Clinical Gestalt for Early Prediction of Delayed Functional and Symptomatic Recovery From Mild Traumatic Brain Injury Is Inadequate.
Korley FK, Peacock WF, Eckner JT, Maio R, Levin S, Bechtold KT, Peters M, Roy D, Falk HJ, Hall AJ, Van Meter TE, Gonzalez R, Diaz-Arrastia R. | Acad Emerg Med. 2019 Dec;26(12):1384-1387
DOI: https://doi.org/10.1111/acem.13844
Keywords: Aucun

RESEARCH LETTER

Editorial : There are limited prognostic tools to guide clinicians in acute risk stratification of adult mild traumatic brain injury patients (mTBI). While the majority of mTBI patients achieve full recovery within 7 to 14 days, approximately 25% to 30% remain symptomatic for 3 or more months postinjury. Early identification of the subset of mTBI patients at high risk for protracted recovery will: 1) facilitate administering the right discharge instructions and subspecialty referral to the right at-risk mTBI patients; 2) enable individualized education of patients regarding their expected course of recovery; 3) allow targeted administration of cognitive and behavioral therapy that has been found to be efficacious when implemented during the acute phase of injury; and 4) enable enrichment of study populations of mTBI clinical trials with patients who are at risk for protract ed recovery and therefore decrease the sample size required for demonstrating therapeutic efficacy.

Conclusion : The accuracy of clinical gestalt for predicting mTBI outcomes on the day of injury is poor. Data-driven strategies are needed to provide clinical decision support for mTBI risk stratification in acute care settings.

Conclusion (proposition de traduction) : La précision de l'expertise clinique pour prédire les résultats des lésions cérébrales traumatiques légères le jour du traumatisme est faible. Des stratégies fondées sur les données sont nécessaires pour fournir une aide à la décision clinique pour la stratification du risque de traumatisme craniocérébral léger dans les établissements de soins d'urgences.

Hot Off the Press: Assessing Risk of Future Suicidality in Emergency Department Patients.
Morgenstern J, Heitz C, Bond C, Milne WK. | Acad Emerg Med. 2019 Dec;26(12):1388-1390
DOI: https://doi.org/10.1111/acem.13775
Keywords: Aucun

Hot Off the Press

Editorial : Suicidal ideation is common, accounting for about 1% of emergency department (ED) visits or about 1.4 million visits a year in the United States. Although there are numerous validated screening tools, such as the PHQ9, the ED-Safe Patient Safety Screener, and the Suicide Behaviors Questionnaire–Revised (SBQ-R), none have been tested against physician gestalt, and none are widely used in clinical practice. The Convergent Functional Information for Suicidality (CFI-S) is a validated screening tool for suicidal ideation, but it has not been tested in an ED setting. The current trial aimed at assessing the accuracy of the CFI-S in the ED, while comparing it to a screening tool already in use and physician gestalt.

Conclusion : We were surprised that 10% of unselected ED patients experienced an event related to suicidality in the 6 months after their ED visit in this cohort. Although that number will vary in different contexts, it is an important reminder for physicians about the suffering our patients experience. Unfortunately, neither the CFI-S screening tool nor the physician gestalt were very accurate at detecting these patients. This is an important area for future research.

Conclusion (proposition de traduction) : Nous avons été surpris de constater que 10 % des patients non sélectionnés aux urgences ont connu un événement lié au suicide dans les 6 mois suivant leur consultation aux urgences dans cette cohorte. Bien que ce nombre varie en fonction des contextes, il constitue un rappel important pour les médecins des souffrances que vivent nos patients. Malheureusement, ni l'outil de dépistage CFI-S ni l'expérience du médecin n'ont été très précis pour détecter ces patients. C'est un domaine important pour la recherche future.

Commentaire : Voir l'article :
Brucker K, Duggan C, Niezer J, Roseberry K, Le-Niculescu H, Niculescu AB, Kline JA. Assessing Risk of Future Suicidality in Emergency Department Patients. Acad Emerg Med. 2019 Apr;26(4):376-383  .

Intensive Glucose Control for Critically Ill Patients.
Conway J, Friedman B. | Acad Emerg Med. 2019 Dec;26:1391–1392
DOI: https://doi.org/10.1111/acem.13777
Keywords: Aucun

The Brass Tacks: Concise Reviews of Published Evidence

Editorial : In the past decade, emergency department (ED) to intensive care unit (ICU) admissions increased by 79% to 2.2 million admissions annually, reflecting the increasing role of emergency medicine physicians in providing care for critically ill patients. Optimal glucose control in critical care patients has been a topic of contention for decades. In 2001 a single-center trial of mechanically ventilated surgical patients found intensive glucose control (maintaining glucose at 80–110 mg/dL) reduced mortality compared to conventional control (180–200 mg/dL only if glucose exceeded 215). Subsequent studies provided conflicting data, and in 2009, the multicenter NICE-SUGAR trial, the largest trial yet, demonstrated increased mortality with intensive glucose control. Current American Diabetes Association (ADA) guidelines, reflecting concern about harms associated with intensive glucose control, recommend conventional glucose control with a target glucose range of 140 to 180 mg/dL for critically ill patients who experience persistent hyperglycemia.

Conclusion : In summary, there was no benefit found with intensive glucose control in critical care patients but there was increased incidence of severe hypoglycemia. With no benefits and increased harms, the most appropriate color rating for intensive glucose control is black (harms > benefits). Current ADA guidelines, citing the findings of prior meta-analyses, recommend conventional glucose control with targeted blood glucose of 140 to 180 mg/dL in critically ill patients who experience persistent hyperglycemia.

Conclusion (proposition de traduction) : En résumé, aucun contrôle du glucose intensif n'a été observé chez les patients en soins intensifs, mais l'incidence de l'hypoglycémie sévère a augmenté. En l'absence d'avantages et de dommages accrus, la couleur la plus appropriée pour un contrôle intensif du glucose est le noir (dommages> avantages). Les lignes directrices actuelles de l'ADA, citant les résultats de méta-analyses antérieures, recommandent un contrôle glycémique conventionnel avec une glycémie ciblée de 140 à 180 mg / dL chez les patients gravement malades qui présentent une hyperglycémie persistante.

Balanced Crystalloids Versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial.
Brown RM, Wang L, Coston TD, Krishnan NI, Casey JD, Wanderer JP, Ehrenfeld JM, Byrne DW, Stollings JL, Siew ED, Bernard GR, Self WH, Rice TW, Semler MW. | Am J Respir Crit Care Med. 2019 Dec 15;200(12):1487-1495
DOI: https://doi.org/10.1164/rccm.201903-0557oc  | Télécharger l'article au format  
Keywords: balanced crystalloids; lactated Ringer’s; saline; sepsis; septic shock

Original Articles

Introduction : Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown.
Objectives : To compare the effect of balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis.

Méthode : Secondary analysis of patients from SMART (Isotonic Solutions and Major Adverse Renal Events Trial) admitted to the medical ICU with an International Classification of Diseases, 10th Edition, Clinical Modification System code for sepsis, using multivariable regression to control for potential confounders.

Résultats : Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical ICU with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality compared with 255 patients (31.2%) in the saline group (adjusted odds ratio [aOR], 0.74; 95% confidence interval [CI], 0.59-0.93; P = 0.01). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs. 40.1%; aOR, 0.78; 95% CI, 0.63-0.97) and a greater number of vasopressor-free days (20 ± 12 vs. 19 ± 13; aOR, 1.25; 95% CI, 1.02-1.54) and renal replacement therapy-free days (20 ± 12 vs. 19 ± 13; aOR, 1.35; 95% CI, 1.08-1.69) compared with the saline group.

Conclusion : Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared with use of saline.

Conclusion (proposition de traduction) : Parmi les patients présentant un sepsis dans un vaste essai randomisé, l'utilisation de cristalloïdes balancés a été associée à une mortalité hospitalière inférieure à 30 jours par rapport à l'utilisation de solution saline.

Tracheal intubation.
McGuire B, Hodge K. | Anaesth Intensive Care Med. 2019 dec:20(12);681–686
DOI: https://doi.org/10.1016/j.mpaic.2019.11.002
Keywords: Aucun

Fundamental Principles

Editorial : Tracheal intubation is the act of placing a tube into the trachea. The tube enables oxygen delivery and removal of carbon dioxide, while also allowing for the administration of pharmacological agents. Intubation is the most reliable method of maintaining an airway under anaesthesia, and for protection against aspiration of stomach contents. Traditionally, intubation is achieved by direct visualization of the glottis, but now indirect laryngoscopy (via a videolaryngoscope) is a common alternative. Prior to embarking upon intubation, a thorough patient history and examination must be undertaken by the laryngoscopist; equipment must be prepared and checked; a trained assistant present; and an experienced anaesthetist available in case assistance is required. Once the endotracheal tube has been placed, correct positioning must be confirmed via both clinical examination and monitoring, including capnography. Tracheal intubation is a procedure that should only be undertaken by trained operators and is not without risk. It is important to note that it is failure to oxygenate patients rather than failure to intubate that ultimately leads to serious morbidity and mortality. The Difficult Airway Society has produced guidelines on how to manage unanticipated difficulty in tracheal intubation; it is essential that every practitioner trained to intubate patients is familiar with these algorithms and the key principles of safe airway management.

Conclusion : Tracheal intubation is commonly used as part of general anaesthesia and during resuscitation. The purpose of tracheal intubation is primarily for airway maintenance and the facilitation of assisted ventilation gas exchange. It also protects the airway against contamination, such as from gastric contents. Pharmacological agents can also be administered via the endotracheal tube, most commonly sedative anaesthetic agents (volatiles) but also bronchodilators.

Conclusion (proposition de traduction) : L'intubation trachéale est couramment utilisée dans le cadre de l'anesthésie générale et en réanimation. L'intubation trachéale vise principalement l'aspiration des voies aériennes et la facilitation des échanges de gaz en ventilation assistée. Il protège également les voies respiratoires contre la contamination, telle que du contenu gastrique. Les agents pharmacologiques peuvent également être administrés via la sonde endotrachéale, le plus souvent des agents anesthésiques sédatifs (volatils) mais également des bronchodilatateurs.

Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe-A Qualitative Study on the Decisionmaking Process of Emergency Department Providers.
Kea B, Alligood T, Robinson C, Livingston J, Sun BC. | Ann Emerg Med. 2019 Dec;74(6):759–771
DOI: https://doi.org/10.1016/j.annemergmed.2019.03.026
Keywords: Aucun

Cardiology

Introduction : Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation.

Méthode : From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians' attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians.

Résultats : Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors.

Conclusion : The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

Conclusion (proposition de traduction) : La décision de prescrire une anticoagulation orale aux urgences est complexe. L'amélioration du respect des recommandations nécessitera une approche multiforme comprenant des améliorations au niveau du système, la formation des médecins et le développement d'outils et de recommandations spécifiques aux urgences.

Use of Tandem Perimortem Cesarean Section and Open-Chest Cardiac Massage in the Resuscitation of Peripartum Cardiomyopathy Cardiac Arrest.
Adan AJ, Nafday A, Beyer AB, Odom MJ, Theyyunni NR, Ward KR. | Ann Emerg Med. 2019 Dec;74(6):772–774
DOI: https://doi.org/10.1016/j.annemergmed.2019.03.012
Keywords: Aucun

Cardiology

Editorial : Cardiac arrest and resuscitation of the pregnant woman at gestational term is rare. Depending on the circumstances of cardiac arrest and its timing, options are limited for allowing successful resuscitation of both mother and neonate. Herein, we describe the use of tandem perimortem cesarean section and thoracotomy for open-chest cardiac massage in a young woman with newly diagnosed peripartum cardiomyopathy. We used goal-directed resuscitation including diagnostic ultrasonography and capnography to assist in decision making and successfully resuscitated both mother and neonate to hospital discharge without discernable long-term complications.

Conclusion : In this case of peripartum cardiomyopathy–associated cardiac arrest of mother and fetus, our emergency team made physiologically guided decisions using a combination of ultrasonography and capnography to perform bedside cesarean section followed by open-chest cardiac massage, resulting in the successful resuscitation of both mother and baby, without discernable complications. We suggest openchest cardiac massage is worth considering in patients with potentially reversible causes of cardiac arrest and poor objective predictors of return of spontaneous circulation.

Conclusion (proposition de traduction) : Dans ce cas de cardiomyopathie péripartum associée à un arrêt cardiaque de la mère et du fœtus, notre équipe d'urgence a pris des décisions physiologiquement guidées en utilisant une combinaison d'échographie et de capnographie pour effectuer une césarienne au chevet du patient suivie d'un massage cardiaque à thorax ouvert, ce qui a permis de réanimer avec succès la mère et le bébé, sans complications discernables. Nous pensons que le massage cardiaque à thorax ouvert est à envisager chez les patients ayant des causes potentiellement réversibles d'arrêt cardiaque et de mauvais prédicteurs objectifs du retour de la circulation spontanée.

How Effective Are Epinephrine and Vasopressin for Improving Survival Among Patients in Cardiac Arrest?.
Gottlieb M, Jani VP, Purim-Shem-Tov YA. | Ann Emerg Med. 2019 Dec;74(6):775–776
DOI: https://doi.org/10.1016/j.annemergmed.2019.04.001  | Télécharger l'article au format  
Keywords: Aucun

Cardiology

Introduction : Authors of this review conducted a thorough search of the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects, MEDLINE, Ovid, and EMBASE from inception and through May 2018. Authors also searched the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations, ClinicalTrials.gov, the ISRCTN registry, the World Health Organization International Clinical Trials Registry Platform, and the NHS Clinical Trials and Medical Research database.

Méthode : Two reviewers independently read the title and abstract, and, if in doubt, read the entire article for inclusion. Disagreements were resolved through discussion between these reviewers and the other 2 authors. There were no language restrictions and translators were used for non- English studies. Authors included all randomized controlled trials comparing standard-dose (or high-dose) epinephrine versus placebo, standard-dose epinephrine versus high-dose epinephrine, or epinephrine versus vasopressin (alone or in combination with epinephrine). Both adult and pediatric patients were included, as well as those with cardiac arrests either outside of the hospital or during hospitalization. Peer- reviewed abstracts and letters to the editor of peer-reviewed journals were also included. Authors excluded animal studies. Primary outcomes included survival to hospital discharge, survival to hospital admission, and neurologic outcome. Return of spontaneous circulation was assessed as a secondary outcome.

Résultats : Two reviewers extracted the data, with differences resolved through discussion in consultation with an additional reviewer. Authors used risk ratios with 95% confidence intervals to compare dichotomous outcomes. Authors dichotomized the neurologic outcomes. Among studies using the Cerebral Performance Category tool, scores less than or equal to 2 were considered a favorable neurologic outcome and those greater than 2 were considered a poor one. Among studies using the modified Rankin Scale, a score less than or equal to 3 was considered a favorable neurologic outcome, whereas a score greater than 3 was considered a poor one. Study quality was assessed with the Cochrane Risk of Bias tool. Articles written by authors of the review were evaluated for bias by 3 independent reviewers. Studies were examined for heterogeneity with c2 and I2 statistics. Publication bias was assessed with forest plots.

Conclusion : Epinephrine is associated with improved overall survival rates, but no difference noted in favorable neurologic outcomes.

Conclusion (proposition de traduction) : L'épinéphrine est associée à une amélioration des taux de survie globale, mais aucune différence n'a été notée dans les résultats neurologiques favorables.

Commentaire : Voir l'article :
Finn J, Jacobs I, Williams TA, Gates S, Perkins GD. Adrenaline and vasopressin for cardiac arrest. Cochrane Database Syst Rev. 2019;1(1):CD003179. Published 2019 Jan 17. doi:10.1002/14651858.CD003179.pub2  .

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.
Carlson JN, Zocchi M, Marsh K, McCoy C, Pines JM, Christensen A, Kornas R, Venkat A. | Ann Emerg Med. 2019 Dec;74(6):786–794
DOI: https://doi.org/10.1016/j.annemergmed.2019.04.025
Keywords: Aucun

Airway

Introduction : Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group.

Méthode : Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations).

Résultats : We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6).

Conclusion : These findings provide insights into the frequency with which emergency physicians perform intubations.

Conclusion (proposition de traduction) : Ces résultats donnent un aperçu de la fréquence à laquelle les médecins urgentistes procèdent à des intubations.

Commentaire : L'incidence des intubations varie selon les médecins urgentistes généralistes (médiane de 10 intubations par an ; IQR de 5 à 17 ; minimum 0, maximum 109). Environ 5 % des médecins urgentistes n'ont procédé à aucune intubation au cours d'une année donnée. Au cours de l'étude, 24,1 % des médecins urgentistes généralistes ont effectué moins de 5 intubations par an (de 21,2 % en 2010 à 25,7 % en 2016). Les médecins urgentistes travaillant dans les urgences générales ont effectué une médiane de 0,7 intubations pour 100 heures cliniques (IQR 0,3 à 1,1) et 2,7 intubations pour 1 000 visites de patients aux urgences (IQR 1,2 à 4,6).

Intubation by Emergency Physicians: How Often Is Enough?.
Kerrey BT, Wang H. | Ann Emerg Med. 2019 Dec;74(6):795–796
DOI: https://doi.org/10.1016/j.annemergmed.2019.06.022
Keywords: Aucun

Airway

Editorial : Intubation is a lifesaving emergency procedure. Emergency medicine residents achieve competency in intubation through intensive training programs, which include regular and frequent performance of intubation in the emergency department (ED). What happens after residency is uncertain; maintenance of any skill is a function of the quality and intensity of initial training plus ongoing experience in clinical practice. Is the intubation experience of emergency physicians enough to maintain the competency acquired during residency?

Conclusion : The study by Carlson et al addresses a critical gap in our knowledge of ED airway management while prompting us to advance our approach to airway research in emergency medicine. The decision to perform intubation for a critically ill patient is fraught with risk and stress; we must leverage technology to develop new approaches that broaden and deepen our understanding of this essential, lifesaving procedure.

Conclusion (proposition de traduction) : L'étude de Carlson et al. comble une lacune importante dans nos connaissances sur la gestion des voies respiratoires en cas d'urgence, tout en nous incitant à faire progresser notre approche de la recherche sur les voies respiratoires en médecine d'urgence. La décision de procéder à l'intubation d'un patient gravement malade est lourde de risques et de stress ; nous devons tirer parti de la technologie pour développer de nouvelles approches qui élargissent et approfondissent notre compréhension de cette procédure essentielle et salvatrice.

Commentaire : Référence correspondante :
Carlson JN, Zocchi M, Marsh K, et al. Procedural Experience With Intubation: Results From a National Emergency Medicine Group. Ann Emerg Med. 2019;74(6):786–794  .

The Association of the Average Epinephrine Dosing Interval and Survival With Favorable Neurologic Status at Hospital Discharge in Out-of-Hospital Cardiac Arrest.
Grunau B, Kawano T, Scheuermeyer FX, Drennan I, Fordyce CB, van Diepen S, Reynolds J, Lin S, Christenson J. | Ann Emerg Med. 2019 Dec;74(6):797–806
DOI: https://doi.org/10.1016/j.annemergmed.2019.04.031
Keywords: Aucun

Emergency Medical Services

Introduction : For patients with out-of-hospital cardiac arrest, the recommended dosing interval of epinephrine is 3 to 5 minutes, but this recommendation is based on expert opinion without data to guide optimal management. We seek to evaluate the association between the average epinephrine dosing interval and patient outcomes.

Méthode : In a secondary analysis of the Resuscitation Outcomes Consortium continuous chest compression trial, we identified consecutive patients treated with greater than or equal to 2 doses of epinephrine. We defined average epinephrine dosing interval as resuscitation duration after the first dose of epinephrine divided by the total administered epinephrine, and categorized the dosing interval in minutes as less than 3, 3 to less than 4, 4 to less than 5, and greater than or equal to 5. We fit a logistic regression model to estimate the association of the average epinephrine dosing interval category with survival with favorable neurologic status (modified Rankin Scale score ≤3) at hospital discharge.

