to examine the relationships among sex, acute heart failure, and related outcomes after STEMI in patients with no prior history of heart failure recorded at baseline.

Méthode : Patients were recruited from a network of hospitals in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776). Main outcome measures were incidence of Killip class ≥II at hospital presentation and risk-adjusted 30-day mortality rates were estimated using inverse probability of weighting and logistic regression models.

Résultats : This study included 10,443 patients (3,112 women). After covariate adjustment and matching for age, cardiovascular risk factors, comorbidities, disease severity, and delay to hospital presentation, the incidence of de novo heart failure at hospital presentation was significantly higher for women than for men (25.1% vs. 20.0%, odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.21 to 1.48). Women with de novo heart failure had higher 30-day mortality than did their male counterparts (25.1% vs. 20.6%; OR: 1.29; 95% CI: 1.05 to 1.58). The sex-related difference in mortality rates was still apparent in patients with de novo heart failure undergoing reperfusion therapy after hospital presentation (21.3% vs. 15.7%; OR: 1.45; 95% CI: 1.07 to 1.96).

Conclusion : Women are at higher risk to develop de novo heart failure after STEMI and women with de novo heart failure have worse survival than do their male counterparts. Therefore, de novo heart failure is a key feature to explain mortality gap after STEMI among women and men.

Conclusion (proposition de traduction) : Les femmes sont plus à risque de développer une insuffisance cardiaque de novo après un STEMI et les femmes atteintes d'insuffisance cardiaque de novo ont une survie pire que leurs homologues masculins. Par conséquent, l'insuffisance cardiaque de novo est une caractéristique clé pour expliquer l'écart de mortalité après un STEMI chez les femmes et les hommes.

ACC/AHA/HRS Versus ESC Guidelines for the Diagnosis and Management of Syncope: JACC Guideline Comparison.
Zachary D Goldberger, Bradley J Petek, Michele Brignole, Win-Kuang Shen, Robert S Sheldon, Monica Solbiati, Jean-Claude Deharo, Angel Moya, Mohamed H Hamdan . | J Am Coll Cardiol. 2019 Nov;74(19):2410-2423
DOI: https://doi.org/10.1016/j.jacc.2019.09.012
Keywords: bifascicular block; clinical practice guidelines; electrophysiological study; implantable loop recorder; orthostatic hypotension; permanent pacemaker; reflex syncope; syncope.

Review

Editorial : Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after extensive (and often expensive) evaluation. Clinical practice guidelines have been developed to help guide the multidisciplinary approach necessary to diagnose and manage the broad spectrum of patients presenting with syncope. The American College of Cardiology/American Heart Association, in collaboration with the Heart Rhythm Society, published its first syncope guidelines in 2017. The European Society of Cardiology released the fourth iteration of its syncope guidelines in 2018. This review highlights the differences and congruencies between the 2 sets of recommendations, their implications for clinical practice, the remaining gaps in understanding, and areas of future research.

Conclusion : Clinical practice guidelines are invaluable resources for practitioners. They offer recommendations about best practices derived from contemporary evidence and consensus from a group of experts in the discipline. Challenges and potential controversies emerge when multiple societies offer different recommendations about the evaluation and management of disease processes. Indeed, it may be difficult for the practitioner to reconcile potential differences when multiple sets of recommendations exist, and carries implications for patient care.
A comparison of the U.S. and European guidelines for the diagnosis and evaluation of syncope yields several insights. There are notable differences in recommendations among the 3 broad domains of care—conduction disease, reflex syncope, and orthostatic hypotension. However, in many respects, the “transatlantic” treatment recommendations are grossly similar—slight differences in COR (e.g., Class IIa vs. Class IIb) can be reconciled, and may relate to the “exact” definitions underlying these recommen- dations, as described in the previous text.
Overall, eliminating all differences in any 2 sets of clinical practice guidelines may never be possible. As such, understanding sources of discordancy is of paramount importance. Even in the era of evidence-based medicine, practitioners will have slightly varied interpretations and opinions of similar data. Despite key discordances, the 2 recent syncope guidelines are complementary.

Conclusion (proposition de traduction) : Une comparaison des lignes directrices américaines et européennes pour le diagnostic et l'évaluation des syncopes donne plusieurs informations. Il existe des différences notables dans les recommandations entre les trois grands domaines de soins - trouble de la conduction, syncope réflexe et hypotension orthostatique. Cependant, à bien des égards, les recommandations de prise en charge thérapeutique « transatlantique » sont très similaires - de légères différences dans la classe de recommandation (par exemple, classe IIa contre classe IIb) peuvent être rapprochées et peuvent se rapporter aux définitions « exactes » qui sous-tendent ces recommandations, comme décrit dans le texte de l'article.
Dans l'ensemble, l'élimination de toutes les différences dans 2 ensembles de lignes directrices de pratique clinique peut ne jamais être possible. À ce titre, la compréhension des sources de discordance est d'une importance capitale. Même à l'ère de la médecine factuelle, les praticiens auront des interprétations et des opinions légèrement différentes de données similaires. Malgré les discordances clés, les 2 directives de syncope récentes sont complémentaires.

Commentaire : Les recommandations en question :
• Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017;70:e39–110  .
• Brignole M, Moya A, de Lange FJ, et al. 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39:1883–948  .

POINTS FORTS
La syncope est une entité clinique commune avec des présentations variables et souvent un mécanisme causal insaisissable, même après une évaluation approfondie.
Des différences clés dans les recommandations ont été notées chez les patients présentants un trouble de la conduction, de syncope réflexe et d'hypotension orthostatique. Cependant, de nombreuses recommandations de prise en charge thérapeutique étaient très similaires.
Des essais randomisés et des investigations transnationales supplémentaires seraient nécessaires pour renforcer les recommandations qui ne sont actuellement étayées que par des niveaux de preuves faibles et dans des domaines de divergence entre les recommandations.

Multimodality Imaging for Best Dealing With Patients in Atrial Arrhythmias.
Donal E, Galli E, Lederlin M, Martins R, Schnell F. | JACC Cardiovasc Imaging. 2019 Nov;12(11 Pt 1):2245-2261
DOI: https://doi.org/10.1016/j.jcmg.2018.06.031
Keywords: Aucun

STATE-OF-THE-ART REVIEW

Editorial : The management of atrial fibrillation (AF) is not only a clinical challenge but also an imaging challenge. The role of different imaging modalities to estimate the thromboembolic risk in AF is a key clinical question. The present review summarizes the advances of myocardial imaging in the stratification of thromboembolic risk, diagnosis, and management of left atrial thrombosis in patients with AF. These imaging techniques are also important for understanding arrhythmias and their consequences. It is becoming fundamental for guiding therapy. Still, large studies are required, but be sure that left atrial imaging will become more and more clinically fundamental.

Conclusion : The assessment of left atrial morphology and function, which has been neglected for a long time, is becoming more and more important in the management of patients with atrial fibrillation. The understanding of the complex interaction between the electrical and anatomical substrates strictly relies on the combination of different imaging techniques and might contribute to an individualized treatment strategy of atrial fibrillation. Recent advances suggest that left atrial imaging might also be useful for a tailored preventive treatment of patients at mild-to-moderate cardioembolic risk. Nevertheless, high-quality studies remain mandatory for moving from actually used clinical scores to a more image-based individualized approach

Conclusion (proposition de traduction) : L'évaluation de la morphologie et de la fonction de l'oreillette gauche, longtemps négligée, devient de plus en plus importante dans la prise en charge des patients atteints de fibrillation auriculaire. La compréhension de l'interaction complexe entre les substrats électriques et anatomiques repose strictement sur la combinaison de différentes techniques d'imagerie et pourrait contribuer à une stratégie de traitement individualisée de la fibrillation auriculaire. Des avancées récentes suggèrent que l'imagerie auriculaire gauche pourrait également être utile pour un traitement préventif personnalisé des patients à risque cardio-embolique léger à modéré. Néanmoins, des études de haute qualité restent obligatoires pour passer de scores cliniques réellement utilisés à une approche individualisée davantage basée sur l'imagerie médicale.

Effect of Ubrogepant vs Placebo on Pain and the Most Bothersome Associated Symptom in the Acute Treatment of Migraine: The ACHIEVE II Randomized Clinical Trial.
Lipton RB, Dodick DW, Ailani J, Lu K4, Finnegan M, Szegedi A, Trugman JM. | JAMA. 2019 Nov 19;322(19):1887-1898
DOI: https://doi.org/10.1001/jama.2019.16711  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Ubrogepant is an oral calcitonin gene-related peptide receptor antagonist under investigation for acute treatment of migraine.
OBJECTIVE : To evaluate the efficacy and tolerability of ubrogepant compared with placebo for acute treatment of a single migraine attack.

Méthode : Phase 3, multicenter, randomized, double-blind, placebo-controlled, single-attack, clinical trial (ACHIEVE II) conducted in the United States (99 primary care and research clinics; August 26, 2016-February 26, 2018). Participants were adults with migraine with or without aura experiencing 2 to 8 migraine attacks per month.
INTERVENTIONS: Ubrogepant 50 mg (n = 562), ubrogepant 25 mg (n = 561), or placebo (n = 563) for a migraine attack of moderate or severe pain intensity.
MAIN OUTCOMES AND MEASURES

Résultats : Among 1686 randomized participants, 1465 received study treatment (safety population; mean age, 41.5 years; 90% female); 1355 of 1465 (92.5%) were evaluable for efficacy. Pain freedom at 2 hours was reported by 101 of 464 participants (21.8%) in the ubrogepant 50-mg group, 90 of 435 (20.7%) in the ubrogepant 25-mg group, and 65 of 456 (14.3%) in the placebo group (absolute difference for 50 mg vs placebo, 7.5%; 95% CI, 2.6%-12.5%; P = .01; 25 mg vs placebo, 6.4%; 95% CI, 1.5%-11.5%; P = .03). Absence of the most bothersome associated symptom at 2 hours was reported by 180 of 463 participants (38.9%) in the ubrogepant 50-mg group, 148 of 434 (34.1%) in the ubrogepant 25-mg group, and 125 of 456 (27.4%) in the placebo group (absolute difference for 50 mg vs placebo, 11.5%; 95% CI, 5.4%-17.5%; P = .01; 25 mg vs placebo, 6.7%; 95% CI, 0.6%-12.7%; P = .07). The most common adverse events within 48 hours of any dose were nausea (50 mg, 10 of 488 [2.0%]; 25 mg, 12 of 478 [2.5%]; and placebo, 10 of 499 [2.0%]) and dizziness (50 mg, 7 of 488 [1.4%]; 25 mg, 10 of 478 [2.1%]; placebo, 8 of 499 [1.6%]).

Conclusion : Among adults with migraine, acute treatment with ubrogepant compared with placebo led to significantly greater rates of pain freedom at 2 hours with 50-mg and 25-mg doses, and absence of the most bothersome migraine-associated symptom at 2 hours only with the 50-mg dose. Further research is needed to assess the effectiveness of ubrogepant against other acute treatments for migraine and to evaluate the long-term safety of ubrogepant among unselected patient populations.

Conclusion (proposition de traduction) : Chez les adultes souffrant de migraine, un traitement à la phase aigüe par ubrogépant par rapport au placebo a permis des taux significativement plus élevés de sédation de la douleur à 2 heures avec des doses de 50 mg et 25 mg, et à l'absence du symptôme associé à la migraine le plus gênant à 2 heures seulement avec le dosage de 50 mg.
Des recherches supplémentaires sont nécessaires pour évaluer l'efficacité de l'ubrogépant contre d'autres traitements aigus de la migraine et pour évaluer l'innocuité à long terme de l'ubrogépant parmi les populations de patients non sélectionnés.

Commentaire : Note :
L'ubrogepant (Ubrelvy aux Etats-Unis) est un nouveau traitement indiqué dans le traitement aigu de la migraine avec ou sans aura chez l'adulte. Il a également comme effet de réduire les symptômes les plus gênants que sont la nausée et l'hypersensibilité à la lumière ou au son.
C'est le premier traitement oral, antagoniste des récepteurs CGRP (Calcitonin Gene-related Peptide).
Il a été approuvé en 2019 par la FDA des Etats-Unis mais n'est pas encore disponible en France.

Physician Confidence in Dental Trauma Treatment and the Introduction of a Dental Trauma Decision-Making Pathway for the Pediatric Emergency Department.
Cully M, Cully J, Nietert PJ, Titus MO. | Pediatr Emerg Care. 2019 Nov;35(11):745-748
DOI: https://doi.org/10.1097/PEC.0000000000001479
Keywords: Aucun

Original Articles

Introduction : The objectives of this study were to (1) survey and report the awareness and confidence of pediatric emergency medicine physicians in the management of dental trauma and (2) determine the prevalence of dental trauma decision-making pathway utilization in the pediatric emergency department.

Méthode : A survey was distributed through e-mail to the pediatric emergency medicine discussion list via Brown University LISTSERV. The survey study included 10 questions and was multiple-choice. The survey contained questions about physician confidence and their use of a dental trauma decision-making pathway.

Résultats : A total of 285 individuals responded to the survey. Somewhat confident was the most common response (61%) followed by not confident (20%) and confident (19%) by respondents in treating dental trauma. Forty-one percent of respondents felt comfortable, 39% somewhat comfortable, 19% not comfortable, and 1% not sure in replanting an avulsed tooth. Only 6% of respondents reported that their pediatric emergency department always or sometimes uses a dental trauma decision-making pathway, whereas 78% of pediatric emergency departments do not.

Conclusion : We believe that the adoption of a decision-making pathway will provide timely management, improve emergency physician comfort, and enhance outcomes for pediatric patients presenting with a dental trauma. A future multicenter review will aim to evaluate these goals based on the utilization of our dental trauma decision-making pathway.

Conclusion (proposition de traduction) : Nous croyons que l'adoption d'un processus décisionnel permettra une gestion rapide, améliorera le confort du médecin d'urgence et améliorera les résultats pour les patients pédiatriques qui présentent un traumatisme dentaire. Un futur examen multicentrique visera à évaluer ces objectifs en fonction de l'utilisation de notre voie de prise de décision en matière de traumatismes dentaires.

Commentaire : 

Buccal Midazolam Compared With Rectal Diazepam Reduces Seizure Duration in Children in the Outpatient Setting.
Moretti R, Julliand S, Rinaldi VE, Titomanlio L. | Pediatr Emerg Care. 2019 Nov;35(11):760-764
DOI: https://doi.org/10.1097/PEC.0000000000001114
Keywords: Aucun

Original Articles

Introduction : Seizures are very common in children. They frequently happen in outpatient settings, in the presence of caregivers who are not always trained in their management. First-line rescue therapy is based on benzodiazepine, historically diazepam. Recent studies have investigated the use of other benzodiazepines in the treatment of acute seizures.

Méthode : The aims of this study were to evaluate the management of pediatric seizures carried out by parents or caregivers in an outpatient setting and to evaluate the differences in terms of immediate management and subsequent outcome when comparing the use of rectal diazepam versus buccal midazolam.
METHODS : In this retrospective study, medical records of children consulting for seizures at the Robert Debré Pediatric Emergency Department of Paris, France, over 18 months were analyzed to evaluate seizure characteristics, management by caregivers, received treatments, and the admission rate.

Résultats : Five hundred ninety-four patients resulted eligible for the study. The interview was completed for 135 children who presented a further episode of seizure after inclusion. In the subgroup of children receiving buccal midazolam, compared with the subgroup receiving intrarectal diazepam, seizure duration was significantly shorter (10.3 vs 48.4 minutes, P = 0.0004), and the risk of a status epilepticus decreased (1 vs 11, P = 0.0008). The admission rate was not different between the 2 subgroups.

Conclusion : Based on our results, buccal midazolam seems to have some advantages compared with rectal diazepam in terms of feasibility in an outpatient setting and in terms of reduced seizure duration.

Conclusion (proposition de traduction) : D'après nos résultats, le midazolam buccal semble présenter certains avantages par rapport au diazépam rectal en termes de faisabilité dans un cadre ambulatoire et en termes de réduction de la durée des crises.

Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.
Tejedor-Sojo J, Chan KN, Bailey M, Williams A, Killgore M, Gillard L, Campo M, Hua H, Jain S. | Pediatr Emerg Care. 2019 Nov;35(11):791-798
DOI: https://doi.org/10.1097/PEC.0000000000001966
Keywords: Aucun

Original Research-QI

Introduction : This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives.

Méthode : We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts.

Résultats : For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change.

Conclusion : A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.

Conclusion (proposition de traduction) : Un projet d'amélioration de la qualité à l'échelle du système impliquant plusieurs établissements de soins ambulatoires a permis de réduire l'utilisation de thérapeutiques et d'interventions inefficaces chez des enfants présentant une bronchiolite et a entraîné des économies importantes. Les améliorations des soins ont été maintenues pendant 3 saisons de bronchiolite.

Commentaire : La dernière recommandation de la HAS sur le sujet :
Prise en charge du premier épisode de bronchiolite aiguë chez le nourrisson de moins de 12 mois  . RPC novembre 2019.

Synchronized Chest Compressions for Pseudo-PEA: Proof of Concept and a Synching Algorithm.
Marill KA, Menegazzi JJ, Koller AC, Sundermann ML, Salcido DD. | Prehosp Emerg Care. 2019 Nov 7:1-13
DOI: https://doi.org/10.1080/10903127.2019.1690605
Keywords: PEA; chest compressions; pulseless electrical activity; swine; synchronized

Article

Introduction : The two objectives of this report are: first, to describe a comparison of chest compressions unsynchronized or synchronized to native cardiac activity in a porcine model of hypotension, and second, to develop an algorithm to provide synchronized chest compressions throughout a range of native heart rates likely to be encountered when treating PEA cardiac arrest.

Méthode : We adapted our previously developed signal-guided CPR system to provide compressions synchronized to native electrical activity in a porcine model of hypotension as a surrogate of PEA arrest. We describe the first comparison of unsynchronized to synchronized compressions in a single animal as a proof-of-concept. We developed an algorithm to provide optimal synchronized chest compressions regardless of intrinsic PEA heart rate while simultaneously maintaining the chest compression rate within a desired range. We tested the algorithm with computer simulations measuring the proportion of intrinsic and compression beats that were synchronized, and the compression rate and its standard deviation, as a function of intrinsic heart rate and heart rate jitter.

Résultats : We demonstrate and compare unsynchronized versus synchronized chest compressions in a single porcine model with an intrinsic rhythm and hypotension. Synchronized, but not unsynchronized, chest compressions were associated with increased blood pressure and coronary perfusion pressure. Our synchronized chest compression algorithm is able to provide synchronized chest compressions to over 90% of intrinsic beats for most heart rates while maintaining an average compression rate between 95 and 135 compressions per minute with relatively low variability.

Conclusion : Synchronized chest compression therapy for pulseless electrical rhythms is feasible. A high degree of synchronization can be maintained over a broad range of intrinsic heart rates while maintaining the compression rate within a satisfactory range. Further investigation to assess benefit for treatment of PEA is warranted.