Résultats : We included 15,909 patients (median age 68 years [interquartile range 56 to 80 years], 35% women, 13% public location, 46% bystander cardiopulmonary resuscitation, and 19% initial shockable rhythm). The median epinephrine dosing interval was 4.3 minutes (interquartile range 3.5 to 5.3 minutes). Survival with favorable neurologic status occurred in 4.7% of patients. Compared with the reference dosing interval of less than 3 minutes, longer epinephrine dosing intervals were associated with lower survival with favorable neurologic status: dosing interval 3 to less than 4 minutes, adjusted odds ratio 0.44 (95% confidence interval 0.32 to 0.60); 4 to less than 5 minutes, adjusted odds ratio 0.26 (95% confidence interval 0.18 to 0.36); and greater than or equal to 5 minutes, adjusted odds ratio 0.21 (95% confidence interval 0.15 to 0.30).

Conclusion : In this out-of-hospital cardiac arrest series, a shorter average epinephrine dosing interval was associated with improved survival with favorable neurologic status.

Conclusion (proposition de traduction) : Dans cette série d'arrêts cardiaques hors hôpital, un intervalle moyen plus court de dosage de l'épinéphrine a été associé à une amélioration de la survie avec un état neurologique favorable.

Epinephrine in Out-of-Hospital Cardiac Arrest: What Is the Role of the Timing Interval?.
Mohr NM, Faine B. | Ann Emerg Med. 2019 Dec;74(6):807–808
DOI: https://doi.org/10.1016/j.annemergmed.2019.05.038
Keywords: Aucun

Emergency Medical Services

Editorial : Almost since its early use, epinephrine has been a controversial therapy for cardiac arrest resuscitation. Epinephrine dose, timeliness, efficacy, and safety in cardiac arrest have all been questioned, fundamentally probing the mechanisms of a drug that has been challenging to study clinically. In this issue of Annals, Grunau et al2 seek to add perspective to this debate with a secondary analysis of data from a Resuscitation Outcomes Consortium trial to assess the association between the average epinephrine dosing interval and patient outcomes.

Conclusion : Science needs a marketplace of ideas to challenge our understanding and to inspire others to subject our hypotheses to rigorous verification. This well-done comparative effectiveness analysis accomplishes that aim. Although the findings of Grunau et al may not lead to rewriting our out-of-hospital protocols yet, they can add another observation to the ongoing debate about the role of epinephrine in cardiac arrest.

Conclusion (proposition de traduction) : La science a besoin d'un marché des idées pour remettre en question notre compréhension et inspirer les autres à soumettre nos hypothèses à une vérification rigoureuse. Cette analyse comparative de l'efficacité bien faite permet d'atteindre cet objectif. Bien que les conclusions de Grunau et al ne conduisent pas encore à une réécriture de nos protocoles extra-hospitaliers, elles peuvent ajouter une autre observation au débat en cours sur le rôle de l'adrénaline dans l'arrêt cardiaque.

How to detect a positive response to a fluid bolus when cardiac output is not measured?.
Ait-Hamou Z, Teboul JL Anguel N, Monnet X. | Ann Intensive Care. 2019 Dec 16;9(1):138
DOI: https://doi.org/10.1186/s13613-019-0612-x  | Télécharger l'article au format  
Keywords: Fluid challenge; Heart rate; Pulse pressure; Pulse pressure variation; Shock index; Volume expansion

Research

Introduction : Volume expansion is aimed at increasing cardiac output (CO), but this variable is not always directly measured. We assessed the ability of changes in arterial pressure, pulse pressure variation (PPV) and heart rate (HR) or of a combination of them to detect a positive response of cardiac output (CO) to fluid administration.

Méthode : We retrospectively included 491 patients with circulatory failure. Before and after a 500-mL normal saline infusion, we measured CO (PiCCO device), HR, systolic (SAP), diastolic (DAP), mean (MAP) and pulse (PP) arterial pressure, PPV, shock index (HR/SAP) and the PP/HR ratio.

Résultats : The fluid-induced changes in HR were not correlated with the fluid-induced changes in CO. The area under the receiver operating characteristic curve (AUROC) for changes in HR as detectors of a positive fluid response (CO increase ≥ 15%) was not different from 0.5. The fluid-induced changes in SAP, MAP, PP, PPV, shock index (HR/SAP) and the PP/HR ratio were correlated with the fluid-induced changes in CO, but with r < 0.4. The best detection was provided by increases in PP, but it was rough (AUROC = 0.719 ± 0.023, best threshold: increase ≥ 10%, sensitivity = 72 [66-77]%, specificity = 64 [57-70]%). Neither the decrease in shock index nor the changes in other indices combining changes in HR, shock index, PPV and PP provided a better detection of a positive fluid response than changes in PP.

Conclusion : A positive response to fluid was roughly detected by changes in PP and not detected by changes in HR. Changes in combined indices including the shock index and the PP/HR ratio did not provide a better diagnostic accuracy.

Conclusion (proposition de traduction) : Une réponse positive au liquide a été grossièrement détectée par des changements de pression artérielle (PP) et non détectée par des changements de fréquence cardiaque (HR). Les changements dans les indices combinés, y compris l'indice de choc et le rapport PP/HR, n'ont pas fourni une meilleure précision diagnostique.

Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
Hussain F, Cooper A, Carson-Stevens A, Donaldson L, Hibbert P, Hughes T, Edwards A. | BMC Emerg Med. 2019 Dec 4;19(1):77
DOI: https://doi.org/10.1186/s12873-019-0289-3  | Télécharger l'article au format  
Keywords: Diagnostic error; Emergency department

Research article

Introduction : Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.

Méthode : A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.

Résultats : There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols.

Conclusion : Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Conclusion (proposition de traduction) : Des modifications des systèmes sont nécessaires pour fournir aux cliniciens un meilleur soutien dans l'évaluation des patients et l'interprétation des investigations. Les interventions visant à réduire les erreurs de diagnostic doivent être évaluées dans le cadre des services d'urgence et pourraient inclure des listes de contrôle normalisées, des rapports structurés et des améliorations des enquêtes technologiques.

The prognostic value of red blood cell distribution width in patients with suspected infection in the emergency department.
Uffen JW, Oomen P, de Regt M, Oosterheert JJ, Kaasjager K. | BMC Emerg Med. 2019 Dec 3;19(1):76
DOI: https://doi.org/10.1186/s12873-019-0293-7  | Télécharger l'article au format  
Keywords: Biomarkers; Emergency department; Emergency medicine; Infection; Internal medicine; Sepsis

Research article

Introduction : Sepsis is a potential life threatening dysregulated immune response to an infection, which can result in multi-organ failure and death. Unfortunately, good prognostic markers are lacking in patients with suspected infection to identify those at risk. Red blood cell distribution width (RDW) is a common and inexpensive hematologic laboratory measurement associated with adverse prognosis in multiple diseases. The aim of this study was to determine the prognostic value of RDW for mortality and early clinical deterioration in patients with a suspected infection in the emergency department.

Méthode : In this single center prospective observational cohort study, consecutive patients with suspected infection presenting for internal medicine in the emergency department between September 2016 and March 2018 were included. For prognostic validation of bedside sepsis scores and RDW receiver operating characteristics were generated. Association between RDW and mortality and ICU admission was analyzed univariate and in a multivariate logistic regression model.

Résultats : 1046 patients were included. In multivariate analyses, RDW was significantly associated with 30-day mortality (OR 1.15, 95% CI: 1.04-1.28) and early clinical deterioration (OR 1.09, 95% CI: 1.00-1.18). For 30-day mortality RDW had an AUROC of 0.66 (95% CI 0.59-0.72). Optimal cut-off value for RDW 2 was 12.95%. For early clinical deterioration RDW had an AUROC of 0.59 (95% CI 0.54-0.63) with an optimal cut-off value of 14.48%.

Conclusion : RDW was found to be a significant independent prognostic factor of 30-day mortality and early clinical deterioration in patients with suspected infection.. Therefore it can be a used as an extra marker besides bedside sepsis scores in identifying patients at risk for worse outcome in patients with suspected infection.

Conclusion (proposition de traduction) : L'IDR s'est avéré être un facteur pronostique indépendant significatif de la mortalité à 30 jours et de la détérioration clinique précoce chez les patients suspectés d'infection.

Commentaire : L'indice de distribution des globules rouges (IDR) correspond à un calcul fait par les automates de la variabilité de la taille des globules rouges. La plage normale de la largeur de distribution des globules rouges (IDR) est de 11 à 15. Une valeur plus élevée indique une plus grande variation de la taille des hématies que la normale (anisocytose) et se voit dans de nombreux types d’anémies.

Non-pulsatile blood flow is associated with enhanced cerebrovascular carbon dioxide reactivity and an attenuated relationship between cerebral blood flow and regional brain oxygenation.
Veraar CM, Rinösl H2, Kühn K, Skhirtladze-Dworschak K, Felli A, Mouhieddine M, Menger J, Pataraia E, Ankersmit HJ, Dworschak M. | Crit Care. 2019 Dec 30;23(1):426
DOI: https://doi.org/10.1186/s13054-019-2671-7  | Télécharger l'article au format  
Keywords: Cerebral blood flow velocity; Cerebral microcirculation; Cerebrovascular carbon dioxide reactivity; Extracorporeal cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Non-pulsatile blood flow; Non-pulsatile left ventricular assist device; Regional brain saturation

Research

Introduction : Systemic blood flow in patients on extracorporeal assist devices is frequently not or only minimally pulsatile. Loss of pulsatile brain perfusion, however, has been implicated in neurological complications. Furthermore, the adverse effects of absent pulsatility on the cerebral microcirculation are modulated similarly as CO2 vasoreactivity in resistance vessels. During support with an extracorporeal assist device swings in arterial carbon dioxide partial pressures (PaCO2) that determine cerebral oxygen delivery are not uncommon-especially when CO2 is eliminated by the respirator as well as via the gas exchanger of an extracorporeal membrane oxygenation machine. We, therefore, investigated whether non-pulsatile flow affects cerebrovascular CO2 reactivity (CVR) and regional brain oxygenation (rSO2).

Méthode : In this prospective, single-centre case-control trial, we studied 32 patients undergoing elective cardiac surgery. Blood flow velocity in the middle cerebral artery (MCAv) as well as rSO2 was determined during step changes of PaCO2 between 30, 40, and 50 mmHg. Measurements were conducted on cardiopulmonary bypass during non-pulsatile and postoperatively under pulsatile blood flow at comparable test conditions. Corresponding changes of CVR and concomitant rSO2 alterations were determined for each flow mode. Each patient served as her own control.

Résultats : MCAv was generally lower during hypocapnia than during normocapnia and hypercapnia (p < 0.0001). However, the MCAv/PaCO2 slope during non-pulsatile flow was 14.4 cm/s/mmHg [CI 11.8-16.9] and 10.4 cm/s/mmHg [CI 7.9-13.0] after return of pulsatility (p = 0.03). During hypocapnia, non-pulsatile CVR (4.3 ± 1.7%/mmHg) was higher than pulsatile CVR (3.1 ± 1.3%/mmHg, p = 0.01). Independent of the flow mode, we observed a decline in rSO2 during hypocapnia and a corresponding rise during hypercapnia (p < 0.0001). However, the relationship between ΔrSO2 and ΔMCAv was less pronounced during non-pulsatile flow.

Conclusion : Non-pulsatile perfusion is associated with enhanced cerebrovascular CVR resulting in greater relative decreases of cerebral blood flow during hypocapnia. Heterogenic microvascular perfusion may account for the attenuated ΔrSO2/ΔMCAv slope. Potential hazards related to this altered regulation of cerebral perfusion still need to be assessed.

Conclusion (proposition de traduction) : La perfusion non pulsatile est associée à une sensibilité accrue au CO₂ cérébrovasculaire, ce qui entraîne une diminution relative plus importante du débit sanguin cérébral pendant l'hypocapnie. La perfusion microvasculaire hétérogène peut expliquer l'atténuation de la pente de ΔMCAv/ΔMCAv. Les dangers potentiels liés à cette altération de la régulation de la perfusion cérébrale doivent encore être évalués.

Driving pressure is not associated with mortality in mechanically ventilated patients without ARDS.
Lanspa MJ, Peltan ID, Jacobs JR, Sorensen JS, Carpenter L, Ferraro JP, Brown SM, Berry JG, Srivastava R, Grissom CK. | Crit Care. 2019 Dec 27;23(1):424
DOI: https://doi.org/10.1186/s13054-019-2698-9  | Télécharger l'article au format  
Keywords: ARDS; Driving pressure; Low tidal volume ventilation; Lung protective ventilation; Respiratory compliance

Research

Introduction : In patients with acute respiratory distress syndrome (ARDS), low tidal volume ventilation has been associated with reduced mortality. Driving pressure (tidal volume normalized to respiratory system compliance) may be an even stronger predictor of ARDS survival than tidal volume. We sought to study whether these associations hold true in acute respiratory failure patients without ARDS.

Méthode : This is a retrospectively cohort analysis of mechanically ventilated adult patients admitted to ICUs from 12 hospitals over 2 years. We used natural language processing of chest radiograph reports and data from the electronic medical record to identify patients who had ARDS. We used multivariable logistic regression and generalized linear models to estimate associations between tidal volume, driving pressure, and respiratory system compliance with adjusted 30-day mortality using covariates of Acute Physiology Score (APS), Charlson Comorbidity Index (CCI), age, and PaO2/FiO2 ratio.

Résultats : We studied 2641 patients; 48% had ARDS (n = 1273). Patients with ARDS had higher mean APS (25 vs. 23, p < .001) but similar CCI (4 vs. 3, p = 0.6) scores. For non-ARDS patients, tidal volume was associated with increased adjusted mortality (OR 1.18 per 1 mL/kg PBW increase in tidal volume, CI 1.04 to 1.35, p = 0.010). We observed no association between driving pressure or respiratory compliance and mortality in patients without ARDS. In ARDS patients, both ΔP (OR1.1, CI 1.06-1.14, p < 0.001) and tidal volume (OR 1.17, CI 1.04-1.31, p = 0.007) were associated with mortality.

Conclusion : In a large retrospective analysis of critically ill non-ARDS patients receiving mechanical ventilation, we found that tidal volume was associated with 30-day mortality, while driving pressure was not.

Conclusion (proposition de traduction) : Dans une vaste analyse rétrospective de patients non atteints de SDRA gravement malades bénéficiant d'une ventilation mécanique, nous avons constaté que le volume courant était associé à une mortalité à 30 jours, contrairement à la « driving pressure ».

Commentaire : La « driving pressure » a été étudiée dans le SDRA.
Elle est la différence entre pression de plateau et la PEP (ΔP = Pplat - PEEP). Elle prend donc nécessairement en compte les propriétés mécaniques pulmonaires.
Des publications sur ce paramètre ont conclu qu’il était associé à la mortalité dans le SDRA : plus la driving pressure est basse, meilleure est la survie (c'est-à-dire que la mortalité était plus faible chez les patients chez qui la driving pressure était plus faible).
Voir l'analyse de l'article sur le site de la SRLF (Société de Réanimation de Langue Française) : La pression motrice est-elle la seule variable ventilatoire pertinente associée à la survie au cours du SDRA ?  . Rédigé par le Dr Jean-Christophe Richard le 26/03/2015.
Article : Amato M, Meade M, Slutsky A and al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372(8):747–55  .

How I use Transcranial Doppler.
Robba C, Taccone FS. | Crit Care. 2019 Dec 23;23(1):420
DOI: https://doi.org/10.1186/s13054-019-2700-6  | Télécharger l'article au format  
Keywords: Cerebral blood flow; Flow velocity; Neurointensive care; Transcranial Doppler

Editorial

Editorial : Transcranial Doppler (TCD) is a bedside, low-cost, and non-invasive technique able to evaluate cerebral hemodynamics; the implementation of transcranial color-coded duplex sonography (TCCS) aids in evaluating the brain anatomy and intracranial lesions, real-time monitoring of “basic” (flow velocity (FV) and pulsatility index (PI)) as well as “advanced” TCD-derived parameters. In practice, we use a 2-MHz probe, and most information is obtained by insonating the middle cerebral artery through the temporal window; other windows include the transorbital, occipital, and submandibular windows. TCCD has the advantage to provide a direct visualization of the cerebral anatomy vessels and allow angle correction to assess FV. TCD/TCCD practice is part of the standard training in our institution, and examinations are routinely performed by the medical staff.

Conclusion : We often use TCD to monitor brain hemodynamics in critically ill patients. Future TCD development, such as the assessment of the compliance of arterial and cerebrospinal fluid compartment as well as critical capillary closing pressure, will further expand its use in this setting.

Conclusion (proposition de traduction) : Nous utilisons souvent le doppler transcrânien pour surveiller l'hémodynamique cérébrale chez les patients gravement malades. Le développement futur du doppler transcrânien, comme l'évaluation de la conformité du compartiment du liquide artériel et cérébrospinal ainsi que la pression de fermeture capillaire critique, étendra encore son utilisation dans ce contexte.

Commentaire : 
Paramètres communs dérivés du Doppler transcranien

Adjuvant vitamin C for sepsis: mono or triple?.
Spoelstra-de Man AME, Oudemans-van Straaten HM, Berger MM. | Crit Care. 2019 Dec 27;23(1):425.
DOI: https://doi.org/10.1186/s13054-019-2717-x  | Télécharger l'article au format  
Keywords: Hydrocortisone; Sepsis; Thiamine; Vitamin C

Editorial

Editorial : Recently, the largest randomized clinical trial (RCT) of intravenous vitamin C in septic patients until now, the CITRIS-ALI trial, showed a 16.5% lower mortality in the vitamin C group compared to placebo, while the primary endpoint deltaSOFA-score after 96h was negative. Mortality curves parted from day 2, which may be due to early circulatory stabilization by vitamin C. Many comments on this trial addressed the methodological problem due to the exclusion of deceased and dis- charged patients from the deltaSOFA-score. Given the early mortality reduction in favor of vitamin C, recalculation with assignment of the worst SOFA score to deceased patients and the best score to discharged patients will undoubtedly show less organ dysfunction. So, the results of the CITRIS-ALI study support the promising role of adjuvant high-dose intravenous vitamin C for septic patients.

Conclusion : So, the CITRIS-ALI results support a potential role for adjuvant high-dose i.v. vitamin C for sepsis. Large RCTs are under way to confirm these results. Whether HAT-therapy induces additional beneficial effect when vitamin C is dosed sufficiently high remains to be demonstrated, although hydrocortisone and thiamine are certainly indicated in specific patient groups.

Conclusion (proposition de traduction) : Les résultats de l'étude CITRIS-ALI confirment un rôle potentiel pour l'administration adjuvante de vitamine C à forte dose i.v. dans la septicémie. De grands essais cliniques randomisés sont en cours pour confirmer ces résultats. Il reste à déterminer si la HAT-thérapie induit un effet bénéfique supplémentaire lorsque la vitamine C est suffisamment dosée, bien que l'hydrocortisone et la thiamine soient certainement indiquées dans des groupes de patients spécifiques.

Commentaire : La HAT-thérapie (hydrocortisone, vitamine C et thiamine) est basée sur l'hypothèse que l'hydrocortisone et la thiamine ont des effets potentiellement synergiques avec la vitamine C.
Voir l'article : Marik PE. Hydrocortisone, Ascorbic Acid and Thiamine (HAT Therapy) for the Treatment of Sepsis. Focus on Ascorbic Acid. Nutrients. 2018 Nov 14;10(11)  .