Conclusion (proposition de traduction) : Un traitement par compression thoracique synchronisée dans l'activité électrique sans pouls (AES) est possible. Un degré élevé de synchronisation peut être maintenu sur une large gamme de fréquences cardiaques intrinsèques tout en maintenant le taux de compression dans une plage satisfaisante. Il est justifié d'effectuer d'autres recherches pour évaluer les avantages du traitement de la l'activité électrique sans pouls (AES).

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest.
Nolan JP, Berg RA, Andersen LW, Bhanji F, Chan PS, Donnino MW, Lim SH, Ma MH, Nadkarni VM, Starks MA, Perkins GD, Morley PT, Soar J; Utstein Collaborators. | Resuscitation. 2019 Nov;144:166-177
DOI: https://doi.org/10.1016/j.resuscitation.2019.08.021  | Télécharger l'article au format  
Keywords: Aucun

Statements from Authoritative Bodies

Introduction : Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

Conclusion : Utstein-style guidelines standardise reporting of the process of care and outcomes for patients with cardiac arrest. This update of the IHCA Utstein reporting guideline includes 6 domains: hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. This consensus IHCA reporting template adopts the style of the recently updated OHCA version.

Conclusion (proposition de traduction) : Les lignes directrices selon le style Utstein normalisent la traçabilité du processus de soins et des résultats pour les patients en arrêt cardiaque. Cette mise à jour de la directive de déclaration des arrêt cardiaques intra-hospitaliers selon le style d'Utstein comprend 6 domaines : les facteurs hospitaliers, les variables des patients, les facteurs pré-événement, les processus d'arrêt cardiaque et de post-réanimation, et les résultats. Ce modèle de rapport consensuel de l'IHCA adopte le style de la version récemment mise à jour de l'arrêt cardiaque extra-hospitalier.

Stress and decision-making in resuscitation: A systematic review.
Groombridge CJ, Kim Y, Maini A, Smit V, Fitzgerald MC. | Resuscitation. 2019 Nov;144:115-122
DOI: https://doi.org/10.1016/j.resuscitation.2019.09.023  | Télécharger l'article au format  
Keywords: Aucun

https://doi.org/10.1016/j.resuscitation.2019.09.023

Introduction : During resuscitation decisions are made frequently and based on limited information in a stressful environment.
AIM : This systematic review aimed to identify human factors affecting decision-making in challenging or stressful situations in resuscitation. The secondary aim was to identify methods of improving decision-making performance under stress.

Méthode : The databases PubMed, EMBASE and The Cochrane Library were searched from their commencement to the 13th of April 2019. MeSH terms and key words were combined (Stress* OR "human factor") AND Decision. Articles were included if they involved decision makers in medicine where decisions were made under challenging circumstances, with a comparator group and an outcome measure relating to change in decision-making performance.

Résultats : 22,368 records in total were initially identified, from which 82 full text studies were reviewed and 16 finally included. The included studies ranged from 1995 to 2018 and included a total of 570 participants. The studies were conducted in several different countries and settings, with participants of varying experience and backgrounds. Of the 16 studies, 5 were randomised controlled trials, 3 of which were deemed to have a high risk of bias. The stressors identified were (i) illness severity (ii) socio-evaluative, (iii) noise, (iv) fatigue. The mitigators identified were (i) cognitive aids including checklists, (ii) stress management training and (iii) meditation.

Conclusion : Human factors contributing to decision-making during resuscitation are identified and can be mitigated by tailored stress training and cognitive aids. Understanding these factors may have implications for clinician education and the development of decision-support tools.

Conclusion (proposition de traduction) : Les facteurs humains contribuant à la prise de décision pendant la réanimation sont identifiés et peuvent être atténués par une formation au stress et des aides cognitives adaptées. La compréhension de ces facteurs peut avoir des implications pour la formation des cliniciens et le développement d'outils d'aide à la décision.

Optimal timing of coronary intervention in patients resuscitated from cardiac arrest without ST-segment elevation myocardial infarction (NSTEMI): A systematic review and meta-analysis.
Barbarawi M, Zayed Y, Kheiri B, Barbarawi O, Al-Abdouh A, Dhillon H, Rizk F, Bachuwa G, Alkotob ML. | Resuscitation. 2019 Nov;144:137-144
DOI: https://doi.org/10.1016/j.resuscitation.2019.06.279
Keywords: Cardiac arrest; Meta-analysis; NSTEMI; Non-ST elevation; Survival

Reviews

Introduction : Performing immediate coronary angiography (CAG) in patients with a cardiac arrest and a non-ST-elevation myocardial infarction (NSTEMI) remains a highly debated topic. We performed a meta-analysis aiming to evaluate the influence of immediate, delayed, and no CAG in patients with cardiac arrest and NSTEMI.

Méthode : A comprehensive literature review of Pubmed/MEDLINE, Cochrane Library, and Embase was performed for all studies that compared immediate CAG to delayed or no CAG in the setting of cardiac arrest and NSTEMI. The primary outcome was long-term mortality and secondary outcomes included short-term mortality and a Cerebral Performance Category (CPC) score of 1-2 at the longest follow-up period. A random-effects model was used to report odds ratios (ORs) with Bayesian 95% credible intervals (CrIs), and ORs with 95% confidence intervals (CIs) for both network and direct meta-analyses, respectively.

Résultats : 11 studies were included in the final analysis: 8 observational, 1 post-hoc analysis and 2 randomized trials, totaling 3702 patients. The mean age was 63.8±12.8 years with 78% males. We found that immediate and delayed CAG were associated with lower long-term mortality when compared to no CAG (OR 0.21; 95% CrI 0.05-0.82) and (OR 0.11; 95% CrI 0.03-0.43), as well as lower short-term mortality (OR 0.17; 95% CrI 0.04-0.64) and (OR 0.07; 95% CrI 0.01-0.29), respectively. In addition, immediate and delayed CAG were associated with a significantly higher number of patients with a CPC score of 1-2 (OR 4.15; 95% CrI 1.10-16.10) and (OR 4.67; 95% CrI 1.53-15.12), respectively. There were no significant differences between immediate or delayed CAG regarding long-term mortality, short-term mortality, or favorable CPC score.

Conclusion : Among patients who survived cardiac arrest with an NSTEMI, CAG is associated with a higher rate of survival and favorable neurological outcomes compared with no CAG. There were no differences between immediate and delayed strategies.

Conclusion (proposition de traduction) : Parmi les patients qui ont survécu à un arrêt cardiaque avec un NSTEMI, l'angiographie coronaire est associée à un taux de survie plus élevé et à des résultats neurologiques favorables par rapport à aucune angiographie coronaire. Il n'y avait aucune différence entre les stratégies immédiates et différées.

Effect of smart devices on the quality of CPR training: A systematic review.
An M, Kim Y, Cho WK. | Resuscitation. 2019 Nov;144:145-156
DOI: https://doi.org/10.1016/j.resuscitation.2019.07.011  | Télécharger l'article au format  
Keywords: CPR quality; CPR training; Cardiopulmonary resuscitation (CPR); Smart devices

Reviews

Introduction : Use of smart devices to provide real-time cardiopulmonary resuscitation (CPR) feedback in the context of out-of-hospital cardiac arrest (OHCA) has considerable potential for improving survival. However, the findings of previous studies evaluating the effectiveness of these devices have been conflicting. Therefore, we conducted a systematic review of the literature to assess the utility of smart devices for improving the quality of CPR during CPR training.

Méthode : Thirteen electronic databases were searched. The articles were reviewed according to the eligibility criteria. CPR quality was evaluated based on the rates and depths of chest compression, and the proportion of adequate depth of chest compressions.

Résultats : Ultimately, 11 studies (5 randomised controlled trials, 1 randomised trial, and 5 randomised cross-over trials) were selected for this systematic review. Eight of these studies used smartphones and three used smartwatches. This review did not find an apparent benefit from smart device use during CPR in terms of maintaining the recommended compression rates and depths of chest compressions. However, all three smartwatch studies reported that the proportion of chest compressions of adequate depth was significantly improved with smartwatch use (smartwatch group vs. non-smartwatch group in the three studies: 65.01% vs. 45.15%, p = 0.01; 64.6% vs. 43.1%, p = 0.049; 98.7% vs. 79.3%, p = 0.002).

Conclusion : This review does not find durable evidence for usefulness of smart devices in CPR training. However, the smartwatches may improve the accuracy of chest compression depth. Future studies with larger sample sizes might be necessary before reaching a firm conclusion.

Conclusion (proposition de traduction) : Cette revue ne trouve pas de preuves durables de l'utilité des appareils intelligents dans la formation en RCP. Cependant, les smartwatches peuvent améliorer la précision de la profondeur de compression thoracique. De futures études avec des échantillons de plus grande taille pourraient être nécessaires avant d'arriver à une conclusion ferme.

Effects of dispatcher-initiated telephone cardiopulmonary resuscitation after out-of-hospital cardiac arrest: A nationwide, population-based, cohort study.
Shibahashi K, Ishida T, Kuwahara Y, Sugiyama K, Hamabe Y. | Resuscitation. 2019 Nov;144:6-14
DOI: https://doi.org/10.1016/j.resuscitation.2019.08.031
Keywords: Bystander; Cardiopulmonary resuscitation; Dispatcher-assisted; Neurological outcomes; Out-of-hospital cardiac arrest

Clinical Papers

Introduction : This study aimed to investigate the effects of dispatcher-initiated telephone cardiopulmonary resuscitation (TCPR) in Japan using a nationwide population-based registry.