Association between hydroxocobalamin administration and acute kidney injury after smoke inhalation: a multicenter retrospective study.
Dépret F, Hoffmann C, Daoud L, Thieffry C, Monplaisir L, Creveaux J, Annane D, Parmentier E, Mathieu D, Wiramus S, Demeure DIt Latte D, Kpodji A, Textoris J, Robin F, Klouche K, Pontis E, Schnell G, Barbier F, Constantin JM, Clavier T, du Cheyron D, Terzi N, Sauneuf B, Guerot E, Lafon T, Herbland A, Megarbane B, Leclerc T, Mallet V, Pirracchio R, Legrand M. | Crit Care. 2019 Dec 23;23(1):421
DOI: https://doi.org/10.1186/s13054-019-2706-0  | Télécharger l'article au format  
Keywords: Acute kidney injury; Burn; Hydroxocobalamin; Intensive care unit; Mortality; Smoke inhalation

Research

Introduction : The use of hydroxocobalamin has long been advocated for treating suspected cyanide poisoning after smoke inhalation. Intravenous hydroxocobalamin has however been shown to cause oxalate nephropathy in a single-center study. The impact of hydroxocobalamin on the risk of acute kidney injury (AKI) and survival after smoke inhalation in a multicenter setting remains unexplored.

Méthode : We conducted a multicenter retrospective study in 21 intensive care units (ICUs) in France. We included patients admitted to an ICU for smoke inhalation between January 2011 and December 2017. We excluded patients discharged at home alive within 24 h of admission. We assessed the risk of AKI (primary endpoint), severe AKI, major adverse kidney (MAKE) events, and survival (secondary endpoints) after administration of hydroxocobalamin using logistic regression models.

Résultats : Among 854 patients screened, 739 patients were included. Three hundred six and 386 (55.2%) patients received hydroxocobalamin. Mortality in ICU was 32.9% (n = 243). Two hundred eighty-eight (39%) patients developed AKI, including 186 (25.2%) who developed severe AKI during the first week. Patients who received hydroxocobalamin were more severe and had higher mortality (38.1% vs 27.2%, p = 0.0022). The adjusted odds ratio (95% confidence interval) of AKI after intravenous hydroxocobalamin was 1.597 (1.055, 2.419) and 1.772 (1.137, 2.762) for severe AKI; intravenous hydroxocobalamin was not associated with survival or MAKE with an adjusted odds ratio (95% confidence interval) of 1.114 (0.691, 1.797) and 0.784 (0.456, 1.349) respectively.

Conclusion : Hydroxocobalamin was associated with an increased risk of AKI and severe AKI but was not associated with survival after smoke inhalation.

Conclusion (proposition de traduction) : L'hydroxocobalamine était associée à un risque accru de lésion rénale aiguë et de lésion rénale aiguë sévère, mais n'était pas associée à la survie après inhalation de fumée.

Influence of dyskalemia at admission and early dyskalemia correction on survival and cardiac events of critically ill patients.
Bouadma L, Mankikian S, Darmon M, Argaud L, Vinclair C, Siami S, Garrouste-Orgeas M, Papazian L, Cohen Y, Marcotte G, Styfalova L, Reignier J, Lautrette A, Schwebel C, Timsit JF; OUTCOMEREA STUDY GROUP. | Crit Care. 2019 Dec 19;23(1):415
DOI: https://doi.org/10.1186/s13054-019-2679-z  | Télécharger l'article au format  
Keywords: Cardiac events; Correction of potassium; Critical care; Mortality; Potassium

Research

Introduction : Our objectives were (1) to characterize the distribution of serum potassium levels at ICU admission, (2) to examine the relationship between dyskalemia at ICU admission and occurrence of cardiac events, and (3) to study both the association between dyskalemia at ICU admission and dyskalemia correction by day 2 on 28-day mortality.

Méthode : Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1999-2014) SETTING: 22 French OUTCOMEREA network ICUs PATIENTS: Patients were classified into six groups according to their serum potassium level at admission: three groups of hypokalemia and three groups of hyperkalemia defined as serious hypokalemia [K+] < 2.5 and serious hyperkalemia [K+] > 7 mmol/L, moderate hypokalemia 2.5 ≤ [K+] < 3 mmol/L and moderate hyperkalemia 6 < [K+] ≤ 7 mmol/L, and mild hypokalemia 3 ≤ [K+] < 3.5 mmol/L and mild hyperkalemia 5 < [K+] ≤ 6 mmol/L. We sorted evolution at day 2 of dyskalemia into three categories: balanced, not-balanced, and overbalanced.

Résultats : None MEASUREMENTS AND MAIN RESULTS: Of 12,090 patients, 2108 (17.4%) had hypokalemia and 1445 (12%) had hyperkalemia. Prognostic impact of dyskalemia and its correction was assessed using multivariate Cox models. After adjustment, hypokalemia and hyperkalemia were independently associated with a greater risk of 28-day mortality. Mild hyperkalemic patients had the highest mortality (hazard ratio (HR) 1.29, 95% confidence interval (CI) [1.13-1.47], p < 0.001). Adjusted 28-day mortality was higher if serum potassium level was not-balanced at day 2 (aHR = 1.51, 95% CI [1.30-1.76], p < 0.0001) and numerically higher but not significantly different if serum potassium level was overbalanced at day 2 (aHR = 1.157, 95% CI [0.84-1.60], p = 0.38). Occurrence of cardiac events was evaluated by logistic regression. Except for patients with serious hypokalemia at admission, the depth of dyskalemia was associated with increased risk of cardiac events.

Conclusion : Dyskalemia is common at ICU admission and associated with increased mortality. Occurrence of cardiac events increased with dyskalemia depth. A correction of serum potassium level by day 2 was associated with improved prognosis.

Conclusion (proposition de traduction) : La dyskaliémie est courante à l'admission aux soins intensifs et associée à une mortalité accrue. La survenue d'événements cardiaques a augmenté avec la profondeur de la dyskaliémie. Une correction du taux de potassium sérique au deuxième jour a été associée à une amélioration du pronostic.

Improving identification of pulmonary embolism-related out-of-hospital cardiac arrest to optimize thrombolytic therapy during resuscitation.
Javaudin F, Lascarrou JB, Esquina H, Baert V, Hubert H, Leclère B; GR-RéAC. | Crit Care. 2019 Dec 13;23(1):409
DOI: https://doi.org/10.1186/s13054-019-2672-6  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest; Pulmonary embolism; Thrombolytic therapy

Research Letter

Editorial : Pulmonary embolism (PE) is responsible for ~ 3% of Out-of-Hospital Cardiac Arrest (OHCA) and is associated with unfavorable prognoses. We have recently shown that thrombolysis during resuscitation was associated with a better survival in the event of a proven pulmonary embolism. The challenge is thus to identify, from the beginning of resuscitation, PE-related OHCA in order to deliver the proper treatment to the patient. This issue is highlighted by the premature stoppage of the TROICA trial [1], which showed no benefit of using thrombolysis in medical cardiac arrests. Our aim was to identify the factors associated with PE-related OHCA.

Conclusion : We recommend that for cases of OHCA for which a cause is not obvious, suspect a pulmonary embolism if the initial rhythm is nonshockable and there is a medical history of thromboembolism. In accordance with the guidelines of the American Heart Association (AHA), these subjects should be treated by thrombolysis during resuscitation, especially when they are young.

Conclusion (proposition de traduction) : Nous recommandons que, pour les cas d'arrêt cardiaqueextra-hospitalier pour lesquels une cause n'est pas évidente, de suspecter une embolie pulmonaire si le rythme initial est non choquable et qu'il existe des antécédents médicaux thromboemboliques. Conformément aux directives de l'American Heart Association (AHA), ces sujets doivent être traités par thrombolyse lors de la réanimation, en particulier lorsqu'ils sont jeunes.

Commentaire : Représentation arborescente de la fréquence des embolies pulmonaires en fonction des facteurs de risque

Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study.
Nakajima M, Kojiro M, Aso S, Matsui H, Fushimi K, Kaita Y, Goto H, Yamaguchi Y, Yasunaga H. | Crit Care. 2019 Dec 12;23(1):407
DOI: https://doi.org/10.1186/s13054-019-2693-1  | Télécharger l'article au format  
Keywords: Ascorbic acid; Burn; Competing risk; Matching; Propensity score; Vitamin C

Research

Introduction : Vitamin C is a well-documented antioxidant that reduces oxidative stress and fluid infusion in high doses; however, the association between high-dose vitamin C and reduced mortality remains unclear. This study evaluates the effect of high-dose vitamin C in severe burn patients under two varying thresholds.

Méthode : We enrolled adult patients with severe burns (burn index ≥ 15) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2016. Propensity score matching was performed between patients who received high-dose vitamin C within 1 day of admission (vitamin C group) and those who did not (control group). High-dose vitamin C was defined as a dosage in excess of 10 g or 24 g within 2 days of admission. The primary outcome was in-hospital mortality.

Résultats : Eligible patients (n = 2713) were categorized into the vitamin C group (n = 157) or control group (n = 2556). After 1:4 propensity score matching, we compared 157 and 628 patients who were administered high-dose vitamin C (> 10-g threshold) and controls, respectively. Under this particular threshold, high-dose vitamin C therapy was associated with reduced in-hospital mortality (risk ratio, 0.79; 95% confidence interval, 0.66-0.95; p = 0.006). In contrast, in-hospital mortality did not differ between the control and high-dose vitamin C group under the > 24-g threshold (risk ratio, 0.83; 95% confidence interval, 0.68-1.02; p = 0.068).

Conclusion : High-dose vitamin C therapy was associated with reduced mortality in patients with severe burns when used under a minimum threshold of 10 g within the first 2 days of admission. While "high-dose" vitamin C therapy lacks a universal definition, the present study reveals that different "high-dose" regimens may yield improved outcomes.

Conclusion (proposition de traduction) : Une administration de vitamine C à forte dose a été associé à une diminution de la mortalité chez les patients souffrant de brûlures graves lorsqu'elle était utilisé sous un seuil minimum de 10 g dans les 2 premiers jours d'admission. Alors que l'administration à haute dose de vitamine C n'a pas de définition universelle, la présente étude révèle que différents régimes à « haute dose » peuvent donner de meilleurs résultats.

A meta-analysis of the effects of therapeutic hypothermia in adult patients with traumatic brain injury.
Chen H, Wu F, Yang P, Shao J, Chen Q, Zheng R. | Crit Care. 2019 Dec 5;23(1):396
DOI: https://doi.org/10.1186/s13054-019-2667-3  | Télécharger l'article au format  
Keywords: Meta-analysis; Mortality; Normothermia; Therapeutic hypothermia; Traumatic brain injury

Review

Introduction : Therapeutic hypothermia management remains controversial in patients with traumatic brain injury. We conducted a meta-analysis to evaluate the risks and benefits of therapeutic hypothermia management in patients with traumatic brain injury.

Méthode : We searched the Web of Science, PubMed, Embase, Cochrane (Central) and Clinical Trials databases from inception to January 17, 2019. Eligible studies were randomised controlled trials that investigated therapeutic hypothermia management versus normothermia management in patients with traumatic brain injury. We collected the individual data of the patients from each included study. Meta-analyses were performed for 6-month mortality, unfavourable functional outcome and pneumonia morbidity. The risk of bias was evaluated using the Cochrane Risk of Bias tool.

Résultats : Twenty-three trials involving a total of 2796 patients were included. The randomised controlled trials with a high quality show significantly more mortality in the therapeutic hypothermia group [risk ratio (RR) 1.26, 95% confidence interval (CI) 1.04 to 1.53, p = 0.02]. Lower mortality in the therapeutic hypothermia group occurred when therapeutic hypothermia was received within 24 h (RR 0.83, 95% CI 0.71 to 0.96, p = 0.01), when hypothermia was received for treatment (RR 0.66, 95% CI 0.49 to 0.88, p = 0.006) or when hypothermia was combined with post-craniectomy measures (RR 0.69, 95% CI 0.48 to 1.00, p = 0.05). The risk of unfavourable functional outcome following therapeutic hypothermia management appeared to be significantly reduced (RR 0.78, 95% CI 0.67 to 0.91, p = 0.001). The meta-analysis suggested that there was a significant increase in the risk of pneumonia with therapeutic hypothermia management (RR 1.48, 95% CI 1.11 to 1.97, p = 0.007).

Conclusion : Our meta-analysis demonstrated that therapeutic hypothermia did not reduce but might increase the mortality rate of patients with traumatic brain injury in some high-quality studies. However, traumatic brain injury patients with elevated intracranial hypertension could benefit from hypothermia in therapeutic management instead of prophylaxis when initiated within 24 h.

Conclusion (proposition de traduction) : Notre méta-analyse a démontré que l'hypothermie thérapeutique n'a pas réduit mais pourrait augmenter le taux de mortalité des patients souffrant de lésions cérébrales traumatiques dans certaines études de haute qualité. Cependant, les patients souffrant de lésions cérébrales traumatiques présentant une hypertension intracrânienne élevée pourraient bénéficier d'une hypothermie dans la gestion thérapeutique au lieu d'une prophylaxie lorsqu'ils sont initiés dans les 24 h.

The prognostic value of serum procalcitonin measurements in critically injured patients: a systematic review.
AlRawahi AN, AlHinai FA, Doig CJ, Ball CG, Dixon E, Xiao Z, Kirkpatrick AW. | Crit Care. 2019 Dec 3;23(1):390
DOI: https://doi.org/10.1186/s13054-019-2669-1  | Télécharger l'article au format  
Keywords: Critical care; Injuries; Intensive care unit; Procalcitonin; Prognosis; Trauma

Research

Introduction : Major trauma is associated with high incidence of septic complications and multiple organ dysfunction (MOD), which markedly influence the outcome of injured patients. Early identification of patients at risk of developing posttraumatic complications is crucial to provide early treatment and improve outcomes. We sought to evaluate the prognostic value of serum procalcitonin (PCT) levels after trauma as related to severity of injury, sepsis, organ dysfunction, and mortality.

Méthode : We searched PubMed, MEDLINE, EMBASE, the Cochrane Database, and references of included articles. Two investigators independently identified eligible studies and extracted data. We included original studies that assessed the prognostic value of serum PCT levels in predicting severity of injury, sepsis, organ dysfunction, and mortality among critically injured adult patients.

Résultats : Among 2015 citations, 19 studies (17 prospective; 2 retrospective) met inclusion criteria. Methodological quality of included studies was moderate. All studies showed a strong correlation between initial PCT levels and Injury Severity Score (ISS). Twelve out of 16 studies demonstrated significant elevation of initial PCT levels in patients who later developed sepsis after trauma. PCT level appeared a strong predictor of MOD in seven out of nine studies. While two studies did not show association between PCT levels and mortality, four studies demonstrated significant elevation of PCT levels in non-survivors versus survivors. One study reported that the PCT level of ≥ 5 ng/mL was associated with significantly increased mortality (OR 3.65; 95% CI 1.03-12.9; p = 0.04).

Conclusion : PCT appears promising as a surrogate biomarker for trauma. Initial peak PCT level may be used as an early predictor of sepsis, MOD, and mortality in trauma population.

Conclusion (proposition de traduction) : La PCT semble prometteuse en tant que biomarqueur de substitution pour les traumatismes. Le niveau maximal de PCT initial peut être utilisé comme un prédicteur précoce de la septicémie, du syndrome de défaillance multiviscérale et de la mortalité dans la population de traumatisés.

The role of transcranial Doppler ultrasonography in differential diagnosis of vertigo in the Emergency Department.
Siniscalchi A, Malferrari G. | Emerg Care J. 2019;15:8341
DOI: https://doi.org/10.4081/ecj.2019.8341  | Télécharger l'article au format  
Keywords: Vertigo; Emergency Department; Posterior circulation stroke; Transcranial Doppler; Transcranial color Doppler

Reviews

Editorial : Vertigo represents about 4% of access to the Emergency Department (ED). Several conditions, such as general medical illnesses, otovestibular diseases and neurological diseases (including posterior circulation stroke) cause acute vertigo. The incidence of cerebrovascular disease in patients with vertigo in ED varies from 3 to 5%. Although neurosonology studies on acute vestibular syndrome are scarce, the use of transcranial Doppler (TCD) and transcranial color Doppler (TCCD) in the management of vertigo patients has several advantages: it can be performed at the patient's bedside and repeated and, furthermore, its use is low-cost. In an acute stroke, with an experienced doctor, it can help distinguish an ischemic stroke from a hemorrhagic stroke. In acute central vertigo induced by posterior circulation stroke, the TCD or TCCD can be a screening test before angiographic neuroradiological studies for stenosis of vertebral or basal arteries.

Conclusion : In conclusion, TCD and TCCD are useful in the evaluation of patients with acute vertigo, as they can highlight steno-occlusive disease of the posterior circulation, arterial dissections and give indirect signs of vertebrobasilar insufficiency, particularly in patients suspected of having an acute ischemic stroke.

Conclusion (proposition de traduction) : En conclusion, le Doppler transcrânien (TCD) et le Doppler transcrânien couleur (TCCD) sont utiles dans l'évaluation des patients atteints de vertige aigu, car ils peuvent mettre en évidence une maladie sténo-occlusive de la circulation postérieure, des dissections artérielles et donner des signes indirects d'insuffisance vertébrobasilaire, en particulier chez les patients suspectés d'avoir un AVC ischémique aigu.

Is the nasal route a viable option for relieving acute pain in pediatric emergency medicine? A literature review.
Aleysae NA | Emerg Care J. 2019;15:8320
DOI: https://doi.org/10.4081/ecj.2019.8320  | Télécharger l'article au format  
Keywords: Intranasal; Analgesia; Acute pain; Pediatric emergency medicine.

Reviews

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

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

Résultats : Seven RCTs and one quasi-randomized study met the inclusion criteria. Five studies compared an intranasal analgesic and an alternative intervention, two compared intranasal fentanyl against ketamine, and one compared two different concentrations of intranasal fentanyl. All included trials reported reductions in pain scores, especially within the first 10 to 30 minutes post-intervention; however, pain reduction was maintained to 60 minutes in only one study. No evidence of significant adverse events was associated with the administration of any intranasal analgesic in any of the included studies

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

Conclusion (proposition de traduction) : Cette revue a identifié huit articles qui ont discuté de l'analgésie intranasale comme une voie possible d'analgésie dans la douleur en pédiatrie. Bien qu'aucun document ne soit entièrement parfait, les résultats soutiennent l'idée que l'analgésie intranasale peut être un analgésique efficace pour le traitement des enfants (3-18 ans) souffrant de douleur aiguë modérée à sévère, et son administration semble causer des effets indésirables minimes.

Determination of the Best Early Warning Scores to Predict Clinical Outcomes of Patients in the Emergency Department.
Spencer W, Smith J, Date P, de Tonnerre E, Taylor DM. | Emerg Med J. 2019 Dec;36(12):716-721
DOI: https://doi.org/10.1136/emermed-2019-208622
Keywords: assessment; clinical management; emergency department

RISK-ASSESSMENT

Introduction : Early warning scores (EWS) are used to predict patient outcomes. We aimed to determine which of 13 EWS, based largely on emergency department (ED) vital sign data, best predict important clinical outcomes.

Méthode : We undertook a prospective cohort study in a metropolitan, tertiary-referral ED in Melbourne, Australia (February-April 2018). Patient demographics, vital signs and management data were collected while the patients were in the ED and EWS were calculated using each EWS criteria. Outcome data were extracted from the medical record (2-day, 7-day and 28-day inhospital mortality, clinical deterioration within 2 days, intensive care unit (ICU) admission within 2 days, admission to hospital). Area under the receiver operator characteristic (AUROC; 95% CIs) curves were used to evaluate the predictive ability of each EWS for each outcome.

Résultats : Of 1730 patients enrolled, 690 patients were admitted to the study hospital. Most EWS were good or excellent predictors of 2-day mortality. When considering the point estimates, the VitalPac EWS was the most strongly predictive (AUROC: 0.96; 95% CI: 0.92 to 0.99). However, when considering the 95% CIs, there was no significant difference between the highest performing EWS. The predictive ability for 7-day and 28-day mortality was generally less. No EWS was a good predictor for clinical deterioration (AUROC range: 0.54-0.70), ICU admission (range: 0.51-0.72) or admission to hospital (range: 0.51-0.68).