Méthode : Adult Japanese patients with out-of-hospital cardiac arrest (OHCA; n = 582,483, age ≥18 years) were selected from a nationwide Utstein-style database (2010-2016) and divided into 3 groups: no bystander CPR (NCPR) before emergency medical service arrival (n = 448,606), bystander-initiated CPR (BCPR) performed without assistance (n = 46,964), and TCPR (n = 86,913). The primary outcome was a favourable neurological outcome 1 month after OHCA.

Résultats : After adjusting for potential confounders, and relative to the NCPR group, significantly better 1-month neurological outcomes were observed in the BCPR group (odds ratio: 2.25, 95% confidence interval: 2.15-2.36; P < 0.001) and in the TCPR group (odds ratio: 1.30, 95% confidence interval: 1.24-1.36; P < 0.001). The collapse-to-CPR time was independently associated with the 1-month outcomes, with a rate of <1% for 1-month favourable neurological outcomes if CPR was initiated >5 min after the collapse.

Conclusion : Patients who received TCPR had significantly better outcomes than those who did not receive CPR. However, the TCPR outcomes were less favourable than those in the BCPR group. Better protocol development and enhanced education are needed to improve dispatcher instructions in Japan, which may help lessen the gap between the BCPR and TCPR outcomes and further improve the outcomes after OHCA.

Conclusion (proposition de traduction) : Les patients qui ont reçu une réanimation cardiorespiratoire par téléphone ont obtenu de bien meilleurs résultats que ceux qui n'ont pas reçu de RCP. Toutefois, les résultats de la réanimation cardiorespiratoire par téléphone étaient moins favorables que ceux du groupe ayant subi une RCP à l'initiative du témoin. L'élaboration de meilleurs protocoles et une meilleure éducation sont nécessaires pour améliorer les instructions des répartiteurs au Japon, ce qui pourrait aider à réduire l'écart entre la RCP effectuée par le témoin et les résultats de la réanimation cardio-pulmonaire par téléphone et à améliorer davantage les résultats après un arrêt cardiaque hors de l'hôpital.

The cardiac arrest survival score: A predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest.
Balan P, Hsi B, Thangam M, Zhao Y, Monlezun D, Arain S, Charitakis K, Dhoble A, Johnson N, Anderson HV, Persse D, Warner M, Ostermayer D, Prater S, Wang H, Doshi P. | Resuscitation. 2019 Nov;144:46-53
DOI: https://doi.org/10.1016/j.resuscitation.2019.09.009
Keywords: Cardiac arrest; Risk stratification

Clinical Papers

Introduction : Out-of-hospital cardiac arrest (OHCA) is associated with high mortality. Current methods for predicting mortality post-arrest require data unavailable at the time of initial medical contact. We created and validated a risk prediction model for patients experiencing OHCA who achieved return of spontaneous circulation (ROSC) which relies only on objective information routinely obtained at first medical contact.

Méthode : We performed a retrospective evaluation of 14,892 OHCA patients in a large metropolitan cardiac arrest registry, of which 3952 patients had usable data. This population was divided into a derivation cohort (n = 2,635) and a verification cohort (n = 1,317) in a 2:1 ratio. Backward stepwise logistic regression was used to identify baseline factors independently associated with death after sustained ROSC in the derivation cohort. The cardiac arrest survival score (CASS) was created from the model and its association with in-hospital mortality was examined in both the derivation and verification cohorts.

Résultats : Baseline characteristics of the derivation and verification cohorts were not different. The final CASS model included age >75 years (odds ratio [OR] = 1.61, confidence interval [CI][1.30-1.99], p < 0.001), unwitnessed arrest (OR = 1.95, CI[1.58-2.40], p < 0.001), home arrest (OR = 1.28, CI[1.07-1.53], p = 0.008), absence of bystander CPR (OR = 1.35, CI[1.12-1.64], p = 0.003), and non-shockable initial rhythm (OR = 3.81, CI[3.19-4.56], p < 0.001). The area under the curve for the model derivation and model verification cohorts were 0.7172 and 0.7081, respectively.

Conclusion : CASS accurately predicts mortality in OHCA patients. The model uses only binary, objective clinical data routinely obtained at first medical contact. Early risk stratification may allow identification of more patients in whom timely and aggressive invasive management may improve outcomes.

Conclusion (proposition de traduction) : Le score "laquo; cardiac arrest survival » prédit avec précision la mortalité chez les patients victimes d'un arrêt cardiaque extra-hospitalier. Le modèle n'utilise que des données cliniques binaires et objectives obtenues systématiquement lors du premier contact médical. La stratification précoce du risque peut permettre d'identifier un plus grand nombre de patients chez lesquels une prise en charge invasive opportune et agressive peut améliorer les résultats.

Commentaire : CaRdiac Arrest Survival Score (CRASS)

One year experience with fast track algorithm in patients with refractory out-of-hospital cardiac arrest.
Adler C, Paul C, Michels G, Pfister R, Sabashnikov A, Hinkelbein J, Braumann S, Djordjevic L, Blomeyer R, Krings A, Böttiger BW, Baldus S, Stangl R. | Resuscitation. 2019 Nov;144:157-165
DOI: https://doi.org/10.1016/j.resuscitation.2019.07.035
Keywords: Extracorporeal cardiopulmonary resuscitation; Neurological outcome; Ongoing CPR; Out-of-hospital cardiac arrest; Refractory cardiac arrest

Clinical Papers

Introduction : Overall prognosis in patients with out-of-hospital cardiac arrest (OHCA) remains poor, especially when return of spontaneous circulation (ROSC) cannot be achieved at the scene. It is unclear if rapid transport to the hospital with ongoing cardiopulmonary resuscitation (CPR) improves outcome in patients with refractory OHCA (rOHCA). The aim of this study was to evaluate the effect of a novel fast track algorithm (FTA) in patients with rOHCA.

Méthode : This prospective single-center study analysed outcome in rOHCA patients treated with FTA. Historical patients before FTA-implementation served as controls. rOHCA was defined as: persistent shockable rhythm after three shocks and 300mg of amiodarone or persistent non-shockable rhythm and continuous CPR for 10min without ROSC after exclusion of treatable arrest causes.

Résultats : 110 consecutive patients with rOHCA (mean age 56±14 years) were included. 40 patients (36%) were treated with FTA, 70 patients (64%) served as historical controls. Pre-hospital time was significantly shorter after FTA implementation (69±18 vs. 79±24min, p=0.02). Favourable neurological outcome (defined as cerebral performance categories Score 1 or 2) was significantly more frequent in FTA patients (27.5% vs. 11.4%, p=0.038). FTA-implementation showed a trend towards improved mortality (70.0% vs. 82.9%, p=0.151). Extracorporeal Life Support was similar between the two groups.

Conclusion : Our study suggests that a rapid transport algorithm with ongoing CPR is feasible, improves neurological outcome and may improve survival in carefully selected patients with rOHCA.

Conclusion (proposition de traduction) : Notre étude suggère qu'un algorithme de transport rapide avec RCP continue est faisable, améliore le résultat neurologique et peut améliorer la survie chez des patients soigneusement sélectionnés avec un arrêt cardiaque réfractaire extra-hospitalier.

The effect of a face mask for respiratory support on breathing in preterm infants at birth.
Kuypers KLAM, Lamberska T, Martherus T, Dekker J, Böhringer S, Hooper SB, Plavka R, Te Pas AB.. | Resuscitation. 2019 Nov;144:178-184
DOI: https://doi.org/10.1016/j.resuscitation.2019.08.043
Keywords: Breathing; Face mask; Preterm infants; Respiratory support; Trigeminocardiac reflex

Clinical papers

Introduction : Applying a mask on the face for respiratory support could induce a trigeminocardiac reflex leading to apnoea and bradycardia. We have examined the effect of applying a face mask on breathing and heart rate in preterm infants at birth.

Méthode : Resuscitation videos of infants ≤ 32 weeks gestation recorded from 2010 until 2018 at the Leiden University Medical Centre and the General University Hospital in Prague were reviewed. All infants received respiratory support via face mask. Breathing and heart rate were noted before and after application of the face mask and over the first 5 min.

Résultats : Recordings of 429 infants were included (median (IQR) gestational age of 28+6 (27+1-30+4) weeks). In 368/429 (86%) infants breathing was observed before application of the face mask and 197/368 (54%) of these infants stopped breathing following application of the face mask. Apnoea occurred at a median of 5 (3-17) seconds after application of the face mask with a duration of 28 (22-34) seconds of the first minute. In a logistic regression model, the occurrence of apnoea after face mask application was inversely associated with gestational age (OR = 1.424 (1.281-1.583), p < 0.001). Infants who stopped breathing had a significantly lower heart rate 82 (66-123) vs 134 (97-151) bpm, p < 0.001) and oxygen saturation (49% (33-59) vs 66% (50-82), p < 0.001) over the first minute after face mask application, compared to infants who continued breathing.

Conclusion : Applying a face mask for respiratory support affects breathing in a large proportion (54%) of preterm infants and this effect is gestational age dependent.

Conclusion (proposition de traduction) : L'application d'un masque facial pour le soutien respiratoire affecte la respiration chez une grande proportion (54 %) des nourrissons prématurés et cet effet dépend de l'âge gestationnel.

Association between ambulance response time and neurologic outcome in patients with cardiac arrest.
Lee DW, Moon HJ, Heo NH; KoCARC. | Am J Emerg Med. 2019 Nov;37(11):1999-2003
DOI: https://doi.org/10.1016/j.ajem.2019.02.021
Keywords: Emergency medical services; Out-of-hospital cardiac arrest; Resuscitation

Original Contribution

Introduction : Emergency medical services (EMS) response time is one of prehospital factors associated with survival rate of patients with out-of-hospital cardiac arrest (OHCA). The objective of this study was to determine whether short EMS response time was associated with improved neurologic outcome of patients with OHCA through prospective analysis.