Conclusion : Several EWS have excellent predictive ability for 2-day mortality and have the potential to risk stratify patients in ED. No EWS adequately predicted clinical deterioration, admission to either ICU or the hospital.

Conclusion (proposition de traduction) : Plusieurs scores d'alerte précoce ont une excellente capacité prédictive de mortalité sur 2 jours et peuvent potentiellement stratifier les patients aux urgences. Aucun score d'alerte précoce n'a prédit de manière satisfaisante l'aggravation clinique, l'admission aux soins intensifs ou à l'hôpital.

Prognostic Accuracy of qSOFA in Predicting 28-day Mortality Among Infected Patients in an Emergency Department: A Prospective Validation Study.
Abdullah SMOB, Sørensen RH, Dessau RBC, Sattar SMRU, Wiese L, Nielsen FE. | Emerg Med J. 2019 Dec;36(12):722-728
DOI: https://doi.org/10.1136/emermed-2019-208456
Keywords: clinical assessment; death/mortality; diagnosis; emergency department; infectious diseases

RISK-ASSESSMENT

Introduction : Few prospective studies have evaluated the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) criteria in emergency department (ED)settings. The aim of this study was to determine the prognostic accuracy of qSOFA compared with systemic inflammatory response syndrome (SIRS) in predicting the 28-day mortality of infected patients admitted to an ED.

Méthode : A prospective observational cohort study of all adult (≥18 years) infected patients admitted to the ED of Slagelse Hospital, Denmark, was conducted from 1 October 2017 to 31 March 2018. Patients were enrolled consecutively and data related to SIRS and qSOFA criteria were obtained from electronic triage record. Information regarding mortality was obtained from the Danish Civil Registration System. The original cut-off values of ≥2 was used to determine the prognostic accuracy of SIRS and qSOFA criteria for predicting 28-day mortality and was assessed by analyses of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios and area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals (CI).

Résultats : A total of 2112 patients were included in this study. A total of 175 (8.3%) patients met at least two qSOFA criteria, while 1012 (47.9%) met at least two SIRS criteria on admission. A qSOFA criteria of at least two for predicting 28-day mortality had a sensitivity of 19.5% (95% CI 13.6% to 26.5%) and a specificity of 92.6% (95% CI 91.4% to 93.7%). A SIRS criteria of at least two for predicting 28-day mortality had a sensitivity of 52.8% (95% CI 44.8% to 60.8%) and a specificity of 52.5% (95% CI 50.2% to 54.7%). The AUROC values for qSOFA and SIRS were 0.63 (95% CI 0.59 to 0.67) and 0.52 (95% CI 0.48 to 0.57), respectively.

Conclusion : Both SIRS and qSOFA had poor sensitivity for 28-day mortality. qSOFA improved the specificity at the expense of the sensitivity resulting in slightly higher prognostic accuracy overall.

Conclusion (proposition de traduction) : Le SIRS et le qSOFA étaient tous deux peu sensibles pour prédire la mortalité à 28 jours. Le qSOFA a amélioré la spécificité au détriment de la sensibilité, ce qui s'est traduit par une précision pronostique légèrement plus élevée dans l'ensemble.

Analysis of Emergency Department Prediction Tools in Evaluating Febrile Young Infants at Risk for Serious Infections.
Yao SHW, Ong GY, Maconochie IK, Lee KP, Chong SL. | Emerg Med J. 2019 Dec;36(12):729-735
DOI: https://doi.org/10.1136/emermed-2018-208210
Keywords: clinical assessment; paediatrics, paediatric emergency medicine; triage

PAEDIATRICS

Introduction : Febrile infants ≤ 3 months old constitute a vulnerable group at risk of serious infections (SI). We aimed to (1) study the test performance of two clinical assessment tools-the National Institute for Health and Care Excellence (NICE) Traffic Light System and Severity Index Score (SIS) in predicting SI among all febrile young infants and (2) evaluate the performance of three low-risk criteria-the Rochester Criteria (RC), Philadelphia Criteria (PC) and Boston Criteria (BC) among well-looking febrile infants.

Méthode : A retrospective validation study was conducted. Serious illness included both bacterial and serious viral illness such as meningitis and encephalitis. We included febrile infants≤3 months old presenting to a paediatric emergency department in Singapore between March 2015 and February 2016. Infants were assigned to high-risk and low-risk groups for SI according to each of the five tools. We compared the performance of the NICE guideline and SIS at initial clinical assessment for all infants and the low-risk criteria-RC, PC and BC-among well-looking infants. We presented their performance using sensitivity, specificity, positive, negative predictive values and likelihood ratios.

Résultats : Of 1057 infants analysed, 326 (30.8%) were diagnosed with SI. The NICE guideline had an overall sensitivity of 93.3% (95% CI 90.0 to 95.7), while the SIS had a sensitivity of 79.1% (95% CI 74.3 to 83.4). The incidence of SI was similar among infants who were well-looking and those who were not. Among the low-risk criteria, the RC performed with the highest sensitivity in infants aged 0-28 days (98.2%, 95% CI 90.3% to 100.0%) and 29-60 days (92.4%, 95% CI 86.0% to 96.5%), while the PC performed best in infants aged 61-90 days (100.0%, 95% CI 95.4% to 100.0%).

Conclusion : The NICE guideline achieved high sensitivity in our study population, and the RC had the highest sensitivity in predicting for SI among well-appearing febrile infants. Prospective validation is required.

Conclusion (proposition de traduction) : La recommandation NICE a atteint une sensibilité élevée dans notre population d'étude, et la RC a eu la plus grande sensibilité pour prédire les infections graves chez les nourrissons fébriles apparaissant bien. Une validation prospective est nécessaire.

What Older People Want From Emergency Care: A Systematic Review.
van Oppen JD, Keillor L, Mitchell Á, Coats TJ, Conroy SP. | Emerg Med J. 2019 Dec;36(12):754-761
DOI: https://doi.org/10.1136/emermed-2019-208589
Keywords: aged; emergency department; frailty; geriatrics; quality

GERIATRIC MEDICINE

Introduction : o evaluate the expectations and preferred outcomes from emergency care among older people or their caregivers.

Méthode : A review protocol was registered. Medline, Embase, CINAHL, PsychInfo, BNI, AgeInfo and the Cochrane Database of Systematic Reviews were searched in their full date ranges to September 2018. Included articles were hand-searched for further citations. Citations were screened for (1) older people aged over 65 years, (2) ED settings and (3) reporting expectations or preferred outcomes for emergency care (as opposed to experience or satisfaction). Quality appraisal and data extraction of eligible articles were undertaken by two reviewers. Themes were synthesised through content analysis and described narratively.

Résultats : Older people wished to have prompt waiting times, efficient care, clear communication and comfortable environments. They had additional and unique expectations for holistic care and support in decision-making. The ED provoked a sense of vulnerability among older people who were likely to have had frailty.

Conclusion : The lack of dominant themes among included studies suggests that older people should be treated as individuals rather than a homogenous group. Establishing individuals' preferred outcomes could improve person-centred care.

Conclusion (proposition de traduction) : L'absence de thèmes dominants parmi les études incluses suggère que les personnes âgées devraient être traitées comme des individus plutôt que comme un groupe homogène. L'établissement des résultats préférés des individus pourrait améliorer les soins centrés sur la personne.

BET 1: Cervical Spine Immobilisation in the Management of Drowning Victims.
Jones T, Rennie A. | Emerg Med J. 2019;36(12):766–767
DOI: https://doi.org/10.1136/emermed-2019-209210.2
Keywords: emergency care systems

BEST EVIDENCE TOPIC REPORTS

Editorial : A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have cervical spine immobilisation. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that cervical spine injuries are rare in drowning and near drowning unless there is a history of diving or a fall or signs of trauma. Cervical spine immobilisation should be reserved for cases where there is a reasonable suspicion of a spinal injury.

Conclusion : The incidence of cervical spine injury overall in drowning is probably less than 0.5%, as suggested by Watson et al. In the study by Hwang et al all those sustaining a cervical spine injury were adolescents, all were sustained at a swimming pool, and all but one were the result of diving. By way of contrast, an autopsy study of 10 people who jumped from high bridges found that six had died from drowning and four from their injuries. None had head or neck injuries of any importance despite the fact that they had fallen 35–37 m, and in one case 51 m. One might have expected significant neck injuries from such a mechanism of injury, but, jumping from a bridge seems to be quite different to diving into a swimming pool and so the injury pattern is different.

Conclusion (proposition de traduction) : L'incidence des lésions de la colonne cervicale dans la noyade est probablement inférieure à 0,5 %, comme le suggèrent Watson et al. Dans l'étude de Hwang et al, tous ceux qui souffraient d'une lésion de la colonne cervicale étaient des adolescents, tous ont été maintenus dans une piscine et tous sauf un étaient le résultat d'une plongée. En revanche, une étude d'autopsie de 10 personnes qui ont sauté des ponts élevés a révélé que six étaient morts de noyade et quatre de leurs blessures. Aucun n'a eu de blessures à la tête ou au cou de quelque importance que ce soit malgré le fait qu'elles soient tombées de 35 à 37 m, et dans un cas de 51 m. On aurait pu s'attendre à des blessures importantes au cou d'un tel mécanisme de blessure, mais sauter d'un pont semble être très différent de plonger dans une piscine et le schéma des blessures est donc différent.

BET 2: CT Head in Investigation of Near Drowning.
Jones T, Rennie A. | Emerg Med J. 2019 Dec;36(12):767-768
DOI: https://doi.org/10.1136/emermed-2019-209210.3
Keywords: emergency care systems

BEST EVIDENCE TOPIC REPORTS

Editorial : A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have a CT head scan as part of their initial assessment. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that anyone with GCS≤4 should have a CT head as an abnormal scan at this stage heralds a very poor prognosis.

Conclusion : Brain damage from drowning is caused by hypoxia and ischaemia. CT and MRI findings are summarised by Restrepo et al. The findings are different according to the age of the patient. Classic hypoxia-associated diffuse loss of grey-white differentiation, effacement of the sulci and decreased density of the basal ganglia is seen in adults. In the studies by Rafaat et al and Romano et al about 80% of the initial CT scans were normal. In the study by Rafaat et al 54% of those who developed abnormalities on a later CT scan died and 42% developed a persistent vegetative state.
In practical terms anyone presenting with a GCS 3 or 4 should have an initial CT brain scan. Others who have been intubated and ventilated could have a delayed CT if they fail to wake up normally after a sedation hold once their chest has improved.

Conclusion (proposition de traduction) : Les lésions cérébrales causées par la noyade sont causées par l'hypoxie et l'ischémie. Les résultats de la TDM et de l'IRM sont résumés par Restrepo et al. Les résultats sont différents selon l'âge du patient. Chez l'adulte, on observe une perte diffuse associée à l'hypoxie classique de différenciation gris-blanc, un effacement des sillons et une diminution de la densité des noyaux gris centraux. Dans les études de Rafaat et al et Romano et al, environ 80 % des scanners initiaux étaient normaux. Dans l'étude de Rafaat et al 54 % de ceux qui ont développé des anomalies sur un scanner plus tard sont décédés et 42 % ont développé un état végétatif persistant.
Concrètement, toute personne présentant un Glasgow 3 ou 4 devrait bénéficier d'un premier scanner cérébral. Ceux qui ont été intubés et ventilés pourraient bénéficier d'un scanner retardé s'ils ne se réveillent pas normalement après une sédation une fois que leur poitrine s'est améliorée.

Effect of Intravenous Contrast for CT Abdomen and Pelvis on Detection of Urgent and Non-Urgent Pathology: Can Repeat CT Within 72 Hours Be Avoided?.
Lamoureux C, Weber S, Hanna T, Grabiel AJ, Clark RH. | Emerg Radiol. 2019 Dec;26(6):601-608
DOI: https://doi.org/10.1007/s10140-019-01704-0
Keywords: CT abdomen and pelvis; IV contrast; Radiology; Repeat CT.

Original Article

Introduction : To determine if administering IV contrast for CT abdomen and pelvis improves detection of urgent and clinically important non-urgent pathology in patients with urgent clinical symptoms compared to patients not receiving IV contrast, and in turn to determine whether repeat CT exams on the same patient within 72 h were of low diagnostic benefit if the first CT was performed with IV contrast.

Méthode : We evaluated 400 consecutive patients who had CT abdomen and pelvis (CT AP) examinations repeated within 72 h. For each patient, demographic data, reason for examination, examination time stamps, and examination technique were documented. CT AP radiology reports were reviewed and both urgent and non-urgent pathology was extracted.

Résultats : Of 400 patients, 63% had their initial CT AP without contrast. Administration of IV contrast for the first CT AP was associated with increased detection of urgent findings compared with non-contrast CT (p = 0.004) and a contrast-enhanced CT AP following an initial non-contrast CT AP examination better characterized both urgent (p = 0.002) and non-urgent findings (p < 0.001). Adherence to ACR appropriateness criteria for IV contrast administration was associated with increased detection of urgent pathology on the first CT (p = 0.02), and the second CT was more likely to be performed with IV contrast if recommended by the radiologist reading the first CT (p = 0.0006).

Conclusion : In the absence of contraindications, encouraging urgent care physicians to preferentially order IV contrast-enhanced CT AP examinations in adherence with ACR appropriateness criteria may increase detection of urgent pathology and avoid short-term repeat CT AP.

Conclusion (proposition de traduction) : En l'absence de contre-indications, encourager les médecins de soins urgents à prescrire préférentiellement des scanners abdominaux et du pelvis avec injection de produits de contraste IV, en conformité avec les critères de pertinence de l'American College of Radiology, peut améliorer la détection d'une pathologie urgente et éviter la répétition à court terme de scanner de l'abdomen et du bassin.

Work shift duration for emergency physicians – the shorter, the better. The French Experience.
Philippon AL | Eur J Emerg Med. 2019 Dec;26(6):396–397
DOI: https://doi.org/10.1097/MEJ.0000000000000639
Keywords: Aucun

Perspective Articles

Editorial : What do we know about the impact of extended shifts? We know that this is bad for both patients and physicians. Since the early 2000s, many studies have compared the impact of extended versus limited shifts. Landrigan et al., in 2004, showed that interns in intensive and coronary care units made 36% more serious medical errors during an extended-hours schedule than during a limited-hours one. Further reports have also showed that reducing interns’ extended work hours would increase sleep duration and decrease attentional failures during overnight duties. Extended-work shifts also affects physicians themselves as highlighted in two studies that reported an increased risk of percutaneous injuries and of motor vehicle crash.

Conclusion : As underlined by Votey, “circadian disruption and sleep deprivation have been the Achilles heel of emergency medicine […] we have responsibility to address sleep deprivation among the practitioners of emergency medicine as an important wellness issue for ourselves and our peers”. So let us take the issue in a different direction: the shorter we are at the hospital, the better we are for the patients and for ourselves. Therefore, it is our responsibility to stop our extended shifts in order to increase safety of both patients and emergency doctors. It is the responsibility of legislators and stakeholders to prevent physicians to work 24-hour shift, and most importantly, our national scientific society (French Society of Emergency Physician SFMU) needs to have a clear position on this important matter and should make a clear statement as this is its responsibility and duty.

Conclusion (proposition de traduction) : Comme l'a souligné Votey, « la perturbation du rythme circadien et le manque de sommeil ont été le talon d'Achille de la médecine d'urgence (…) nous avons la responsabilité de traiter la privation de sommeil chez les praticiens de la médecine d'urgence comme une question importante pour notre bien-être et celui de nos pairs ».
Alors, prenons la question dans une autre direction : moins nous restons à l'hôpital, mieux c'est pour les patients et pour nous-mêmes. Par conséquent, il est de notre responsabilité d'arrêter nos temps de travail prolongés afin d'accroître la sécurité des patients et des médecins urgentistes. Il est de la responsabilité du législateur et des parties prenantes d'empêcher les médecins de travailler 24 heures sur 24 et, plus important encore, notre société scientifique nationale (la Société française de Médecine d'urgence - SFMU) doit avoir une position claire sur cette question importante et devrait faire une déclaration claire car c'est sa responsabilité et son devoir.

Commentaire : Déclaration de l'American College of Emergency Physicians (ACEP) sur le sujet :
How to Design the Optimal Schedule for Working Shifts  .

Predictive criteria for acute heart failure in emergency department patients with acute dyspnoea: the PREDICA study.
Roncalli J, Picard F, Delarche N, Faure I, Pradeau C, Thicoipe M, Galinier M, Charpentier S. | Eur J Emerg Med. 2019 Dec;26(6):400-404
DOI: https://doi.org/10.1097/MEJ.0000000000000622
Keywords: Aucun

Original Articles

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

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

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

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

Conclusion (proposition de traduction) : Nous avons identifié plusieurs prédicteurs indépendants du diagnostic final d'insuffisance cardiaque aiguë. Ils devraient contribuer à l'élaboration de stratégies de diagnostic dans les services d'urgence. Cependant, le jugement empirique du clinicien semblent très bien fonctionner seul.

End tidal carbon dioxide monitoring in acute asthma: a prospective pilot study in emergency department patients.
Truchot J, Gayet AR, Philippon AL, Chauvin A, Malka J, Vicaut E, Plaisance P. | Eur J Emerg Med. 2019 Dec;26(6):412-416
DOI: https://doi.org/10.1097/MEJ.0000000000000581
Keywords: Aucun

Original Articles

Introduction : The peak expiratory flow rate (PEFR) is the gold standard for monitoring asthmatic patients. However, its measurement requires understanding and active participation. End tidal carbon dioxide (EtCO2) may be considered an accurate surrogate for PaCO2, a severity marker in acute asthma. We studied the use of EtCO2 as a monitoring tool in acute asthma.

Méthode : This was a prospective study that included consecutive patients admitted to our emergency department for acute asthma exacerbation. Data were collected at first medical contact (T0) and after 1 h of treatment (T60). The primary endpoint was the change in EtCO2; the secondary endpoints included changes in the EtCO2 Q angle value, plateau T time, and change in EtCO2 values for the patients with a PEFR ratio less than 50% after treatment.

Résultats : Fifty-five patients were included and 36 waveforms were analysed. The mean age was 37 years and 26 (47%) were women. The median initial PEFR was 200 [interquartile range (IQR): 150-240]; the median EtCO2 at T0 and T60 was 35 (IQR: 30-38) and 34 (IQR: 29-37). There was no significant change in EtCO2 after treatment. There was no significant change in the Q angle and the T time after treatment. At T60, 20 (36%) patients had a PEFR ratio less than 50%. Change in EtCO2 from T60 to T0 was associated with a PEFR ratio less than 50%.

Conclusion : After 1 h of treatment, there was no significant change in EtCO2. A decrease in EtCO2 seems to be associated with a higher risk of PEFR ratio less than 50% after treatment.

Conclusion (proposition de traduction) : Après 1 h de traitement, il n'y a pas eu de changement significatif dans l'EtCO₂. Une diminution de l'EtCO₂ semble être associée à un risque plus élevé de constater un débit expiratoire de pointe (peak-flow) inférieur à 50 % après traitement.

Commentaire : Évaluation de la gravité d’une crise d’asthme (d’après le GRAPP) :

Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting.
Silcock DJ, Corfield AR, Staines H, Rooney KD. | Eur J Emerg Med. 2019 Dec;26(6):433-439
DOI: https://doi.org/10.1097/MEJ.0000000000000589
Keywords: Aucun

Original articles

Introduction : Early intervention and response to deranged physiological parameters in the critically ill patient improve outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service in the UK. The quick Sepsis-related Organ Failure Assessment Score (qSOFA) was developed as a simple bedside criterion to identify adult patients outwith the ICU with suspected infection who are likely to have a prolonged ICU stay or die in hospital. We aim to compare the ability of NEWS and qSOFA to predict adverse outcomes in a prehospital population.