Méthode : We performed a prospective observational analysis of collected data from KoCARC registry between October 2015 and December 2016. OHCA patients aged 18 years or older with presumed cardiac etiology by emergency physicians in emergency department were included in this study.

Résultats : Of 3187 cardiac arrest patients enrolled in the KoCARC registry, 2309 patients were included in the final analysis. Response time threshold was 11.5 min for prehospital return of spontaneous circulation and 7.5 min for survival to discharge and favorable neurologic outcome. Patients in the ≤7.5 min response time group showed increased odds of survival to discharge (OR: 1.54, 95% CI: 1.13-2.10, p = .006) and favorable neurologic recovery (OR: 2.01, 95% CI: 1.36-2.99, p = .001). When response time was decreased by 1 min, all outcomes were improved (survival to discharge, OR: 1.08; 95% CI: 1.04-1.12, p < .001; favorable neurological outcome, OR: 1.14, 95% CI: 1.07-1.21, p < .001).

Conclusion : We found that shorter EMS response time could lead to favorable neurologic outcome in patients with OHCA of presumed cardiac origin. EMS response time threshold associated with improved favorable outcome was ≤7.5 min.

Conclusion (proposition de traduction) : Nous avons constaté qu'un temps de réponse des services médicaux d'urgence plus court pouvait conduire à un résultat neurologique favorable chez les patients avec OHCA d'origine cardiaque présumée. Le seuil de temps de réponse Edes services médicaux d'urgenceS associé à une amélioration du résultat favorable était ≤ 7,5 min.

BLUE protocol ultrasonography in Emergency Department patients presenting with acute dyspnea.
Bekgoz B, Kilicaslan I, Bildik F, Keles A, Demircan A, Hakoglu O, Coskun G, Demir HA. | Am J Emerg Med. 2019 Nov;37(11):2020-2027
DOI: https://doi.org/10.1016/j.ajem.2019.02.028
Keywords: BLUE protocol; Bedside lung ultrasonography; Dyspnea; Emergency Department

Original contribution

Introduction : Dyspnea is a common Emergency Department (ED) symptom requiring prompt diagnosis and treatment. The bedside lung ultrasonography in emergency (BLUE) protocol is defined as a bedside diagnostic tool in intensive care units. The aim of this study was to investigate the test performance characteristics of the BLUE-protocol ultrasonography in ED patients presenting with acute dyspnea.

Méthode : This study was performed as a prospective observational study at the ED of a tertiary care university hospital over a 3-month period. The BLUE-protocol was applied to all consecutive dyspneic patients admitted to the ED by 5 emergency physicians who were certified for advanced ultrasonography. In addition to the BLUE-protocol, the patients were also evaluated for pleural and pericardial effusion.

Résultats : A total of 383 patients were included in this study (mean age, 65.5 ± 15.5 years, 183 (47.8%) female and 200 (52.2%) male). According to the BLUE-protocol algorithm, the sensitivities and specificities of the BLUE-protocol are, respectively, 87.6% and 96.2% for pulmonary edema, 85.7% and 99.0% for pneumonia, 98.2% and 67.3% for asthma/COPD, 46.2% and 100% for pulmonary embolism, and 71.4% and 100% for pneumothorax. Although not included in the BLUE-protocol algorithm, pleural or pericardial effusion was detected in 82 (21.4%) of the patients.

Conclusion : The BLUE-protocol can be used confidently in acute dyspneic ED patients. For better diagnostic utility of the BLUE-protocol in EDs, it is recommended that the BLUE-protocol be modified for the assessment of pleural and pericardial effusion. Further diagnostic evaluations are needed in asthma/COPD groups in terms of the BLUE-protocol.

Conclusion (proposition de traduction) : Le protocole BLUE peut être utilisé en toute confiance chez les patients présentant une dyspnée aiguë aux urgences. Pour une meilleure utilisation diagnostique du protocole BLUE dans les services d'urgence, il est recommandé de modifier le protocole BLUE pour l'évaluation de l'épanchement pleural et péricardique. D'autres évaluations diagnostiques sont nécessaires dans les groupes asthme/BPCO en termes de protocole BLUE.

Commentaire : 

Pharmacokinetic effects of endotracheal, intraosseous, and intravenous epinephrine in a swine model of traumatic cardiac arrest.
Burgert JM, Johnson AD, O'Sullivan JC, Blalock WJ, Duffield BC, Albright BP, Herzog CC, Moore MS, Dempster KS, Rauch JW. | Am J Emerg Med. 2019 Nov;37(11):2043-2050
DOI: https://doi.org/10.1016/j.ajem.2019.02.035
Keywords: Aucun

Original Contribution

Introduction : Limited prospective data exist regarding epinephrine's controversial role in managing traumatic cardiac arrest (TCA). This study compared the maximum concentration (Cmax), time to maximum concentration (Tmax), plasma concentration over time, return of spontaneous circulation (ROSC), time to ROSC, and odds of ROSC of epinephrine administered by the endotracheal (ETT), intraosseous (IO), and intravenous (IV) routes in a swine TCA model.

Méthode : Forty-nine Yorkshire-cross swine were assigned to seven groups: ETT, tibial IO (TIO), sternal IO (SIO), humeral IO (HIO), IV, CPR with defibrillation (CPRD), and CPR only. Swine were exsanguinated 31% of their blood volume and cardiac arrest induced. Chest compressions began 2 min post-arrest. At 4 min post-arrest, 1 mg epinephrine was administered, and blood specimens collected over 4 min. Resuscitation continued until ROSC or 30 min elapsed

Résultats : The Cmax of IV epinephrine was significantly higher than the TIO group (P = 0.049). No other differences in Cmax, Tmax, ROSC, and time to ROSC existed between the epinephrine groups (P > 0.05). Epinephrine levels were detectable in two of seven ETT swine. No significant difference in ROSC existed between the epinephrine groups and CPRD group (P > 0.05). Significant differences in ROSC existed between all groups and the CPR only group (P < 0.05). No significant differences in odds of ROSC were noted.

Conclusion : The pharmacokinetics of IV, HIO, and SIO epinephrine were comparable. Endotracheal epinephrine absorption was highly variable and unreliable compared to IV and IO epinephrine. Epinephrine appeared to have a lesser role than volume replacement in resuscitating TCA.

Conclusion (proposition de traduction) : La pharmacocinétique de l'épinéphrine (adrénaline) IV, intra-osseuse humérale et sternale était comparable. L'absorption de l'adrénaline endotrachéale était très variable et peu fiable par rapport à l'adrénaline IV et intra-osseuse. L'épinéphrine semble avoir un rôle moindre que le remplacement du volume dans la réanimation d'un arrêt cardiaque traumatique.

Lung and cardiac ultrasound (LuCUS) protocol in diagnosing acute heart failure in patients with acute dyspnea.
Dehbozorgi A, Eslami Nejad S, Mousavi-Roknabadi RS, Sharifi M, Tafakori A, Jalli R. | Am J Emerg Med. 2019 Nov;37(11):2055-2060
DOI: https://doi.org/10.1016/j.ajem.2019.02.040
Keywords: Acute heart failure; Diagnostic strategy; Dyspnea; Emergency department; Ultrasound

Original Contribution

Introduction : To investigate the accuracy of lung and cardiac ultrasound (LuCUS) protocol in diagnosing Acute Heart Failure (AHF) in patients who refer to Emergency Department (ED) with acute dyspnea.

Méthode : This was an interventional study on adult patients, who were referred with chief complaint of undifferentiated acute dyspnea to the ED of Namazi hospital, the largest referral center in southern Iran. The intervention was LuCUS protocol, which was performed by Emergency Physicians (EPs) at the bedside. All patients' files were reviewed separately by two independent specialists, who were blinded to LuCUS results for final diagnosis as gold standard, then the results of LuCUS were compared with it. All data were analyzed and diagnostic tests were calculated (α = 0.05).

Résultats : In 100 patients enrolled in the study, 28% had the final diagnosis as AHF. The LuCUS protocol had the sensitivity of 64% (95%CI, 44%-81%), specificity of 97% (95%CI, 90%-100%), positive predicative value of 90% (95%CI, 69%-97%), negative predicative value of 88% (95%CI, 81%-92%), positive likelihood ratio of 23.14 (95%CI, 5.74-93.3), negative likelihood ratio of 0.37 (95%CI, 0.22-0.6), and accuracy of 88% (95%CI, 80%-94%).

Conclusion : LuCUS protocol can be used by EPs as a practical tool to differentiate the cardiac and non-cardiac etiologies of acute dyspnea, specifically AHF, as it is more accurate than clinical diagnosis by itself. Hence, it is recommend that while conducting further studies in order to achieve more generalizable results, EPs can employ it alongside their clinical evaluations to have a faster and more accurate diagnosis.

Conclusion (proposition de traduction) : Le protocole LuCUS peut être utilisé par les médecins urgentistes comme un outil pratique pour différencier les étiologies cardiaques et non cardiaques de la dyspnée aiguë, en particulier l'insuffisance cardiaque aiguë, car il est plus précis que le diagnostic clinique en soi.
Par conséquent, il est recommandé que, tout en menant des études supplémentaires afin d'obtenir des résultats plus généralisables, les médecins urgentistes puissent l'utiliser parallèlement à leurs évaluations cliniques pour avoir un diagnostic plus rapide et plus précis.

Commentaire : Voir les articles :
• Russell FM, Ehrman RR. A Modified Lung and Cardiac Ultrasound Protocol Saves Time and Rules in the Diagnosis of Acute Heart FailureJ Emerg Med. 2017 Jun;52(6):839-845  
• Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E, Bailitz J. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocolAcad Emerg Med. 2015 Feb;22(2):182-91  

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis.
Liu C, Lu G, Wang D, Lei Y, Mao Z, Hu P, Hu J, Liu R, Han D, Zhou F. | Am J Emerg Med. 2019 Nov;37(11):2072-2078
DOI: https://doi.org/10.1016/j.ajem.2019.02.045
Keywords: Acute kidney injury; Balanced crystalloid; Meta-analysis; Normal saline; Trial sequential analysis

Original contribution

Introduction : Fluid resuscitation is a fundamental component of the management of critically ill patients, but whether choice of crystalloid affects patient outcomes remains controversial. Therefore, we performed this meta-analysis to compare the efficacy and safety of balanced crystalloids with normal saline.

Méthode : We searched the MEDLINE, Cochrane Central and EMBASE up to October 2018 to identify randomized controlled trials (RCTs) that compared balanced crystalloids versus normal saline in critically ill patients. The primary outcome was mortality. The secondary results were the incidence of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). Two authors independently screened articles based on the inclusion and exclusion criteria. The meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0.

Résultats : Nine RCTs were identified. The pooled analyses showed that there were no significant differences in mortality (relative risk (RR) = 0.93, 95% confidence interval (CI) = 0.86, 1.01, P = 0.08), incidence of AKI (RR 0.94, 95% CI 0.88, 1.00, P = 0.06) or RRT use rate (RR 0.94, 95% CI 0.69, 1.27, P = 0.67) between balanced crystalloids and normal saline groups. However, TSA did not provide conclusive evidence.

Conclusion : Among critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding.

Conclusion (proposition de traduction) : Parmi les patients en situation critique recevant un remplissage par cristalloïde, l'utilisation d'un cristalloïde balancé par rapport à une solution saline normale n'a pas réduit la mortalité, le risque de lésions rénales aiguës graves ou le taux d'utilisation de la greffe rénale. D'autres grands essais cliniques randomisés sont nécessaires pour confirmer ou réfuter cette constatation.

HVNI vs NIPPV in the treatment of acute decompensated heart failure: Subgroup analysis of a multi-center trial in the ED.
Haywood ST, Whittle JS, Volakis LI, Dungan G 2nd, Bublewicz M, Kearney J, Ashe T, Miller TL, Doshi P. | Am J Emerg Med. 2019 Nov;37(11):2084-2090
DOI: https://doi.org/10.1016/j.ajem.2019.03.002
Keywords: Acute decompensated heart failure; Critical care; Emergency medicine; High flow nasal cannula; Non-invasive positive-pressure ventilation

Original contribution

Introduction : Managing respiratory failure (RF) secondary to acute decompensated heart failure (ADHF) with non-invasive positive-pressure ventilation (NIPPV) has been shown to significantly improve morbidity and mortality in patients presenting to the emergency department (ED). This subgroup analysis compares high-velocity nasal insufflation (HVNI), a form of high-flow nasal cannula, with NIPPV in the treatment of RF secondary to ADHF with respect to therapy failure, as indicated by the requirement for intubation or all-cause arm failure including subjective crossover to the alternate therapy.

Méthode : The subgroup analysis is from a larger randomized control trial of adults presenting to the ED with RF requiring NIPPV support. Patients were randomly selected to therapy, and subgroup selection was established a priori in the original study as a discharge diagnosis. The primary outcome was therapy failure at 72 h after enrolment.

Résultats : Subgroup analysis included a total of 22 HVNI and 20 NIPPV patients which fit discharge diagnosis ADHF. Baseline patient characteristics were not statistically significant. Primary outcomes were not statistically significant: intubation rate (p = 1.000), therapy success (p = 1.000). Repeated measures (vitals, dyspnea, blood gases) showed comparable differences over initial 4 h. Physicians scored HVNI superior on patient comfort/tolerance (p < 0.001), ease of use (p = 0.004), and monitoring (p = 0.036). Limitations were technical inability to blind the clinician team and lack of power of the subgroup analysis.

Conclusion : In conclusion, this subgroup analysis suggests HVNI may be non-inferior to NIPPV in patients with respiratory failure secondary to ADHF that do not need emergent intubation.

Conclusion (proposition de traduction) : En conclusion, cette analyse de sous-groupe suggère que l'oxygénothérapie à haut débit peut être non inférieure à la VNI chez les patients présentant une insuffisance respiratoire secondaire à une insuffisance cardiaque décompensée aiguë qui n'ont pas besoin d'une intubation.

Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: A before-after study.
Macé J, Marjanovic N, Faranpour F, Mimoz O, Frerebeau M, Violeau M, Bourry PA, Guénézan J, Thille AW, Frat JP. | Am J Emerg Med. 2019 Nov;37(11):2091-2096
DOI: https://doi.org/10.1016/j.ajem.2019.03.004
Keywords: Acute hypoxemic respiratory failure; Acute respiratory distress; Dyspnea; Emergency department; High-flow oxygen therapy

Original contribution

Introduction : To compare clinical impact after early initiation of high-flow nasal cannula oxygen therapy (HFNC) versus standard oxygen in patients admitted to an emergency department (ED) for acute hypoxemic respiratory failure.

Méthode : We performed a prospective before-after study at EDs in two centers including patients with acute hypoxemic respiratory failure defined by a respiratory rate above 25 breaths/min or signs of increased breathing effort under additional oxygen for a pulse oximetry above 92%. Patients with cardiogenic pulmonary edema or exacerbation of chronic lung disease were excluded. All patients were treated with standard oxygen during the first period and with HFNC during the second. The primary outcome was the proportion of patients with improved respiratory failure 1 h after treatment initiation (respiratory rate ≤ 25 breaths/min without signs of increased breathing effort). Dyspnea and blood gases were also assessed.

Résultats : Among the 102 patients included, 48 were treated with standard oxygen and 54 with HFNC. One hour after treatment initiation, patients with HFNC were much more likely to recover from respiratory failure than those treated with standard oxygen: 61% (33 of 54 patients) versus 15% (7 of 48 patients), P < 0.001. They also showed greater improvement in oxygenation (increase in PaO2 was 31 mm Hg [0-67] vs. 9 [-9-36], P = 0.02), and in feeling of breathlessness.

Conclusion : As compared to standard oxygen, patients with acute hypoxemic respiratory failure treated with HFNC at the ED had better oxygenation, less breathlessness and were more likely to show improved respiratory failure 1 h after initiation.

Conclusion (proposition de traduction) : Par rapport à l'oxygène standard, les patients présentant une insuffisance respiratoire hypoxémique aiguë traités par Oxygénothérapie à haut débit (Optiflow) au service des urgences avaient une meilleure oxygénation, moins de dyspnée et étaient plus susceptibles de présenter une insuffisance respiratoire améliorée 1h après l'initiation (du traitement).

The value of ischemia-modified albumin and oxidative stress markers in the diagnosis of acute appendicitis in adults.
Hakkoymaz H, Nazik S, Seyithanoğlu M, Güler Ö, Şahin AR, Cengiz E, Yazar FM. | Am J Emerg Med. 2019 Nov;37(11):2097-2101
DOI: https://doi.org/10.1016/j.ajem.2019.03.005
Keywords: Acute appendicitis; Ischemia-modified albumin; Oxidative stress markers

Original contribution

Introduction : The present study evaluates the predictive value of such markers as ischemia-modified albumin (IMA), malondialdehyde (MDA) and glutathione peroxide (GSH-Px), in addition to parameters associated with inflammation, oxidative stress and ischemia, playing roles in the pathology of acute appendicitis (AA), including c-reactive protein (CRP), procalcitonin (PCT) and complete blood count (CBC) parameters and their ratios, for the diagnosis of AA in adults.

Méthode : The study included 51 patients with histologically confirmed appendicitis and 45 healthy controls who referred to the emergency care unit between January and June 2018. The appendicitis cases were classified into two groups, as complicated and non-complicated, based on postoperative pathological investigations.

Résultats : Of all the appendicitis cases, 68.5% (n = 35) were non-complicated and 31.4% (n = 16) were complicated. IMA (positive LR = 3.0, negative LR = 0.1), GSH-Px (positive LR = 0.5, negative LR = 1.8), MDA (positive LR = 1.8, negative LR = 0.6), CRP (positive LR = 7.2, negative LR = 0.2), PCT (positive LR = 0.7, negative LR = 1.3), WBC (positive LR = 2.9, negative LR = 0.3), neutrophil-lymphocyte ratio (positive LR = 3.2, negative LR = 0.1) thrombocyte lymphocyte ratio (positive LR = 1.6, negative LR = 0.5) and IMA/albumin ratio (positive LR = 3.3, negative LR = 0.1) levels in the appendicitis cases were evaluated by a characteristic receiver operating characteristic (ROC) curve. In addition, IMA levels were significantly higher in the complicated cases (0.40 ± 0.05 AbsU) than in the non-complicated cases (0.29 ± 0.04 AbsU) (p < 0.0001).

Conclusion : Our results showed that IMA (negative LR = 0.1), CRP (positive LR = 7.2, negative LR = 0.2), NLR (negative LR = 0.1) and IMA/albumin ratio (negative LR = 0.1) can serve as important diagnostic biomarkers for AA patients. We therefore believe that before clinically confirming an AA diagnosis, these parameters may be used as diagnostic tools in addition to CBC parameters, CRP levels and radiological imaging studies.