Méthode : All clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to mortality over a 2-month period. The performance of the NEWS and qSOFA in identifying the endpoints of 30-day mortality, ICU admission and a combined endpoint of 48 h. ICU admission or 30-day mortality was analysed.

Résultats : Complete data were available for 1713 patients. For the primary outcome of ICU admission within 48 h or 30-day mortality, the odds ratio for a qSOFA score of 3 compared with 0 was 124.1 [95% confidence interval (CI): 13.5-1137.7] and the odds ratio for a high NEWS category, compared with the low NEWS category was 9.82 (95% CI: 5.74-16.81). Comparison of qSOFA and NEWS performance was assessed using receiver operating characteristic curves. The area under the receiver operating characteristic curve for the primary outcome for qSOFA was 0.679 (95% CI: 0.624-0.733), for NEWS category was 0.707 (95% CI: 0.654-0.761) and for NEWS total score was 0.740 (95% CI: 0.685-0.795). Comparison of the receiver operating characteristic curves between NEWS total score and qSOFA using DeLong's test showed NEWS total score to be superior to qSOFA at predicting combined ICU admission within 48 h of presentation or 30-day mortality (P = 0.011).

Conclusion : Our study shows qSOFA can identify patients at risk of adverse outcomes in the prehospital setting. However, NEWS is superior to qSOFA in a prehospital environment at identifying patients at risk of adverse outcomes.

Conclusion (proposition de traduction) : Notre étude montre que le qSOFA peut identifier les patients présentant un risque d'effets indésirables dans le contexte préhospitalier. Cependant, le score NEWS est supérieur au qSOFA dans un environnement préhospitalier pour identifier les patients présentant un risque d'évolution défavorable.

Real-time estimation of inpatient beds required in emergency departments.
Noel G, Bonte N, Persico N, Bar C, Luigi S, Roch A, Michelet P, Gentile S, Viudesa G. | Eur J Emerg Med. 2019 Dec;26(6):440-445
DOI: https://doi.org/10.1097/MEJ.0000000000000600
Keywords: Aucun

Original articles

Introduction : Long boarding time in emergency department (ED) leads to increased morbidity and mortality. Prediction of admissions upon triage could improve ED care efficiency and decrease boarding time.
OBJECTIVE : To develop a real-time automated model (MA) to predict admissions upon triage and compare this model with triage nurse prediction (TNP).

Méthode : A cross-sectional study was conducted in four EDs during 1 month. MA used only variables available upon triage and included in the national French Electronic Emergency Department Abstract. For each patient, the triage nurse assessed the hospitalization risk on a 10-point Likert scale. Performances of MA and TNP were compared using the area under the receiver operating characteristic curves, the accuracy, and the daily and hourly mean difference between predicted and observed number of admission.

Résultats : A total of 11 653 patients visited the EDs, and 19.5-24.7% were admitted according to the emergency. The area under the curves (AUCs) of TNP [0.815 (0.805-0.826)] and MA [0.815 (0.805-0.825)] were similar. Across EDs, the AUCs of TNP were significantly different (P < 0.001) in all EDs, whereas AUCs of MA were all similar (P>0.2). Originally, using daily and hourly aggregated data, the percentage of errors concerning the number of predicted admission were 8.7 and 34.4%, respectively, for MA and 9.9 and 35.4%, respectively, for TNP.

Conclusion : A simple model using variables available in all EDs in France performed well to predict admission upon triage. However, when analyzed at an hourly level, it overestimated the number of inpatient beds needed by a third. More research is needed to define adequate use of these models.

Conclusion (proposition de traduction) : Un modèle simple utilisant des variables disponibles dans tous les services d'urgence en France s'est bien comporté pour prévoir l'admission après triage. Cependant, analysé au niveau horaire, il surestime le nombre de lits d’hospitalisation nécessaires d’un tiers. Des recherches supplémentaires sont nécessaires pour définir une utilisation adéquate de ces modèles.

Prevalence of pulmonary embolism in emergency department patients with isolated syncope: a prospective cohort study.
Raynal PA, Cachanado M, Truchot J, Damas-Perrichet C, Feral-Pierssens AL, Goulet H, Deltour S, Boussouar S, Donciu V, Simon T, Freund Y, Philippon AL. | Eur J Emerg Med. 2019 Dec;26(6):458-461
DOI: https://doi.org/10.1097/MEJ.0000000000000625
Keywords: Aucun

Original articles

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

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

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

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

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

Fluid resuscitation in trauma: what are the best strategies and fluids?.
Ramesh GH, Uma JC, Farhath S. | Int J Emerg Med. 2019 Dec 4;12(1):38.
DOI: https://doi.org/10.1186/s12245-019-0253-8  | Télécharger l'article au format  
Keywords: Colloid; Crystalloid; Delayed resuscitation; Fluid resuscitation; Permissive hypotension; Prehospital care; Trauma

Review

Introduction : Traumatic injuries pose a global health problem and account for about 10% global burden of disease. Among injured patients, the major cause of potentially preventable death is uncontrolled post-traumatic hemorrhage.

Discussion : This review discusses the role of prehospital trauma care in low-resource/remote settings, goals, principles and evolving strategies of fluid resuscitation, ideal resuscitation fluid, and post-resuscitation fluid management. Management of fluid resuscitation in few special groups is also discussed.

Conclusion : Prehospital trauma care systems reduce mortality in low-resource/remote settings. Delayed resuscitation seems a better option when transport time to definitive care is shorter whereas goal-directed resuscitation with low-volume crystalloid seems a better option if transport time is longer. Few general recommendations regarding the choice of fluid are provided. Adhering to evidence-based clinical practice guidelines and local modifications based on patient population, available resources, and expertise will improve patient outcomes.

Conclusion (proposition de traduction) : Les systèmes de soins préhospitaliers en traumatologie réduisent la mortalité dans les milieux éloignés ou à faibles ressources. La réanimation retardée semble être une meilleure option lorsque le temps de transport vers les soins définitifs est plus court, tandis que la réanimation ciblée par un cristalloïde à faible volume semble être une meilleure option si le temps de transport est plus long. Peu de recommandations générales concernant le choix du solutés sont proposées. L'adhésion aux directives de pratique clinique fondées sur les preuves et les adaptations locales en fonction de la population de patients traitée, des ressources disponibles et de l'expertise amélioreront les résultats pour les patients.

The influence of past experiences on future willingness to perform bystander cardiopulmonary resuscitation.
Chew KS, Ahmad Razali S, Wong SSL, Azizul A, Ismail NF, Robert SJKCA, Jayaveeran YA. | Int J Emerg Med. 2019 Dec 12;12(1):40
DOI: https://doi.org/10.1186/s12245-019-0256-5  | Télécharger l'article au format  
Keywords: Bystander cardiopulmonary resuscitation; Cardiac arrest; Pay-it-forward

Original Research

Introduction : The influence of past familial experiences of receiving cardiopulmonary resuscitation (CPR) and medical help in various cardiac arrest and nonfatal cardiac events toward willingness to "pay it forward" by helping the next cardiac arrest victim was explored.

Méthode : Using a validated questionnaire, 6248 participants were asked to rate their willingness to perform bystander chest compression with mouth-to-mouth ventilation and chest compression-only CPR. Their past familial experiences of receiving cardiopulmonary resuscitation (CPR) and medical help in various cardiac arrest and nonfatal cardiac events were also recorded.

Résultats : Kruskal-Wallis test with post hoc Dunn's pairwise comparisons showed that the following were significantly more willing to perform CPR with mouth-to-mouth ventilation: familial experience of "nonfatal cardiac events" (mean rank = 447) vs "out-of-hospital cardiac arrest with no CPR" (mean rank = 177), U = 35442.5, z = -2.055, p = 0.04; "in-hospital cardiac arrest and successful CPR" (mean rank = 2955.79) vs "none of these experiences" (mean rank = 2468.38), U = 111903, z = -2.60, p = 0.01; and "in-hospital cardiac arrest with successful CPR" (mean rank = 133.45) vs "out-of-hospital arrest with no CPR" (mean rank = 112.36), U = 4135.5, z = -2.06, p = 0.04. For compression-only CPR, Kruskal-Wallis test with multiple runs of Mann-Whitney U tests showed that "nonfatal cardiac events" group was statistically higher than the group with "none of these experiences" (mean rank = 3061.43 vs 2859.91), U = 1194658, z = -2.588, p = 0.01. The groups of "in-hospital cardiac arrest with successful CPR" and "in-hospital cardiac arrest with transient return of spontaneous circulation" were the most willing groups to perform compression-only CPR.

Conclusion : Prior familial experiences of receiving CPR and medical help, particularly among those with successful outcomes in a hospital setting, seem to increase the willingness to perform bystander CPR.

Conclusion (proposition de traduction) : Les expériences familiales antérieures de RCP et d'aide médicale, en particulier chez les personnes ayant obtenu de bons résultats en milieu hospitalier, semblent accroître la volonté de pratiquer la RCP en présence de témoins.

Type 1 or Type 2 Myocardial Infarction in Patients with a History of Coronary Artery Disease: Data from the Emergency Department.
Putot A, Jeanmichel M, Chagué F, Avondo A, Ray P, Manckoundia P, Zeller M, Cottin Y. | J Clin Med. 2019 Dec 2;8(12). pii: E2100
DOI: https://doi.org/10.3390/jcm8122100
Keywords: coronary artery disease; hospital mortality; myocardial infarction; type 2 myocardial infarction

Article

Introduction : A type 2 myocardial infarction (T2MI) is the result of an imbalance between oxygen supply and demand, without acute atherothrombosis. T2MI is frequent in emergency departments (ED), but has not been extensively evaluated in patients with previously known coronary artery disease (CAD).

Méthode : Our study assessed the incidence and characteristics of T2MI compared to type 1 (T1MI) in CAD patients admitted to an ED.

Résultats : Our study assessed the incidence and characteristics of T2MI compared to type 1 (T1MI) in CAD patients admitted to an ED. Among 33,669 consecutive patients admitted to the ED, 2830 patients with T1MI or T2MI were systematically included after prospective adjudication by the attending clinician according to the universal definition. Among them, 619 (22%) patients had a history of CAD. Using multivariable analysis, CAD history was found to be an independent predictive factor of T2MI versus T1MI (odds ratio (95% confidence interval) = 1.38 (1.08-1.77), p = 0.01). Among CAD patients, those with T2MI (n = 254) were older (median age: 82 vs. 72 years, p < 0.001), and had more frequent comorbidities and more frequent three-vessel disease at the coronary angiography (56% vs. 43%, p = 0.015). Percutaneous coronary intervention was by far less frequent after T2MI than after T1MI (28% vs. 67%, p < 0.001), and in-hospital mortality was twice as high in T2MI (15% vs. 7% for T1MI, p < 0.001). Among biomarkers, the C reactive protein (CRP)/troponin Ic ratio predicted T2MI remarkably well (C-statistic (95% confidence interval) = 0.84 (0.81-0.87, p < 0.001).

Conclusion : In a large unselected cohort of MI patients in the ED, a quarter of patients had previous CAD, which was associated with a 40% higher risk of T2MI. CRP/troponin ratios could be used to help distinguish T2MI from T1MI.

Conclusion (proposition de traduction) : Dans une grande cohorte non sélectionnée de patients se présentant avec un infarctus du myocarde aux urgences, un quart des patients avaient une maladie coronarienne antérieure, qui était associée à un risque 40 % plus élevé d'infarctus du myocarde de type 2. Les rapports CRP/troponine pourraient être utilisés pour aider à distinguer l'infarctus du myocarde de type 2 de l'infarctus du myocarde de type 1.

Ischemic Stroke Risk in Patients With Nonvalvular Atrial Fibrillation.
Alkhouli M, Friedman PA. | J Am Coll Cardiol. 2019 Dec 17;74(24):3050-3065
DOI: https://doi.org/10.1016/j.jacc.2019.10.040
Keywords: Aucun

JACC REVIEW TOPIC OF THE WEEK

Editorial : The last decade has witnessed remarkable advances in pharmacological and nonpharmacological strategies for stroke prevention in patients with atrial fibrillation. However, the currently available clinical stroke risk prediction models do not account for key nonclinical factors (arrhythmia burden, left atrial physiology and anatomy, chemical and electrocardiographic markers) and other competing clinical risks. Hence, their ability to identify patients who will derive the most benefit from pharmacological and mechanical risk prevention strategies remain limited. In this paper, the authors review the current and evolving ischemic stroke risk prediction schemes in patients with nonvalvular atrial fibrillation, highlight the strengths and weaknesses of the models, and discuss the unmet needs in this field.

Conclusion : The prevalence of AF and the burden of its associated morbidities continue to rise worldwide. Despite the advances in ischemic stroke prevention strategies in these patients, our current stroke risk prediction tools remain basic and imprecise. There is an unmet need to incorporate various elements to the current risk factor–based stroke prediction schemes to optimize our stroke prevention practices. The time has come for a comprehensive study that provides a holistic approach to risk assessment in this high-risk population.

Conclusion (proposition de traduction) : La prévalence et la morbidité liées à la FA continuent d'augmenter dans le monde. Malgré les progrès des stratégies de prévention des AVC ischémiques chez ces patients, nos outils actuels de prédiction du risque d'AVC restent basiques et imprécis. Il existe un besoin non satisfait d'incorporer divers éléments aux schémas actuels de prévision des AVC basés sur les facteurs de risque afin d'optimiser nos pratiques de prévention des AVC. Le temps est venu pour une étude approfondie qui propose une approche holistique de l'évaluation des risques dans cette population à haut risque.

Impact of Renal Impairment on Beta-Blocker Efficacy in Patients With Heart Failure.
Kotecha D, Gill SK, Flather MD, Holmes J, Packer M, Rosano G, Böhm M, McMurray JJV, Wikstrand J, Anker SD, van Veldhuisen DJ, Manzano L, von Lueder TG, Rigby AS, Andersson B, Kjekshus J, Wedel H, Ruschitzka F, Cleland JGF, Damman K, Redon J, Coats AJS; Beta-Blockers in Heart Failure Collaborative Group. | J Am Coll Cardiol. 2019 Dec 10;74(23):2893-2904
DOI: https://doi.org/10.1016/j.jacc.2019.09.059
Keywords: beta-blockers; heart failure; mortality; renal impairment

ORIGINAL INVESTIGATION

Introduction : Moderate and moderately severe renal impairment are common in patients with heart failure and reduced ejection fraction, but whether beta-blockers are effective is unclear, leading to underuse of life-saving therapy.
Objectives : This study sought to investigate patient prognosis and the efficacy of beta-blockers according to renal function using estimated glomerular filtration rate (eGFR).

Méthode : Analysis of 16,740 individual patients with left ventricular ejection fraction <50% from 10 double-blind, placebo-controlled trials was performed. The authors report all-cause mortality on an intention-to-treat basis, adjusted for baseline covariates and stratified by heart rhythm.

Résultats : Median eGFR at baseline was 63 (interquartile range: 50 to 77) ml/min/1.73 m2; 4,584 patients (27.4%) had eGFR 45 to 59 ml/min/1.73 m2, and 2,286 (13.7%) 30 to 44 ml/min/1.73 m2. Over a median follow-up of 1.3 years, eGFR was independently associated with mortality, with a 12% higher risk of death for every 10 ml/min/1.73 m2 lower eGFR (95% confidence interval [CI]: 10% to 15%; p < 0.001). In 13,861 patients in sinus rhythm, beta-blockers reduced mortality versus placebo; adjusted hazard ratio (HR): 0.73 for eGFR 45 to 59 ml/min/1.73 m2 (95% CI: 0.62 to 0.86; p < 0.001) and 0.71 for eGFR 30 to 44 ml/min/1.73 m2 (95% CI: 0.58 to 0.87; p = 0.001). The authors observed no deterioration in renal function over time in patients with moderate or moderately severe renal impairment, no difference in adverse events comparing beta-blockers with placebo, and higher mortality in patients with worsening renal function on follow-up. Due to exclusion criteria, there were insufficient patients with severe renal dysfunction (eGFR <30 ml/min/1.73 m2) to draw conclusions. In 2,879 patients with atrial fibrillation, there was no reduction in mortality with beta-blockers at any level of eGFR.

Conclusion : Patients with heart failure, left ventricular ejection fraction <50% and sinus rhythm should receive beta-blocker therapy even with moderate or moderately severe renal dysfunction.

Conclusion (proposition de traduction) : Les patients présentant une insuffisance cardiaque, une fraction d'éjection ventriculaire gauche < 50 % et un rythme sinusal doivent recevoir un traitement bêtabloquant même en cas de dysfonction rénale modérée ou modérément sévère.

Outcomes of Women Compared With Men After Non-ST-Segment Elevation Acute Coronary Syndromes.
Sarma AA, Braunwald E, Cannon CP, Guo J, Im K, Antman EM, Gibson CM, Newby LK, Giugliano RP, Morrow DA, Wiviott SD, Sabatine MS, O'Donoghue ML. | J Am Coll Cardiol. 2019 Dec 17;74(24):3013-3022
DOI: https://doi.org/10.1016/j.jacc.2019.09.065
Keywords: acute coronary syndromes; non–ST-segment elevation myocardial infarction; women

ORIGINAL INVESTIGATION

Introduction : It remains disputed whether women are at excess risk of adverse outcomes versus men after non-ST-segment elevation acute coronary syndromes (NSTEACS) or whether differences are explained by discordant risk factors. Objectives: A sex-specific analysis of cardiovascular outcomes after NSTEACS across trials conducted by the Thrombolysis In Myocardial Infarction (TIMI) Study Group was performed to determine the impact of sex on cardiovascular outcomes in this dataset.

Méthode : en TIMI trials were identified that enrolled >2,500 patients with NSTEACS within 30 days of hospitalization. Cox proportional hazards models were used to examine the association of sex with major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, or stroke) after adjusting for relevant risk factors in individual trials; point estimates were then combined by using random effects models. Individual components of the composite outcome and all-cause mortality were also analyzed.

Résultats : Among 68,730 patients with NSTEACS, 19,827 (29%) were women. Women were older and more frequently had hypertension, diabetes, prior heart failure, and renal impairment than men. Before considering relevant confounders, women were at similar risk of MACE compared with men (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 0.99 to 1.09; p = 0.16) but at higher risk of all-cause death (HR: 1.12; 95% CI: 1.01 to 1.24; p = 0.03). After adjustment for baseline differences, risks of MACE (HR: 0.93; 95% CI: 0.88 to 0.98; p < 0.01) and all-cause death (HR: 0.84; 95% CI: 0.78 to 0.90; p < 0.0001) were lower among women compared with men.

Conclusion : After accounting for cardiovascular risk factors, women enrolled in clinical trials were at lower risk of major adverse cardiovascular events than men after non–ST-segment elevation acute coronary syndromes. Women, however, remain undertreated with many evidence-based therapies.

Conclusion (proposition de traduction) : Après prise en compte des facteurs de risque cardiovasculaire, les femmes inscrites aux essais cliniques présentaient un risque plus faible d'événements cardiovasculaires majeurs que les hommes après des syndromes coronariens aigus avec élévation du segment non ST. Cependant, les femmes restent sous-traitées avec de nombreuses thérapies fondées sur des preuves.

Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial.
Guihard B, Chollet-Xémard C, Lakhnati P, Vivien B, Broche C, Savary D, Ricard-Hibon A, Marianne Dit Cassou PJ, Adnet F, Wiel E, Deutsch J, Tissier C, Loeb T, Bounes V, Rousseau E, Jabre P, Huiart L, Ferdynus C, Combes X. | JAMA. 2019 Dec 17;322(23):2303-2312
DOI: https://doi.org/10.1001/jama.2019.18254
Keywords: Aucun

Original investigation

Introduction : Rocuronium and succinylcholine are often used for rapid sequence intubation, although the comparative efficacy of these paralytic agents for achieving successful intubation in an emergency setting has not been evaluated in clinical trials. Succinylcholine use has been associated with several adverse events not reported with rocuronium.
OBJECTIVE : To assess the noninferiority of rocuronium vs succinylcholine for tracheal intubation in out-of-hospital emergency situations.

Méthode : Multicenter, single-blind, noninferiority randomized clinical trial comparing rocuronium (1.2 mg/kg) with succinylcholine (1 mg/kg) for rapid sequence intubation in 1248 adult patients needing out-of-hospital tracheal intubation. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. The date of final follow-up was August 31, 2016.
INTERVENTIONS : Patients were randomly assigned to undergo tracheal intubation facilitated by rocuronium (n = 624) or succinylcholine (n = 624).
MAIN OUTCOMES AND MEASURES: The primary outcome was the intubation success rate on first attempt. A noninferiority margin of 7% was chosen. A per-protocol analysis was prespecified as the primary analysis.

Résultats : Among 1248 patients who were randomized (mean age, 56 years; 501 [40.1%] women), 1230 (98.6%) completed the trial and 1226 (98.2%) were included in the per-protocol analysis. The number of patients with successful first-attempt intubation was 455 of 610 (74.6%) in the rocuronium group vs 489 of 616 (79.4%) in the succinylcholine group, with a between-group difference of -4.8% (1-sided 97.5% CI, -9% to ∞), which did not meet criteria for noninferiority. The most common intubation-related adverse events were hypoxemia (55 of 610 patients [9.0%]) and hypotension (39 of 610 patients [6.4%]) in the rocuronium group and hypoxemia (61 of 616 [9.9%]) and hypotension (62 of 616 patients [10.1%]) in the succinylcholine group.

Conclusion : Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.

Conclusion (proposition de traduction) : Parmi les patients subissant une intubation endotrachéale dans un contexte de l'urgence extrahoispitalière, le rocuronium, par rapport à la succinylcholine, n'a pas démontré de non-infériorité en ce qui concerne le taux de réussite de la première tentative d'intubation.

Artificial Intelligence in Health Care: A Report From the National Academy of Medicine.
Matheny ME, Whicher D, Thadaney Israni S. | JAMA. 2019 Dec 17
DOI: https://doi.org/10.1001/jama.2019.21579
Keywords: Aucun

Viewpoint

Editorial : The promise of artificial intelligence (AI) in health care offers substantial opportunities to improve patient and clinical team outcomes, reduce costs, and influence population health. Current data generation greatly exceeds human cognitive capacity to effectively manage information, and AI is likely to have an important and complementary role to human cognition to support delivery of personalized health care. For example, recent innovations in AI have shown high levels of accuracy in imaging and signal detection tasks and are considered among the most mature tools in this domain.

Conclusion : Health care is at a critical juncture for the safe and effective use of AI algorithms and tools in supporting the health of patients. The technical capacity exists to leverage these tools to transform health care. The challenges are unrealistic expectations, biased and nonrepresentative data, inadequate prioritization of equity and inclusion, the risk of exacerbating health care disparities, low levels of trust, uncertain regulatory and tort environments, and inadequate evaluation before scaling narrow AI.

Conclusion (proposition de traduction) : Les soins de santé se trouvent à un moment critique pour l'utilisation sûre et efficace des algorithmes et des outils d'IA pour soutenir la santé des patients. La capacité technique existe pour exploiter ces outils afin de transformer les soins de santé. Les défis à relever sont les suivants : attentes irréalistes, données biaisées et non représentatives, priorité insuffisante accordée à l'équité et à l'inclusion, risque d'exacerbation des disparités en matière de soins de santé, faible niveau de confiance, environnement réglementaire et délictuel incertain et évaluation inadéquate avant de procéder à une évaluation de l'IA étroite.

Screening for Abdominal Aortic Aneurysm: US Preventive Services Task Force Recommendation Statement.
US Preventive Services Task Force, Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW Jr, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong J. | JAMA. 2019 Dec 10;322(22):2211-2218
DOI: https://doi.org/10.1001/jama.2019.18928
Keywords: Aucun

Practice Guideline

Editorial : An abdominal aortic aneurysm (AAA) is typically defined as aortic enlargement with a diameter of 3.0 cm or larger. The prevalence of AAA has declined over the past 2 decades among screened men 65 years or older in various European countries. The current prevalence of AAA in the United States is unclear because of the low uptake of screening. Most AAAs are asymptomatic until they rupture. Although the risk for rupture varies greatly by aneurysm size, the associated risk for death with rupture is as high as 81%.

Conclusion : The USPSTF recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked. (B recommendation) The USPSTF recommends that clinicians selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked rather than routinely screening all men in this group. (C recommendation) The USPSTF recommends against routine screening for AAA with ultrasonography in women who have never smoked and have no family history of AAA. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA with ultrasonography in women aged 65 to 75 years who have ever smoked or have a family history of AAA. (I statement).

Conclusion (proposition de traduction) : L'USPSTF recommande un dépistage unique de l'anévrisme de l'aorte abdominale par échographie chez les hommes âgés de 65 à 75 ans qui ont déjà fumé. (Recommandation B)
L'USPSTF recommande que les cliniciens proposent un dépistage sélectif de l'anévrisme de l'aorte abdominale par échographie chez les hommes âgés de 65 à 75 ans qui n'ont jamais fumé plutôt que de procéder à un dépistage systématique de tous les hommes de ce groupe. (Recommandation C)
L'USPSTF ne recommande pas le dépistage systématique de l'anévrisme de l'aorte abdominale par échographie chez les femmes qui n'ont jamais fumé et n'ont pas d'antécédents familiaux d'anévrisme de l'aorte abdominale. (Recommandation D)
L'USPSTF conclut que les preuves actuelles sont insuffisantes pour évaluer le bénéfice/risque du dépistage de l'anévrisme de l'aorte abdominale par échographie chez les femmes âgées de 65 à 75 ans qui ont déjà fumé ou qui ont des antécédents familiaux d'anévrisme de l'aorte abdominale. (Je déclare).

Gachot B, Coriat P. | Med Droit. 2019 December;2019(159):137-141
DOI: https://doi.org/10.1016/j.meddro.2019.04.001
Keywords: Health care-associated infection; Nosocomial infection; Faultness liability; Law of March 4th 2002

Responsabilité civile

Editorial : Au cours de ces dernières années, le terme d’infection nosocomiale a laissé la place à celui, plus large, d’infection associée aux soins, la plausibilité de l’association entre l’infection et les soins prodigués devant dans tous les cas faire l’objet d’une analyse rigoureuse. En expertise, pour qu’une infection associée aux soins soit à la demande du magistrat qualifiée de nosocomiale, il faudra qu’elle ait bien été contractée dans un établissement de santé et soit en lien avec un acte ou l’environnement de soins. Le Code de Santé Publique tout comme la jurisprudence la plus récente, judiciaire et administrative, donnent désormais une définition proche de l’infection nosocomiale. Le principe de la responsabilité sans faute des établissements de santé en matière d’infection nosocomiale a été consacré par la loi du 4 mars 2002, les cas les plus graves (décès ; déficit fonctionnel permanent > 25 %) étant indemnisés par l’ONIAM.

Conclusion (proposition de traduction) : Le risque médico-judiciaire des infections nosocomiales est désormais important. Pour être qualifiée de nosocomiale, une infection doit être associée à un acte ou l’environnement de soins (avec un lien établi entre eux) et avoir été contractée dans un établissement de soins. L’indemnisation de l’infection nosocomiale incombera soit à la solidarité nationale pour les cas les plus graves, soit à l’établissement de soins où l’infection a été contractée, qu’une faute ait été ou non mise en évidence. C’est dire l’importance du travail de l’expert judiciaire qui, dans son rapport, doit littéralement disséquer le lien de causalité entre l’acte de soins litigieux et la survenue de l’infection. La qualité de ce travail a pu également contribuer, au fil des années, àfac ̧onner la jurisprudence tant judiciaire qu’administrative quitend à rejoindre désormais, en matière de définition de l’infectionnosocomiale, l’approche scientifique qui en est faite.

A Systematic Review of Testicle Survival Time After a Torsion Event.
Mellick LB, Sinex JE, Gibson RW, Mears K. | Pediatr Emerg Care. 2019 Dec;35(12):821-825
DOI: https://doi.org/10.1097/pec.0000000000001287
Keywords: Aucun

Original article

Introduction : The time window for possible salvage and survival of a torsed testicle is commonly thought to be 6 to 8 hours. However, survival of torsed testicles with or without subsequent atrophy is known to occur outside that critical time window. In this article, we performed a systematic review of the English literature to provide a more accurate understanding of reported time frames of testicle survival after a torsion event.
Objectives : The primary research question was to determine the relationship between time to treatment and the rate of survival for testicles of male patients presenting with testicular torsion (TT).

Méthode : A systematic review of the literature was performed and structured according to PRISMA guidelines. An exhaustive library search was performed after search strategies were developed for multiple databases that included PubMed, Cochrane library, Ovid MEDLINE, Web of Science, and ProQuest Theses and Dissertations. Two different searches were developed including "testicular torsion" and TT with the search term "time" added. Articles specifically reporting TT case series, testicle outcomes, and time to surgical or manual treatment were selected for review. In addition to and preceding the systematic review, an exhaustive manual search of the literature was also performed by the authors. As a result of these searches, a total of 30 studies with data considered relevant to the research question were included. The information extracted from the articles was tabulated with regard to time intervals to treatment and survival outcome.

Résultats : The systematic review process and protocol are reported in this article. A total of 30 studies were found that reported case series of TT patients and their outcomes as well as time to treatment reported in useful time frames. From these reports, a total of 2116 TT patients were culled, and their outcomes and time to treatment are reported. Because the time to treatment was reported variously in different case series, the 3 most common formats for reporting time to treatment and outcome were used. When overlap between the tables existed, the data were tallied and reported cumulatively. When reported in 6-hour intervals (1,283 patients), survival at 0 to 6 hours was 97.2%; 7 to 12 hours, 79.3%; 13 to 18 hours, 61.3%; 19 to 24 hours, 42.5%; 25 to 48 hours, 24.4%; and greater than 48 hours, 7.4%. Moreover, we reported cumulative survival data based on reporting for all 3 groups of patients. Testicular salvage in the first 12 hours is 90.4%, from 13 to 24 hours survival is 54.0%, and beyond 24 hours survival is 18.1%. Testicle survival after TT was significant beyond the commonly held 6 to 8 hour time frame and even after more than 24 hours of ischemia.

Conclusion : Survival of the testicle irrespective of subsequent atrophy, decreased spermatogenesis or impaired endocrine function after testicular torsion can be much longer than the 6 to 8 hours that is commonly taught. Our systematic review of the literature demonstrates that survival percentages are significant even past 24 hours of torsion. This information should encourage aggressive management of patients presenting with testicular torsion pain that has been ongoing for many hours.

Conclusion (proposition de traduction) : La survie du testicule indépendamment d'une atrophie ultérieure, d'une diminution de la spermatogenèse ou d'une altération de la fonction endocrinienne après une torsion testiculaire peut être beaucoup plus longue que les 6 à 8 heures couramment enseignées. Notre revue systématique de la littérature démontre que les pourcentages de survie sont significatifs même après 24 heures de torsion. Ces informations devraient encourager une prise en charge agressive des patients présentant une douleur à la torsion testiculaire qui dure depuis de nombreuses heures.

Is Radiography Necessary for Pediatric Emergency Department Clinicians to Safely Manage Ankle Injuries?.
Ramasubbu RA | Pediatr Emerg Care. 2019 Dec;35(12):826-830
DOI: https://doi.org/10.1097/pec.0000000000001197
Keywords: Aucun

Original article

Introduction : Ankle radiography in the pediatric emergency department exposes a radiosensitive population to harmful ionizing radiation and is costly to health care systems. This study aimed to determine if ankle injuries in children could be managed safely and effectively without radiography.

Méthode : This prospective study enrolled 94 patients with ankle injuries between July 14, 2015, and December 16, 2015. Participating clinicians filled out a tick-box questionnaire describing their predicted diagnosis and management. In March 2016, we looked retrospectively at TRAK to determine how these patients were actually managed and compared this with the predictions.

Résultats : Agreement was calculated for the predicted and actual presence of a fracture, with a κ value of 0.433. The intraclass correlation coefficient was calculated to determine interrater reliability between predicted management and actual management, showing an average score of 0.801. Of the 16 patients found to be Low Risk Ankle Rule positive, none were found to have high-risk fractures.

Conclusion : This study found that radiographs are necessary for the management of pediatric ankle injuries. However, there is scope to reduce radiography by implementing the Low Risk Ankle Rule.

Conclusion (proposition de traduction) : Cette étude a révélé que les radiographies sont nécessaires pour la gestion des blessures pédiatriques à la cheville. Cependant, il est possible de réduire la radiographie en appliquant la règle de la cheville à faible risque (Low Risk Ankle Rule).

Commentaire : Concernant la règle d'Ottawa ou « Low Risk Ankle Rule »:
Boutis K, Grootendorst P, Willan A, Plint AC, Babyn P, Brison RJ, Sayal A, Parker M, Mamen N, Schuh S, Grimshaw J, Johnson D, Narayanan U. Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries. CMAJ. 2013 Oct 15;185(15):E731-8  .
 
Radiographie de la cheville ou du pied indiquée en pédiatrie si présence d’un des signes ou symptômes suivant (Urgence CHU Sainte-Justine 2016  ) :
• Douleur malléole interne ou portion postérieure de la malléole (sur 6 cm)
• Douleur malléole externe ou portion postérieur de la malléole (sur 6 cm)
• Incapacité de mise en charge et de faire 4 pas (immédiatement et lors de l’examen)
• Douleur base du 5^e métatarse
• Douleur os naviculaire
• Douleur « mid-foot ».
Référence : Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992 Apr;21(4):384-90  .
 

Autre référence :
Marson BA, Craxford S, Ollivere BJ. Management of ankle fractures in children. Br J Hosp Med (Lond). 2019 Apr 2;80(4):201-203  .

An Intervention to Increase Knowledge and Utilization of the Low Risk Ankle Rule Among Pediatric Emergency Department Providers.
Loftus KV, Gittelman MA, FitzGerald M, Pomerantz WJ. | Pediatr Emerg Care. 2019 Dec;35(12):831-836
DOI: https://doi.org/10.1097/PEC.0000000000001987
Keywords: Aucun

Original article

Introduction : The Low Risk Ankle Rule (LRAR) can assist pediatric emergency department providers in reducing radiographs without missing significant fractures. Most providers are unaware of this tool. This study sought to educate providers about the LRAR then determine their self-reported use immediately and 2 months after education.

Méthode : A web-based survey was e-mailed to providers at one large pediatric emergency department. The survey assessed knowledge and use of the rule. Clinical scenarios, in which radiographs were not indicated, helped determine radiograph ordering practices. After a brief LRAR tutorial, respondents were requeried about radiograph ordering practices along with likelihood of future LRAR use. At 2 months, radiograph ordering was again assessed using the same scenarios; interim LRAR use was also determined.

Résultats : Response rates on the initial and follow-up surveys were 61.4% and 96.2%, respectively. A minority (20%) had heard of the LRAR. Providers initially reported ordering radiographs on 84% of ankle injuries and 82.5% ordered radiographs in the scenario. Immediately after education, only 32% ordered a radiograph in the scenario; 85% reported that they would use the tool consistently. At 2 months, there was no significant change in radiograph ordering practices (79.5% vs 84%). In the interim, 30% reported using the rule at least once.

Conclusion : Most pediatric emergency department providers were unfamiliar with the LRAR. After a brief tutorial, most providers reported that planning to use the tool and self-reported radiograph ordering was significantly reduced; however, at 2 months, clinical practice was unaffected. Further work to implement the tool into practice is necessary.

Conclusion (proposition de traduction) : La plupart des intervenants des services d'urgences pédiatriques ne connaissaient pas la règle d'Ottawa.
Après un bref tutoriel, la plupart des intervenants ont indiqué leur intention d'utiliser l'outil et la réduction considérable de la prescription auto-déclarée de radiographies ; cependant, à 2 mois, la pratique clinique n'était pas modifiée. Des travaux supplémentaires sont nécessaires pour mettre en œuvre l'outil dans la pratique.

The Impact of Treatment With Continuous Positive Airway Pressure on Acute Carbon Monoxide Poisoning.
Caglar B, Serin S, Yilmaz G, Torun A, Parlak I. | Prehosp Disaster Med. 2019 Dec;34(6):588-591
DOI: https://doi.org/10.1017/s1049023x19005028
Keywords: carbon monoxide poisoning; non-invasive ventilation; toxicology

Original Research

Introduction : Approximately 50,000 patients per year present at emergency departments (EDs) because of carbon monoxide (CO) intoxication. The hypothesis of this study was that the half-life of CO and the regression period of complaints could be reduced more rapidly by applying oxygen with the Continuous Positive Airway Pressure (CPAP) modality using a non-invasive mechanical ventilator.

Méthode : The patients were divided into Group 1 and Group 2 in terms of the treatment method applied. Patients in Group 1 received FiO2 1.0 15 l/minute oxygen at room temperature for at least 30 minutes with a non-rebreather mask. Patients in Group 2 received FiO2 1.0 oxygen at 12 cmH2O pressure with non-invasive mechanical ventilation for at least 30 minutes with an oronasal mask in the CPAP modality.

Résultats : The median values (interquartile range) of carboxyhemoglobin (COHb) levels at zero and 30 minutes of patients were 19% (8) and 14% (6) in Group 1 and 22% (8) and nine percent (3) in Group 2; a median difference of six percent (2) was detected in Group 1 and of 13% (4) in Group 2 in the first 30 minutes (P <.001). When the symptoms of the patients were examined, the median values of Group 1 and Group 2 at zero minutes were both eight units and at 30 minutes were five and three units, respectively. A decrease of five units was determined in the median of Group 2 in the first 30 minutes, and a decrease of two units in the median of Group 1 (P <.001).

Conclusion : The use of CPAP was determined to more rapidly reduce COHb level as opposed to high-flow oxygen therapy. It is also thought that it may enable earlier discharge by reducing the duration of the emergency follow-up since it provides a faster improvement in the symptoms of the patients.

Conclusion (proposition de traduction) : L'utilisation de la CPAP a été déterminante pour réduire plus rapidement le taux de carboxyhémoglobine contrairement à l'oxygénothérapie à haut débit. On pense également qu'il pourrait permettre une sortie plus précoce en réduisant la durée du suivi aux urgences, car elle permet une amélioration plus rapide des symptômes des patients.

Accuracy of National Early Warning Score 2 (NEWS2) in Prehospital Triage on In-Hospital Early Mortality: A Multi-Center Observational Prospective Cohort Study.
Martín-Rodríguez F, López-Izquierdo R, Del Pozo Vegas C, Delgado Benito JF, Carbajosa Rodríguez V, Diego Rasilla MN, Martín Conty JL, Mayo Iscar A, Otero de la Torre S, Méndez Martín V, Castro Villamor MA. | Prehosp Disaster Med. 2019 Dec;34(6):610-618
DOI: https://doi.org/10.1017/s1049023x19005041
Keywords: clinical decision making; early mortality; early warning score; mass-casualty incident; triage

Original Research

Introduction : In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center.
Hypothesis/problem: The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs.

Méthode : This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours.

Résultats : From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2).

Conclusion : Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).

Conclusion (proposition de traduction) : Les scores préhospitaliers du NEWS2 sont faciles à obtenir et représentent un test fiable, ce qui en fait un système idéal pour aider à l'évaluation initiale des patients à haut risque, et pour déterminer leur niveau de triage de manière efficace et efficiente. Le système médical d'urgence préhospitalier (PhEMS) devrait évaluer l'inclusion de NEWS2 comme système de triage, qui est particulièrement utile pour le deuxième triage (priorité d'évacuation).

Commentaire : Calcul du score en ligne : National Early Warning Score (NEWS) 2  
Attention, le NEWS2 (et tout score d'alerte précoce) doit être utilisé en complément du jugement clinique, et non pour le remplacer.