Conclusion (proposition de traduction) : Nos résultats ont montré que l'IMA (VPN = 0,1), la CRP (VPP = 7,2, VPN = 0,2), le rapport polynucléaires neutrophiles/lymphocytes (VPN = 0,1) et le rapport IMA/albumine (VPN = 0,1) peuvent servir de biomarqueurs diagnostiques importants pour patients présentant une appendicite aiguë. Nous pensons donc qu'avant de confirmer cliniquement un diagnostic d'appendicite aiguë, ces paramètres peuvent être utilisés comme outils de diagnostic en plus des paramètres de numération globulaire complets, des niveaux de CRP et des études d'imagerie radiologique.

Commentaire : Valeur prédictive négative (VPN)
Valeur prédictive positive (VPP)

Point-of-care lung ultrasound in children with non-cardiac respiratory distress or tachypnea.
Özkaya AK, Başkan Vuralkan F, Ardıç Ş. | Am J Emerg Med. 2019 Nov;37(11):2102-2106
DOI: https://doi.org/10.1016/j.ajem.2019.05.063
Keywords: Children; Lung ultrasound; PoCLUS; Respiratory distress; Tachypnea

Original contribution

Introduction : The purpose of this study was to evaluate the feasibility and diagnostic benefit of point-of-care ultrasound (PoCLUS) in children with non-cardiac respiratory distress or tachypnea.

Méthode : In this prospective observational study, children aged between 1 month and 18 years with respiratory distress, tachypnea, or both, at triage were included. Concordance and accuracy of the emergency department (ED) and ultrasound diagnoses, length of stay, and time elapsing until ED and ultrasound diagnoses were calculated.

Résultats : One hundred forty-five patients were evaluated. The mean age of the children in the study was 67 ± 58 months. Seventy-nine patients (56%) were boys. Mean length of stay in the ED was 124.6 ± 76.5 min. Mean time to ultrasound diagnosis was 29.32 ± 15.71 min, compared to 46.75 ± 32.65 min for ED diagnosis, which was significantly longer (p < 0.001). Concordance between ultrasound and ED diagnoses was almost perfect for pneumonia, acute bronchiolitis, asthma and croup (0.8 < Ƙ < 1), and good for other non-pulmonary causes (0.6 < Ƙ < 0.8). Overall concordance for all diagnoses was also good (Ƙ = 0.76). Ultrasound diagnosis was more sensitive than ED diagnosis for pneumonia, acute bronchiolitis, and other non-pulmonary causes (81.4%-74.42%; 97.3%-86.49%; and 100%-95.83%, respectively). In addition, ultrasound diagnosis was more specific than ED diagnosis for pneumonia, acute bronchiolitis and other non-pulmonary causes (100%-97.35%; 99.07%-98.15%; and 93.39%-88.43%, respectively). However, ultrasound and ED diagnoses exhibited similar sensitivity and specificity values for asthma (97.22%-97.22%; and 99.08%-100%).

Conclusion : PoCLUS may constitute a beneficial and rational approach in the evaluation of children with increased work of breathing in the ED, and can also expedite the diagnostic process.

Conclusion (proposition de traduction) : L'échographie pulmonaire au point de service peut constituer une approche bénéfique et rationnelle dans l'évaluation des enfants avec un travail respiratoire accru aux urgences et peut également accélérer le processus de diagnostic.

The relationship between the severity of pain and stone size, hydronephrosis and laboratory parameters in renal colic attack.
Sasmaz Mİ, Kirpat V. | Am J Emerg Med. 2019 Nov;37(11):2107-2110
DOI: https://doi.org/10.1016/j.ajem.2019.06.013
Keywords: Aucun

Original contribution

Introduction : In this study, we investigated the relationship between the severity of pain level and hydronephrosis, hematuria and pyuria presence in the acute renal colic attack and whether there was a correlation between the stone size and inflammatory markers.

Méthode : The patients' pain scores determined by Visual Analog Scale (VAS), CRP, WBC and NLR levels from the laboratory results, hematuria and pyuria presence in the urine analysis and hydronephrosis presence in the imaging methods were recorded. Moreover, stone size was measured for the patients for whom computed tomography (CT) method was applied.

Résultats : Mean age of the 275 patients was 41.0 ± 14.9 and 61.1% of them were male. The patients' mean VAS score was 73.3 ± 16.5.The mean VAS score of the groups of which hematuria and pyuria were positive and which have hydronephrosis finding was statistically higher than those whose were negative. The mean stone size was 5.2 ± 2.1 mm, and those with signs of hydronephrosis on their CT (n = 66) were 5.4 ± 2.3 mm, while those with no signs of hydronephrosis (n = 57) were 4.9 ± 1.7. No statistical difference was found in stone size between patients with hydronephrosis and those without. Not any correlations were determined between the stone size and VAS pain score of the cases.

Conclusion : We detected that the pain level was not correlated with the stone size and big stones were not statistically riskier in the hydronephrosis development. However, we think that the risk of complications such as hydronephrosis is higher in the patients whose pain level are higher and the infection may be accompanied by this group.

Conclusion (proposition de traduction) : Nous avons trouvé que le niveau de douleur n'était pas corrélé à la taille du calcul et que les gros calculs n'étaient pas statistiquement plus risquées dans l'apparition de l'hydronéphrose. Cependant, nous pensons que le risque de complications telles que l'hydronéphrose est plus élevé chez les patients dont le niveau de douleur est plus élevé et que l'infection peut être accompagnée par ce groupe.

An Analysis of Adherence to Tactical Combat Casualty Care Guidelines for the Administration of Tranexamic Acid.
Fisher AD, Carius BM, April MD, Naylor JF, Maddry JK, Schauer SG. | J Emerg Med. 2019 Nov;57(5):646-652
DOI: https://doi.org/10.1016/j.jemermed.2019.08.027
Keywords: TCCC; hemorrhage; tourniquet; tranexamic acid; trauma

Prehospital Care

Introduction : Hemorrhage is the leading cause of potentially survivable deaths in combat. Previous research demonstrated that tranexamic acid (TXA) administration decreased mortality among casualties. For casualties expected to receive a transfusion, the Committee on Tactical Combat Casualty Care (TCCC) recommends TXA. Despite this, the use and adherence of TXA in the military prehospital combat setting, in accordance with TCCC guidelines, is low.
OBJECTIVES: We sought to analyze TXA administration and use among combat casualties reasonably expected to require blood transfusion, casualties with tourniquet placement, amputations, and gunshot wounds.

Méthode : Based on TCCC guidelines, we measured proportions of patients receiving prehospital TXA: casualties undergoing tourniquet placement, casualties sustaining amputation proximal to the phalanges, patients sustaining gunshot wounds, and patients receiving ≥10 units of blood products within 24 h of injury. Univariable and multivariable analyses were also completed.

Résultats : Within our dataset, 255 subjects received TXA. Four thousand seventy-one subjects had a tourniquet placed, of whom 135 (3.3%) received prehospital TXA; 1899 subjects had an amputation proximal to the digit with 106 (5.6%) receiving prehospital TXA; and 6660 subjects had a gunshot wound with 88 (1.3%) receiving prehospital TXA. Of 4246 subjects who received ≥10 units of blood products within the first 24 h, 177 (4.2%) received prehospital TXA.

Conclusion : We identified low TXA administration despite TCCC recommendations. Future studies should seek to both identify reasons for limited TXA administration and methods to increase future utilization.

Conclusion (proposition de traduction) : Nous avons identifié une faible administration d'acide tranexamique malgré les recommandations du Tactical Combat Casualty Care. De futures études devraient chercher à la fois à identifier les raisons de l'administration limitée d'acide tranexamique et les méthodes pour augmenter l'utilisation future.

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.
CRASH-3 trial collaborators | Lancet. 2019 Nov 9;394(10210):1713-1723
DOI: https://doi.org/10.1016/S0140-6736(19)32233-0  | Télécharger l'article au format  
Keywords: Aucun

Articles

Introduction : Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI.

Méthode : This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat.

Résultats : Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86-1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80-1·00]). The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64-0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91-1·07]; p value for heterogeneity 0·030). Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74-1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90-1·33]).

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) : Nos résultats montrent que l'acide tranexamique est sans danger chez les patients souffrant d'une lésion cérébrale traumatique et que le traitement dans les 3 heures suivant la blessure réduit la mort liée à une blessure à la tête. Les patients doivent être traités dès que possible après une blessure.

Commentaire : Commentaires :
Cap AP. CRASH-3: a win for patients with traumatic brain injury. Lancet. 2019 Nov 9;394(10210):1687-1688  .

Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus.
Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, Shinnar S, Conwit R, Meinzer C, Cock H, Fountain N, Connor JT, Silbergleit R; NETT and PECARN Investigators.. | N Engl J Med. 2019 Nov 28;381(22):2103-2113
DOI: https://doi.org/10.1056/NEJMoa1905795
Keywords: Aucun

Original article

Introduction : The choice of drugs for patients with status epilepticus that is refractory to treatment with benzodiazepines has not been thoroughly studied.

Méthode : In a randomized, blinded, adaptive trial, we compared the efficacy and safety of three intravenous anticonvulsive agents - levetiracetam, fosphenytoin, and valproate - in children and adults with convulsive status epilepticus that was unresponsive to treatment with benzodiazepines. The primary outcome was absence of clinically evident seizures and improvement in the level of consciousness by 60 minutes after the start of drug infusion, without additional anticonvulsant medication. The posterior probabilities that each drug was the most or least effective were calculated. Safety outcomes included life-threatening hypotension or cardiac arrhythmia, endotracheal intubation, seizure recurrence, and death.