Intraosseous Needles in Pediatric Cadavers: Rate of Malposition.
Maxien D, Wirth S, Peschel O, Sterzik A, Kirchhoff S, Kreimeier U, Reiser MF, Mück FG. | Resuscitation. 2019 Dec;145:1-7
DOI: https://doi.org/10.1016/j.resuscitation.2019.09.028
Keywords: Intraosseous needles; Pediatric cadavers; Vascular access

Clinical Papers

Introduction : Intraosseous vascular access is a commonly conducted procedure especially in pediatric resuscitation. Very high success rates for intraosseous (IO) devices are reported. Aim of the study was to describe the rates of malposition of intraosseous needles (ION) in pediatric cadavers via post-mortem computed tomography (PMCT).

Méthode : 212 consecutive pediatric cadavers underwent PMCT, of which 38 cadavers had visible ION and were included in the study. They were divided into two subgroups depending on their age (n = 22 infant cadavers (age <1 year) and n = 16 child cadavers (age ≥1 year)). Two independent readers evaluated the number and position of ION.

Résultats : In 22 infant cadavers 34 ION were found. Malposition of at least one ION was visible in 14 subjects (64%), among which 7 cadavers (32%) even had no correctly placed ION, thus being without established vascular access. Overall, 16 of the 34 used ION devices (47%) were in malposition. 23 ION were found in 16 child cadavers. In 8 subjects (50%) at least one ION was malpositioned, among which 3 cadavers (19%) had no correctly placed ION, resulting in a complete absence of vascular access. Overall, 9 of the 23 ION devices (39%) were malpositioned.

Conclusion : Our study showed relatively high malposition rates for ION devices in pediatric cadavers which was not to be assumed regarding the success rates of 80% and higher in previous literature. This should be clarified by further studies in living patients.

Conclusion (proposition de traduction) : Notre étude a montré des taux de malposition relativement élevés pour les dispositifs d'aiguilles intra-osseuses chez les cadavres pédiatriques, ce qui n'était pas à supposer en ce qui concerne les taux de réussite de 80 % et plus dans la littérature précédente. Cela devrait être clarifié par d'autres études sur des patients vivants.

Chest Compression Release Velocity Factors During Out-Of-Hospital Cardiac Resuscitation.
Beger S, Sutter J, Vadeboncoeur T, Silver A, Hu C, Spaite DW, Bobrow B. | Resuscitation. 2019 Dec;145:37-42
DOI: https://doi.org/10.1016/j.resuscitation.2019.09.024
Keywords: CCRV; CPR; Cardiac arrest; Chest compression release velocity; Chest compressions; Compressions; EMS; Emergency medicine; Feedback; Haemodynamics; OHCA; Out of hospital cardiac arrest; Resuscitation

Clinical Papers

Introduction : Higher chest compression release velocity (CCRV) has been associated with better outcomes after out-of-hospital cardiac arrest (OHCA), and patient factors have been associated with variations in chest wall compliance and compressibility. We evaluated whether patient sex, age, weight, and time in resuscitation were associated with CCRV during pre-hospital resuscitation from OHCA.

Méthode : Observational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Subject-level mean CCRV during the first 10 min of compressions was correlated with categorical variables by the Wilcoxon rank-sum test and with continuous variables by the Spearman's rank correlation coefficient. Generalized estimating equation and linear mixed-effect models were used to study the trend of CCRV over time.

Résultats : During the study period, 2535 adult OHCA cases were treated. After exclusion criteria, 1140 cases remained for analysis. Median duration of recorded compressions was 8.70 min during the first 10 min of CPR. An overall decline in CCRV was observed even after adjusting for compression depth. The subject-level mean CCRV was higher for minutes 0-5 than for minutes 5-10 (mean 347.9 mm/s vs. 339.0 mm/s, 95% CI of the difference -12.4 to -5.4, p < 0.0001). Males exhibited a greater mean CCRV compared to females [344.4 mm/s (IQR 307.3-384.6) vs. 331.5 mm/s (IQR 285.3-385.5), p = 0.013]. Mean CCRV was negatively correlated with age and positively correlated with patient weight.

Conclusion : CCRV declines significantly over the course of resuscitation. Patient characteristics including male sex, younger age, and increased weight were associated with a higher CCRV.

Conclusion (proposition de traduction) : La vitesse de libération des compressions thoraciques diminue de manière significative au cours de la réanimation. Les caractéristiques des patients, notamment le sexe masculin, le jeune âge et leur poids accru, ont été associées à une vitesse de libération des compressions thoraciques plus élevée.

The Effects of Route of Admission to a Percutaneous Coronary Intervention Centre Among Patients With Out-Of-Hospital Cardiac Arrest.
Suh J, Ahn KO, Shin SD. | Resuscitation. 2019;145:50–55
DOI: https://doi.org/10.1016/j.resuscitation.2019.09.032
Keywords: Coronary intervention; Out-of-hospital cardiac arrest; Patient transfer; Percutaneous

Clinical Papers

Introduction : Patients with OHCA who are not transported directly to a percutaneous coronary intervention (PCI)-capable hospital may eventually undergo an inter-hospital transfer (IHT). The aim of the present study was to investigate the effects of route of admission to a PCI centre among patients with OHCA.

Méthode : We included patients with OHCA of presumed cardiac aetiology that were admitted to a PCI centre between January 2015 and December 2016. The exposure variable was route of admission: direct versus indirect. The 'direct' group was defined as patients who were transferred directly from the field to a PCI centre by emergency medical service (EMS) providers. The 'indirect' group was defined as patients who underwent IHT from a non-PCI centre to a PCI centre. The primary outcome was neurological recovery. We evaluated the effects of route of admission using multivariable logistic regression analysis after adjusting for potential confounders.

Résultats : There were total of 4363 eligible patients: 3488 (78.2%) in the direct group and 975 (21.8%) in the indirect group. Neurologic recovery was better in the direct group (38.0%) than in the indirect group (29.0%). After adjusting for potential confounders, indirect admission was negatively associated with outcomes (adjusted odds ratio [aOR] 0.70; 95% confidence interval [CI] 0.58-0.85).

Conclusion : The route of admission to a PCI centre is associated with neurological recovery among resuscitated patients with OHCA of presumed cardiac aetiology. This has implications for regionalized EMS transport and IHT protocols for patients with OHCA.

Conclusion (proposition de traduction) : L’admission dans un centre d'angioplastie est associée à la récupération neurologique chez les patients réanimés après d'un arrêt cardiaque extra-hospitalier dont une étiologie cardiaque est suspectée. Cela a des implications pour le transport régionalisé des services médicaux d'urgence et les protocoles de transfert inter-hospitalier pour les patients présentant un arrêt cardiaque extra-hospitalier.

Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality.
O'Connell KJ, Keane RR, Cochrane NH, Sandler AB, Donoghue AJ, Kerrey BT, Myers SR, Vazifedan T, Mullan PC. | Resuscitation. 2019 Dec;145:158–165
DOI: https://doi.org/10.1016/j.resuscitation.2019.08.015
Keywords: CPR; Cardiopulmonary resuscitation; Pediatric; Resuscitation

Clinical Papers

Introduction : Minimizing pauses in chest compressions during cardiopulmonary resuscitation (CPR) is recommended by the American Heart Association (AHA) and is associated with improved patient outcomes. We studied the quality of pediatric CPR performed in a tertiary pediatric emergency department (ED) with a focus on pauses in chest compressions.

Méthode : We conducted an observational study of CPR quality in two pediatric EDs using video review during pediatric cardiac arrest. Events were reviewed for AHA guideline adherence. Parameters of CPR performance were described according to individual compressor segment. Pauses in compressions were analyzed for duration and pause activities.

Résultats : From a 30-month period, 81 cardiac arrests were analyzed, including 1003 individual compressor segments and 900 pauses. Median chest compression fraction was 91%, with a median pause duration of 4 s (IQR 2, 10); 22% of pauses were prolonged (>10 s). Pulse checks occurred in 23% of pauses; 62% were prolonged. Checking a single pulse site (p < 0.001) and having fingers ready pre-pause (p = 0. 001) were associated with significantly shorter pause duration. Pause duration was correlated with the number of pause tasks (r = 0.559, p < 0.001). “Coordinated pauses” (pulse check, rhythm check and compressor change) were rare (6%) and long in duration (19 s; IQR 11, 30).

Conclusion : Prolonged pauses in chest compressions occurred frequently during CPR and were associated with pulse checks and multiple simultaneous tasks. Checking a single pulse site with fingers ready on the pulse site pre-pause could decrease pause duration and improve CPR quality.

Conclusion (proposition de traduction) : Des pauses prolongées dans les compressions thoraciques sont constatées fréquemment pendant la RCP et ont été l'occasion de la recherche d'un pouls et à de multiples tâches simultanées. La vérification d'un site constatant la présence d'un pouls généré par la RCP, avec les doigts pré-positionnés avant la pause de la RCP, pourrait réduire la durée de la pause et améliorer la qualité de la RCP.

Bystander-initiated Conventional vs Compression-Only Cardiopulmonary Resuscitation and Outcomes After Out-Of-Hospital Cardiac Arrest Due to Drowning.
Fukuda T, Ohashi-Fukuda N, Hayashida K, Kondo Y, Kukita I. | Resuscitation. 2019 Dec;145:166-174
DOI: https://doi.org/10.1016/j.resuscitation.2019.08.026
Keywords: Basic life support; Cardiopulmonary resuscitation; Drowning; Epidemiology; Out-of-hospital cardiac arrest

Clinical papers

Introduction : Great emphasis has been placed on rescue breathing in out-of-hospital cardiac arrest (OHCA) due to drowning. However, there is no evidence about the effect of rescue breathing on neurologically favorable survival after OHCA due to drowning. The aim of this study is to examine the effect of bystander-initiated conventional (with rescue breathing) versus compression-only (without rescue breathing) cardiopulmonary resuscitation (CPR) in OHCA due to drowning.

Méthode : This nationwide population-based observational study using prospectively collected government-led registry data included patients with OHCA due to drowning who were transported to an emergency hospital in Japan between 2013 and 2016. The primary outcome was one-month neurologically favorable survival.

Résultats : The full cohort (n = 5121) comprised 2486 (48.5%) male patients, and the mean age was 72.4 years (standard deviation, 21.6). Of these, 968 (18.9%) received conventional CPR, and 4153 (81.1%) received compression-only CPR. 928 patients receiving conventional CPR were propensity-matched with 928 patients receiving compression-only CPR. In the propensity score-matched cohort, one-month neurologically favorable survival was not significantly different between the two groups (7.5% in the conventional CPR group vs. 6.6% in the compression-only CPR group; risk ratio, 1.15; 95% confidence interval, 0.82-1.60; P = 0.4147). This association was consistent across a variety of subgroup analyses.

Conclusion : Among patients with OHCA due to drowning, there were no differences in one-month neurologically favorable survival between bystander-initiated conventional and compression-only CPR groups, although several important data (e.g., water temperature, submersion duration, or body of water) could not be addressed. Further study is warranted to confirm our findings.

Conclusion (proposition de traduction) : Parmi les patients en arrêt cardiaque extra-hospitalier sur une noyade, il n'y a pas eu de différences en terme de survie neurologique favorable à un mois entre les groupes de RCP conventionnels et de RCP par compression uniquement, bien que plusieurs données importantes (par exemple, la température de l'eau, la durée de l'immersion ou le plan d'eau) n'aient pas pu être traitées. Une étude plus approfondie est nécessaire pour confirmer nos conclusions.

Prehospital Advanced Airway Management for Paediatric Patients With Out-Of-Hospital Cardiac Arrest: A Nationwide Cohort Study.
Okubo M, Komukai S, Izawa J, Gibo K, Kiyohara K, Matsuyama T, Kiguchi T, Iwami T, Callaway CW, Kitamura T. | Resuscitation. 2019 Dec;145:175-184
DOI: https://doi.org/10.1016/j.resuscitation.2019.09.007
Keywords: Advanced airway management; Out-of-hospital cardiac arrest; Paediatrics; Risk-set matching; Time-dependent propensity score analysis

Clinical papers

Introduction : Although prehospital advanced airway management (AAM) (i.e., endotracheal intubation [ETI] and insertion of supraglottic airways [SGA]) has been performed for paediatric out-of-hospital cardiac arrest (OHCA), the effect of AAM has not been fully studied. We evaluated the association between prehospital AAM for paediatric OHCA and patient outcomes.

Méthode : We conducted an observational cohort study, using the All-Japan Utstein Registry between 2014 and 2016. We included paediatric patients (age <18 years) with OHCA. We calculated time-dependent propensity score at each minute after initiation of cardiopulmonary resuscitation by EMS providers, using a Fine-Gray regression model. We sequentially matched patients who received AAM during cardiac arrest to patients at risk of receiving AAM within the same minute (risk-set matching). The primary outcome was 1-month survival. Secondary outcome was 1-month survival with favourable functional status, defined as Cerebral Performance Category score of 1 or 2.

Résultats : We analysed 3801 paediatric patients with OHCA. 481 patients (12.7%) received AAM and 3320 (87.3%) did not. Among the 3801 analysed patients, 912 patients underwent risk-set matching. In the matched cohort, AAM was not associated with 1-month survival (AAM: 52/456 [11.4%] vs. no AAM: 44/456 [9.6%]; risk ratio [RR], 1.15 [95% CI, 0.76-1.73]; risk difference [RD], 1.5% [-3.0 to 6.1%]) or favourable functional status (AAM: 9/456 [2.0%] vs. no AAM: 10/456 [2.2%]; RR, 0.69 [95% CI, 0.26-1.79]; RD, -0.8% [-2.9 to 1.3%]).

Conclusion : Among paediatric patients with OHCA, we found that prehospital AAM was not associated with 1-month survival or favourable functional status.

Conclusion (proposition de traduction) : Parmi les patients pédiatriques en arrêt cardiaque extra-hospitalier, nous avons constaté que la gestion spécialisée des voies aériennes supérieures en préhospitalier n'était pas associée à une survie d'un mois ou à un état fonctionnel favorable.

Demographic characteristics and delayed neurological sequelae risk factors in carbon monoxide poisoning.
Sarı Doğan F, Güneysel Ö, Gökdağ E, Güneş M, Sümen SG. | Am J Emerg Med. 2019 Dec 20. pii: S0735-6757(19)30844-7
DOI: https://doi.org/10.1016/j.ajem.2019.12.037
Keywords: Carbon monoxide poisoning; Carboxyhemoglobin; Delayed neurological sequelae; Hyperbaric oxygen

ARTICLES IN PRESS

Introduction : Carbon monoxide (CO) is a colorless, odorless gas and tasteless. CO poisoning (COP) is one of the most frequently encountered inhalation poisonings. The most common cause of morbidity in COP is delayed neurological sequelae (DNS). DNS is the occurrence of neuropsychiatric findings within 2-240 days after discharge of patients with COP and there are no definitive diagnostic criteria. The aim of our study is; to determine the risk factors and incidence of DNS.

Méthode : Our study is a retrospective, observational study. Patients with the diagnosis of COP in the emergency department between 2015 and 2016 were included in the study. Patients age, gender, findings in the initial physical examination (PE) and neurological examination (NE), blood carboxyhemoglobin (COHb) level, relation between hyperbaric oxygen (HBO) treatment and DNS were assessed.

Résultats : Total of 72 patients were included in the study. Mean age was 33.43 ± 20.89. It was determined that pathological findings in the initial NE are a significant predictive factor for DNS (Odds ratio 18.600, p:0.004). Significant relation between NE and HBO treatment was present (p:00.1). There was no statistically significant relationship between initial COHb level and receiving HBO treatment (p:0.9). Median COHb level of patients with DNS was 30 (min:10, max: 43), median COHb level of patients without DNS was 25 (min:10, max:44) and there was no statistically significant relationship between the two groups according to COHb levels (p:0.7).

Conclusion : Pathological findings in the initial neurological examination had a predictive value for delayed neurological sequelae in patients with carbon monoxide poisoning.

Conclusion (proposition de traduction) : Les résultats pathologiques de l'examen neurologique initial avaient une valeur prédictive des séquelles neurologiques à long terme chez les patients souffrant d'une intoxication au monoxyde de carbone.

Commentaire : Voir l'article de Schaub E, Pellegrini M, Pugin D. L’intoxication au monoxyde de carbone en 2009. Rev Med Suisse 2009;5:1606-1609  .
(…) La présentation clinique initiale d’une intoxication au CO est généralement aspécifique. Céphalées, nausées, vertiges, asthénie peuvent faire évoquer une virose ou une intoxication alimentaire. Barret rapporte d’ailleurs près de 30 % d’erreurs de diagnostic. En fonction de l’importance de l’intoxication, le tableau clinique peut rapidement évoluer vers une perte de connaissance, un coma et un collapsus cardiorespiratoire. Une exposition chronique à de faibles doses de CO (50 à 80 ppm) peut se manifester par une baisse des performances intellectuelles, des difficultés d’apprentissage et une altération de l’acuité visuelle et auditive, alors qu’une exposition aiguë à des concentrations très élevées (1000 ppm et plus) peut entraîner un décès immédiat. Les complications sévères les plus fréquentes pouvant survenir au stade aigu sont cardiaques (troubles du rythme et ischémie coronarienne), pulmonaires (œdème aigu du poumon), musculaires (rabdomyolyse avec atteinte rénale possible) et viscérales (pancréatite). Des manifestations neurologiques telles que convulsions, apraxie, amnésie, agnosie, parkinsonisme, cécité corticale, incontinence peuvent faire partie du tableau initial de l’intoxication. La perte de connaissance et le coma sont des signes de gravité témoignant d’une intoxication sévère qui nécessite une prise en charge agressive immédiate.
A l’examen clinique, on retrouve le plus souvent une tachycardie et une tachypnée. Si on observe parfois une hypertension, c’est généralement l’hypotension qui prédomine. Comme en témoignent des études observationnelles et l’expérimentation animale, la mortalité aiguë de l’intoxication au CO semble majoritairement liée à une atteinte cardiaque. La coloration rouge cerise classiquement décrite est très rarement retrouvée en pratique. (…)

The Intensity of Pain in the Prehospital Setting Is Most Strongly Reflected in the Respiratory Rate Among Physiological Parameters.
Jan-Otto A, Salmir N, Johan H, Erik H, Christer A. | Am J Emerg Med. 2019 Dec;37(12):2125–2131
DOI: https://doi.org/10.1016/j.ajem.2019.01.032
Keywords: Intensity; Pain; Prehospital setting; Vital parameters

Original Contribution

Introduction : In order to treat pain optimally, the Emergency Medical Service (EMS) clinician needs to be able to make a reasonable estimation of the severity of the pain. It is hypothesised that various physiological parameters will change as a response to pain.
Aim : In a cohort of patients who were seen by EMS clinicians, to relate the patients' estimated intensity of pain to various physiological parameters.

Méthode : Patients who called for EMS due to pain in a part of western Sweden were included. The intensity of pain was assessed according to the visual analogue scale (VAS) or the Numerical Rating Scale (NRS). The following were assessed the same time as pain on EMS arrival: heart rate, systolic and diastolic blood pressure, respiratory rate, moist skin and paleness.

Résultats : In all, 19,908 patients (≥18 years), were studied (51% women). There were significant associations between intensity of pain and the respiratory rate (r = 0.198; p < 0.0001), heart rate (r = 0.037; p < 0.0001), systolic blood pressure (r = -0.029; p < 0.0001), moist skin (r = 0.143; p < 0.0001) and paleness (r = 0.171; p < 0.0001). The strongest association was found with respiratory rate among patients aged 18-64 years (r = 0.258; p < 0.0001).

Conclusion : In the prehospital setting, there were significant but weak correlations between intensity of pain and physiological parameters. The most clinically relevant association was found with an increased respiratory rate and presence of pale and moist skin among patients aged < 65 years. Among younger patients, respiratory rate may support in the clinical evaluation of pain.