Résultats : A total of 384 patients were enrolled and randomly assigned to receive levetiracetam (145 patients), fosphenytoin (118), or valproate (121). Reenrollment of patients with a second episode of status epilepticus accounted for 16 additional instances of randomization. In accordance with a prespecified stopping rule for futility of finding one drug to be superior or inferior, a planned interim analysis led to the trial being stopped. Of the enrolled patients, 10% were determined to have had psychogenic seizures. The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes occurred in 68 patients assigned to levetiracetam (47%; 95% credible interval, 39 to 55), 53 patients assigned to fosphenytoin (45%; 95% credible interval, 36 to 54), and 56 patients assigned to valproate (46%; 95% credible interval, 38 to 55). The posterior probability that each drug was the most effective was 0.41, 0.24, and 0.35, respectively. Numerically more episodes of hypotension and intubation occurred in the fosphenytoin group and more deaths occurred in the levetiracetam group than in the other groups, but these differences were not significant.

Conclusion : In the context of benzodiazepine-refractory convulsive status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin, and valproate each led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, and the three drugs were associated with similar incidences of adverse events.

Conclusion (proposition de traduction) : Dans le contexte de l'état de mal épileptique convulsif réfractaire aux benzodiazépines, les anticonvulsivants levetiracetam, fosphénytoïne et valproate ont tous entraîné l'arrêt des crises et amélioré la vigilance à 60 minutes chez environ la moitié des patients et les trois médicaments étaient associés à des effets indésirables semblables.

Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability.
Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, Spencer FA, Sharma S, D'Aragon F, Deshaies JF, Le Gal G, Lazo-Langner A, Wu C, Rudd-Scott L, Bates SM, Julian JA; PEGeD Study Investigators. | N Engl J Med. 2019 Nov 28;381(22):2125-2134
DOI: https://doi.org/10.1056/NEJMoa1909159
Keywords: Aucun

Original article

Introduction : Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP.

Méthode : We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism.

Résultats : A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9).

Conclusion : A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up.

Conclusion (proposition de traduction) : La combinaison d'une faible probabilité clinique pré-test et d'un taux de D-dimères inférieur à 1000 ng par millilitre a permis d'identifier un groupe de patients à faible risque d'embolie pulmonaire, pendant le suivi.

Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest.
François B, Cariou A, Clere-Jehl R, Dequin PF, Renon-Carron F, Daix T, Guitton C, Deye N, Legriel S, Plantefève G, Quenot JP, Desachy A, Kamel T, Bedon-Carte S, Diehl JL, Chudeau N, Karam E, Durand-Zaleski I, Giraudeau B, Vignon P, Le Gouge A; CRICS-TRIGGERSEP Network and the ANTHARTIC Study Group.. | N Engl J Med. 2019 Nov 7;381(19):1831-1842
DOI: https://doi.org/10.1056/NEJMoa1812379
Keywords: Aucun

Original article

Introduction : Patients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown.

Méthode : We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin-clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia.

Résultats : A total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P = 0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups.

Conclusion : A 2-day course of antibiotic therapy with amoxicillin-clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28.

Conclusion (proposition de traduction) : Un traitement antibiotique de 2 jours avec de l'amoxicilline-clavulanate chez des patients bénéficiant d'une stratégie de gestion de la température ciblée de 32 à 34 ° C après un arrêt cardiaque extra-hospitalier avec un rythme choquable initial a entraîné une incidence plus faible de pneumonie précoce acquise sous respirateur que le placebo. Aucune différence significative entre les groupes n'a été observée pour d'autres variables cliniques clés, telles que les jours sans ventilateur et la mortalité au 28ème jour.

Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation.
Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T, Balasubramanian V, Russo AM, Rajmane A, Cheung L, Hung G, Lee J, Kowey P, Talati N, Nag D, Gummidipundi SE, Beatty A, Hills MT, Desai S, Granger CB, Desai M, Turakhia MP; Apple Heart Study Investigators.. | N Engl J Med. 2019 Nov 14;381(20):1909-1917
DOI: https://doi.org/10.1056/NEJMoa1901183
Keywords: Aucun

Original article

Introduction : Optical sensors on wearable devices can detect irregular pulses. The ability of a smartwatch application (app) to identify atrial fibrillation during typical use is unknown.

Méthode : Participants without atrial fibrillation (as reported by the participants themselves) used a smartphone (Apple iPhone) app to consent to monitoring. If a smartwatch-based irregular pulse notification algorithm identified possible atrial fibrillation, a telemedicine visit was initiated and an electrocardiography (ECG) patch was mailed to the participant, to be worn for up to 7 days. Surveys were administered 90 days after notification of the irregular pulse and at the end of the study. The main objectives were to estimate the proportion of notified participants with atrial fibrillation shown on an ECG patch and the positive predictive value of irregular pulse intervals with a targeted confidence interval width of 0.10.

Résultats : We recruited 419,297 participants over 8 months. Over a median of 117 days of monitoring, 2161 participants (0.52%) received notifications of irregular pulse. Among the 450 participants who returned ECG patches containing data that could be analyzed - which had been applied, on average, 13 days after notification - atrial fibrillation was present in 34% (97.5% confidence interval [CI], 29 to 39) overall and in 35% (97.5% CI, 27 to 43) of participants 65 years of age or older. Among participants who were notified of an irregular pulse, the positive predictive value was 0.84 (95% CI, 0.76 to 0.92) for observing atrial fibrillation on the ECG simultaneously with a subsequent irregular pulse notification and 0.71 (97.5% CI, 0.69 to 0.74) for observing atrial fibrillation on the ECG simultaneously with a subsequent irregular tachogram. Of 1376 notified participants who returned a 90-day survey, 57% contacted health care providers outside the study. There were no reports of serious app-related adverse events.

Conclusion : The probability of receiving an irregular pulse notification was low. Among participants who received notification of an irregular pulse, 34% had atrial fibrillation on subsequent ECG patch readings and 84% of notifications were concordant with atrial fibrillation. This siteless (no on-site visits were required for the participants), pragmatic study design provides a foundation for large-scale pragmatic studies in which outcomes or adherence can be reliably assessed with user-owned devices.

Conclusion (proposition de traduction) : La probabilité de recevoir une notification de pouls irrégulier était faible. Parmi les participants qui ont reçu une notification de pouls irrégulier, 34 % avaient une fibrillation atriale lors des lectures ultérieures de patchs ECG et 84 % des notifications concordaient avec une fibrillation atriale. Cette conception d'étude pragmatique sans site (aucune visite sur place n'a été nécessaire pour les participants) fournit une base pour des études pragmatiques à grande échelle dans lesquelles les résultats ou l'adhésion peuvent être évalués de manière fiable avec des appareils appartenant aux utilisateurs.

Ticagrelor with or without Aspirin in High-Risk Patients after PCI.
Mehran R, Baber U, Sharma SK, Cohen DJ, Angiolillo DJ, Briguori C, Cha JY, Collier T, Dangas G, Dudek D, Džavík V, Escaned J, Gil R, Gurbel P, Hamm CW, Henry T, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff M, Kunadian V, Marx SO, Mehta SR, Moliterno D, Ohman EM, Oldroyd K, Sardella G, Sartori S, Shlofmitz R, Steg PG, Weisz G, Witzenbichler B, Han YL, Pocock S, Gibson CM.. | N Engl J Med. 2019 Nov 21;381(21):2032-2042
DOI: https://doi.org/10.1056/NEJMoa1908419
Keywords: Aucun

Original article

Introduction : Monotherapy with a P2Y12 inhibitor after a minimum period of dual antiplatelet therapy is an emerging approach to reduce the risk of bleeding after percutaneous coronary intervention (PCI).

Méthode : In a double-blind trial, we examined the effect of ticagrelor alone as compared with ticagrelor plus aspirin with regard to clinically relevant bleeding among patients who were at high risk for bleeding or an ischemic event and had undergone PCI. After 3 months of treatment with ticagrelor plus aspirin, patients who had not had a major bleeding event or ischemic event continued to take ticagrelor and were randomly assigned to receive aspirin or placebo for 1 year. The primary end point was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding. We also evaluated the composite end point of death from any cause, nonfatal myocardial infarction, or nonfatal stroke, using a noninferiority hypothesis with an absolute margin of 1.6 percentage points.

Résultats : We enrolled 9006 patients, and 7119 underwent randomization after 3 months. Between randomization and 1 year, the incidence of the primary end point was 4.0% among patients randomly assigned to receive ticagrelor plus placebo and 7.1% among patients assigned to receive ticagrelor plus aspirin (hazard ratio, 0.56; 95% confidence interval [CI], 0.45 to 0.68; P<0.001). The difference in risk between the groups was similar for BARC type 3 or 5 bleeding (incidence, 1.0% among patients receiving ticagrelor plus placebo and 2.0% among patients receiving ticagrelor plus aspirin; hazard ratio, 0.49; 95% CI, 0.33 to 0.74). The incidence of death from any cause, nonfatal myocardial infarction, or nonfatal stroke was 3.9% in both groups (difference, -0.06 percentage points; 95% CI, -0.97 to 0.84; hazard ratio, 0.99; 95% CI, 0.78 to 1.25; P<0.001 for noninferiority).

Conclusion : Among high-risk patients who underwent PCI and completed 3 months of dual antiplatelet therapy, ticagrelor monotherapy was associated with a lower incidence of clinically relevant bleeding than ticagrelor plus aspirin, with no higher risk of death, myocardial infarction, or stroke.

Conclusion (proposition de traduction) : Parmi les patients à haut risque qui ont subi une intervention coronarienne percutanée et terminé 3 mois de double thérapie antiplaquettaire, le ticagrelor en monothérapie a été associé à une incidence plus faible de saignements cliniquement significatifs que le ticagrelor plus l'aspirine, sans risque plus élevé de décès, d'infarctus du myocarde ou d'accident vasculaire cérébral.