Conclusion (proposition de traduction) : Dans le cadre préhospitalier, on a constaté des corrélations significatives mais faibles entre l'intensité de la douleur et les paramètres physiologiques.
L'association la plus pertinente sur le plan clinique a été trouvée avec une augmentation de la fréquence respiratoire et la présence d'une peau pâle et humide chez les patients âgés de moins de 65 ans. Chez les patients plus jeunes, la fréquence respiratoire peut aider à l'évaluation clinique de la douleur.

Intravenous Dexketoprofen Versus Paracetamol in Non-Traumatic Musculoskeletal Pain in the Emergency Department: A Randomized Clinical Trial.
Demirozogul E, Yilmaz A, Ozen M, Turkcuer I, Seyit M, Arikan C. | Am J Emerg Med. 2019 Dec;37(12):2136–2142
DOI: https://doi.org/10.1016/j.ajem.2019.01.040
Keywords: Dexketoprofen; Intravenous; Pain relief; Paracetamol

Original contribution

Introduction : Although acute musculoskeletal pain has a wide range of causes from tendinitis, muscle spasm, to bone and joint injuries, it is a frequent occurrence in emergency services. Paracetamol and non-steroidal anti-inflammatory analgesics (NSAID) are common used in the treatment of musculoskeletal pain. This study sets out to compare the effectiveness of intravenous dexketoprofen and paracetamol in musculoskeletal pain relief.

Méthode : This prospective, randomized, double blind, controlled study was carried out in a university emergency room. The participating patients were randomized into two groups to receive either 50 mg of dexketoprofen or 1000 mg of paracetamol intravenously by rapid infusion in 150 ml of normal saline. Visual analogue scale (VAS), Numeric Rating Scala (NRS) was employed for pain measurement at baseline, after 15, after 30 and after 60 mins.

Résultats : 200 patients were included in the study, excluding 7342 of them. The mean age of the patients was calculated as 32,6. Paracetamol and dexketoprofen intervention decreases NRS pain scores over time. When compared to all pain locations, the NRS pain score of the patients was found to be statistically more effective in dexketoprofen than in paracetamol (p = 0.001). Paracetamol and dexketoprofen intervention reduces pain VAS scores over time. When the VAS pain score of the patients was compared to all pain locations, dexketoprofen was found to be statistically more effective than paracetamol (p = 0.001).

Conclusion : Intravenous dexketoprofen seemed to achieve superior analgesia to intravenous paracetamol when compared with all pain locations in patients with non-traumatic musculoskeletal pain.

Conclusion (proposition de traduction) : Le dextropropoxyphène par voie intraveineuse semble atteindre une analgésie supérieure à celle du paracétamol par voie intraveineuse par rapport à toutes les localisations de la douleur chez les patients souffrant de douleurs musculo-squelettiques non traumatiques.

Commentaire : Le dextropropoxyphène (Di-Antalvic), opiacé apparenté à la méthadone, a été retiré du marché français le 1er mars 2011…
Retrait du marché le 1er mars 2011 des spécialités contenant du dextropropoxyphène - Lettre aux prescripteurs (16/02/2011)  

Risk Factors for Seizure Recurrence in a Pediatric Observation Unit.
Gultekingil A, Teksam O, Haliloglu G, Yalnizoglu D. | Am J Emerg Med. 2019 Dec;37(12):2151–2154
DOI: https://doi.org/10.1016/j.ajem.2019.01.042
Keywords: Children; Emergency; Observation; Recurrence; Seizure

Original contribution

Introduction : Most patients present with seizures to pediatric emergency department (PED) are observed for extended periods for the risk of possible acute recurrence. Objective: The aim of this study is to determine the risk factors of acute recurrence within first 24 h.

Méthode : Patients who presented to PED with seizure during past 24 h were enrolled. Demographic features, number and duration of seizures, diagnostic studies, physical examination findings, presence and time of seizure recurrence in PED were noted.

Résultats : 187 patients were eligible for the study. 46% had recurrence of seizures in 24 h, 90,8% of recurrence within the first 6 h. Univariate analysis showed that younger patients, epileptic patients who were on multiple antiepileptic drugs (AEDs), who had multiple seizures during the past 24 h, who had abnormal neurological examination or neuroimaging findings had increased risk of seizure recurrence. Multivariate analysis showed that number of seizures during the past 24 h and previous use of AEDs was significantly associated with increased risk of recurrence.

Conclusion : Risk factors for acute recurrence should be evaluated for each patient. Patients without risk factors and no seizures during the first 6 h should not be observed for extended periods in PED.

Conclusion (proposition de traduction) : Les facteurs de risque de récidive aiguë doivent être évalués pour chaque patient. Les patients ne présentant pas de facteurs de risque et n'ayant pas eu de crises pendant les 6 premières heures ne doivent pas être observés pendant de longues périodes aux urgences pédiatriques.

Prehospital Quick Sequential Organ Failure Assessment Score to Predict In-Hospital Mortality Among Patients With Trauma.
Miyamoto K, Shibata N, Ogawa A, Nakashima T, Kato S. | Am J Emerg Med. 2019 Dec;37(12):2165–2170
DOI: https://doi.org/10.1016/j.ajem.2019.03.007
Keywords: In-hospital mortality; Prehospital; Quick sequential organ failure assessment score; Trauma; Triage

Original contribution

Introduction : The quick sequential organ failure assessment (qSOFA) score is calculated from three variables measured at the scene of trauma-systolic blood pressure, respiratory rate and consciousness. This study aimed to evaluate the discriminative ability of the prehospital qSOFA score for in-hospital mortality in patients with trauma.

Méthode : This retrospective multicenter study used data from 42,722 patients with trauma included in a Japanese nationwide trauma registry. All included patients were aged ≥18 years old and transferred to hospitals from the scenes of injury. The primary outcome was in-hospital mortality.

Résultats : The included patients had a mean age of 59.4 ± 21.5 years and a male predominance (63%). In-hospital mortality occurred in 2612 patients (6%), while 2-day mortality occurred in 1189 of 42,339 patients (3%). When patients were stratified by qSOFA scores, in-hospital mortality rates of 0.9% (105/11783), 5% (941/17839), 12% (1280/11132) and 15% (286/1968) were associated with qSOFA scores of 0, 1, 2 and 3, respectively (P < 0.0001 for trend). The area under the receiver operating characteristics curve of the qSOFA score for in-hospital mortality was 0.70 (95% confidence interval: 0.69-0.71). A qSOFA score cutoff value ≥1 yielded a sensitivity and specificity of 0.96 and 0.29, respectively, overall, and a sensitivity of 0.99 in patients younger than 65 years.

Conclusion : The prehospital qSOFA score was strongly associated with in-hospital mortality in patients with trauma. A prehospital qSOFA score cutoff of ≥1 can be used to identify patients at a very low risk of death, especially in younger age groups.

Conclusion (proposition de traduction) : Le score qSOFA préhospitalier était fortement associé à la mortalité hospitalière chez les patients traumatisés. Un seuil de score qSOFA préhospitalier ≥1 peut être utilisé pour identifier les patients à très faible risque de décès, en particulier dans les groupes d'âge plus jeunes.

Efficacy of Low-Dose Nebulized Epinephrine as Treatment for Croup: A Randomized, Placebo-Controlled, Double-Blind Trial.
Lee JH, Jung JY, Lee HJ, Kim Dk, Kwak YH, Chang I, Kwon H, Choi YJ, Park JW, Paek SH, Cho JH . | Am J Emerg Med. 2019 Dec;37(12):2171–2176
DOI: https://doi.org/10.1016/j.ajem.2019.03.012
Keywords: Croup; Nebulizer; Pediatric; l-Epinephrine

Original contribution

Introduction : Croup treatment usually involves a single dose of systemic dexamethasone combined with nebulized epinephrine. However, the optimal dose of l-epinephrine remains unclear. We examined whether a low dose (0.1 mg/kg) was inferior to the conventional dose (0.5 mg/kg) of 1:1000 nebulized l-epinephrine in patients with moderate to severe croup.

Méthode : This randomized double-blind clinical non-inferiority trial was conducted in three pediatric emergency departments from May 2015 to October 2017. Children 6 months to 5 years old with moderate to severe croup (Westley scale scores 3-11) were eligible. Subjects were randomly assigned to the conventional dose (0.5 mg/kg: maximum 5 mg) or low dose (0.1 mg/kg; maximum 1 mg) group. All subjects received 0.6 mg/kg dexamethasone. Croup scores and other vital signs were measured before and at 30, 60, 90, and 120 min after nebulized l-epinephrine administration. The primary outcome was the change in croup score after 30 min.

Résultats : The final analysis included 84 patients. The groups did not differ significantly in terms of demographic parameters. At 30 min after treatment with nebulized l-epinephrine, the croup scores in both groups were significantly reduced from the baseline values (p < 0.05) and did not differ between the two groups (p = 0.42). Neither blood pressure nor heart rate differed between the two groups.

Conclusion : Low-dose 1:1000 l-epinephrine was not inferior in croup score reduction to the conventional dose in patients with moderate to severe croup.

Conclusion (proposition de traduction) : La faible dose de 1:1000 de l-épinéphrine n'était pas inférieure dans la réduction du score de croup à la dose conventionnelle chez les patients présentant un croup modéré à sévère.

Accuracy of Ultrasound for Endotracheal Intubation Between Different Transducer Types.
Gottlieb M, Holladay D, Burns K, Gore SR, Wulff C, Shah S, Bailitz J. | Am J Emerg Med. 2019 Dec;37(12):2182–2185
DOI: https://doi.org/10.1016/j.ajem.2019.03.016
Keywords: Curvilinear; Endotracheal; Frequency; Intubation; Linear; Probe; Transducer; Ultrasound

Original contribution

Introduction : Ultrasound has been increasingly utilized for the identification of endotracheal tube (ETT) location after an intubation attempt, particularly among patients in cardiac arrest. However, prior studies have varied with respect to the choice of transducer and no studies have directly compared the accuracy between transducer types. Our study is the first to directly compare the accuracy of ETT confirmation between the linear and curvilinear transducer.

Méthode : This study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumferences. Cadavers were randomized to tracheal or esophageal intubation. Blinded sonographers assessed the location of the ETT using either a linear or curvilinear transducer in an alternating sequence. Accuracy of sonographer identification, time to identification, and operator confidence were assessed.

Résultats : Four hundred and five assessments were performed with 198 (48.9%) tracheal and 207 (51.1%) esophageal intubations. The linear transducer was 98% (95% CI 95.1% to 99.2%) accurate. The curvilinear transducer was 95% (95% CI 91.1% to 97.3%) accurate. The mean time to identification was significantly lower with the linear transducer [7.46 s (95% CI 6.23 to 8.7 s)] as compared with the curvilinear transducer [11.63 s (95% CI 9.05 to 14.2 s)]. The mean operator confidence was significantly higher with the linear transducer [4.84/5.0 (95% CI 4.76 to 4.91)] than with the curvilinear transducer [4.44/5.0 (95% CI 4.3 to 4.57)]. All operators preferred the linear transducer over the curvilinear transducer.

Conclusion : The diagnostic accuracy of ultrasound for ETT confirmation did not significantly differ between ultrasound transducer types, but the curvilinear transducer was associated with a longer time to confirmation and lower operator confidence. Further studies are needed to determine if the accuracy would change with more novice providers or in specific patient populations.

Conclusion (proposition de traduction) : La précision diagnostique de l'échographie pour la confirmation du placement de la sonde d'intubation en intra-trachéal ne différait pas significativement entre les types de transducteurs à ultrasons, mais le transducteur curviligne (convexe 2-5 MHz) était associé à un temps de confirmation plus long et à une confiance de l'opérateur plus faible.
Des études supplémentaires sont nécessaires pour déterminer si la précision changerait avec davantage de prestataires novices ou dans des populations de patients spécifiques.

Commentaire : La sonde convexe est aussi appelée « abdominale ».

Incidence and risk factors for hyperlactatemia in ED patients with acute metformin overdose.
Taub ES, Hoffman RS, Manini AF. | Am J Emerg Med. 2019 Dec;37(12):2205-2208
DOI: https://doi.org/10.1016/j.ajem.2019.03.033
Keywords: Acetaminophen; Hyperlactatemia; Lactic acidosis; Metformin; Overdose

Original contribution

Introduction : The goals of this study are to describe clinical characteristics and risk factors for metabolic acidosis with hyperlactatemia in emergency department (ED) patients with acute metformin overdose.

Méthode : This was a secondary analysis of data from a retrospective observational cohort of adult ED patients presenting with acute drug overdose at two tertiary care hospitals over 5 years. The primary outcomes were: (1) hyperlactatemia, defined as a lactate concentration ≥ 2 mmol/L at any point during hospital admission and, (2) metformin associated lactic acidosis (MALA), defined as a lactate concentration ≥ 5 mmol/L and pH <7.35 at any point during hospital admission.

Résultats : We screened 3739 acute overdoses; 2872 met eligibility, 56 self-reported metformin overdose (57% female, mean age 55.8). Of these, 39 had measured lactate values. There was a high incidence of hyperlactatemia (56.4%); MALA was less frequent (17.9%). There were no deaths. Low serum bicarbonate was an independent clinical risk factor for hyperlactatemia (adjusted p < 0.05). Acetaminophen co-exposure was an independent clinical risk factor for MALA (OR 24.40, 95% CI 1.6-376.4).

Conclusion : In ED patients with acute metformin overdose, initial hyperlactatemia is common but MALA is unusual. Acetaminophen co-exposure is a novel independent risk factor for the occurrence of MALA that deserves further investigation.

Conclusion (proposition de traduction) : Chez les patients des services d'urgence présentant un surdosage aigu en metformine, l'hyperlactatémie initiale est courante mais l'acidose lactique associée à la metformine est inhabituelle. La co-exposition à l'acétaminophène est un nouveau facteur de risque indépendant de survenue d'une acidose lactique associée à la metformine qui mérite une étude plus approfondie.

WAMAMI: emergency physicians can accurately identify wall motion abnormalities in acute myocardial infarction.
Croft PE, Strout TD, Kring RM, Director L, Vasaiwala SC, Mackenzie DC. | Am J Emerg Med. 2019 Dec;37(12):2224-2228
DOI: https://doi.org/10.1016/j.ajem.2019.03.037
Keywords: Aucun

Original contribution

Introduction : The ability to identify wall motion abnormalities may be useful for emergency clinicians, but is not typically evaluated in point-of-care echocardiograms. We sought to determine if emergency physicians with basic training in emergency echocardiography could identify regional wall motion abnormalities (RWMA) in patients admitted with ST-elevation myocardial infarction (STEMI).

Méthode : We prospectively enrolled patients with admitted with STEMI. Resident physicians with basic training in emergency ultrasound, blinded to other patient data, performed a point-of-care echocardiogram to evaluate for RWMA. If present, they also recorded the suspected territory of the RWMA. We calculated test performance characteristics and compared the agreement between point-of-care and comprehensive echocardiogram for RWMA and territory.

Résultats : 75 patients with STEMI were enrolled, and 62% had a RMWA. RWMA were identified with excellent test performance characteristics (sensitivity 88% (95% CI 75-96); specificity 92% (95% CI 75-99)). There was substantial agreement between the point-of-care echocardiogram and reference standard (K = 0.79; 95% CI: 0.64-0.94).

Conclusion : Emergency physicians with core training in point-of-care echocardiography can accurately identify RMWA.

Conclusion (proposition de traduction) : Les médecins des urgences ayant une formation de base en échocardiographie au point d'intervention peuvent identifier avec précision les anomalies régionales du mouvement des parois (RMWA).

Intravenous fluid bolus rates and pediatric diabetic ketoacidosis resolution.
Pruitt LG, Jones G, Musso M, Volz E, Zitek T. | Am J Emerg Med. 2019 Dec;37(12):2239-2241
DOI: https://doi.org/10.1016/j.ajem.2019.03.039
Keywords: Intravenous fluids; Magnesium; Pediatric diabetic ketoacidosis

Original contribution

Introduction : Recent data have challenged the notion that rapid intravenous fluid administration results in adverse neurologic outcomes in children with diabetic ketoacidosis (DKA). While many physicians still administer a cautious 10 cc/kg bolus of intravenous fluids for pediatric DKA patients, there may be benefits to using a larger bolus.

Méthode : This was a retrospective chart review of all pediatric patients with DKA presenting to a single emergency department (ED) between 2013 and 2015. Patients who received a bolus of 10 cc/kg or less in the ED were compared to patients who received >10 cc/kg of fluids. The primary outcome was the difference in hospital length-of-stay between the two groups. Secondarily, we compared groups with regards to the time to bicarbonate normalization.

Résultats : In sum, 170 pediatric DKA ED visits were analyzed. Patients who received a 10 cc/kg bolus or less of fluids in the ED had a mean hospital length-of-stay > that was 0.38 days longer (95% CI: 0.006 to 0.75 days) than those who received >10 cc/kg. On multivariable regression analysis, the difference between groups was diminished and no longer statistically significant. The time to bicarbonate normalization was 0.12 days longer (95% CI -0.029 to 0.27) in the 10 cc/kg or less group than the >10 cc/kg group.

Conclusion : After adjustment for confounders, no statistically significant differences in outcomes were seen in pediatric DKA patients who received a 10 cc/kg bolus or less compared to those who received a larger initial bolus.

Conclusion (proposition de traduction) : Après ajustement des facteurs de confusion, aucune différence statistiquement significative n'a été observée dans les résultats des patients pédiatriques présentant une acidocétose diabétique qui ont reçu un bolus 10 cc/kg ou moins, par rapport à ceux qui ont reçu un bolus initial plus important.

Implementation of a Computerized Decision Support System for Computed Tomography Scan Requests for Nontraumatic Headache in the Emergency Department.
Royuela A, Abad C, Vicente A, Muriel A, Romera R, Fernandez-Felix BM, Corres J, Fernandez Bustos P, Ortega A, Heras-Mosteiro J, Garcia Latorre R, Zamora J. | J Emerg Med. 2019 Dec;57(6):780-790
DOI: https://doi.org/10.1016/j.jemermed.2019.08.026
Keywords: CDSS; algorithm; cranial CT; emergency department; nontraumatic headache.

Original contribution

Introduction : Nontraumatic headache is a frequent complaint in the emergency department (ED). Cranial computed tomography (CT) is a widely available test for the diagnostic work-up, despite the risk of exposure to ionizing radiation.
Objectives : We sought to develop and evaluate a cranial CT request computerized decision support system (CDSS) for adults with their first presentation of unusual severe nontraumatic headache in the ED.

Méthode : Electronic database searches identified clinical decision and prediction rules and studies delineating risk factors in nontraumatic headache. A long list of risk factors extracted from these articles was reduced by a 30-member multidisciplinary expert panel (radiologists, emergency physicians, methodologists), using a 90% agreement threshold. This shortlist was used to develop the algorithm for the cranial CT request CDSS, which was implemented in March 2016. Impact evaluation compared CT scan frequency and diagnostic yield of pathologic findings before (March-August 2015) and after (March-August 2016) implementation.

Résultats : From the 10 selected studies, 10 risk factors were shortlisted to activate a request for cranial CT. Before implementation, 377 cranial CTs were ordered (15.3% of 2469 CT scans) compared with 244 after (9.5% of 2561 CT scans; pre-post difference 5.74%; 95% confidence interval [CI] 3.92-7.56%; p < 0.001), corresponding to a 37.6% relative reduction in the test ordering rate (95% CI 25.7-49.5%; p < 0.001). Despite the reduction in cranial CT scans, we did not observe an increase in pathological findings after introducing the decision support system (70 cases before [18.5%] vs. 35 cases after [14.3%]; pre-post difference -4.0% [95% CI -10.0 to 1.6%]; p = 0.170).

Conclusion : In nontraumatic headache among adults seen in the ED, CDSS decreased the cranial CT request rate but the diagnostic yield did not improve.

Conclusion (proposition de traduction) : Dans les céphalées non traumatiques chez les adultes vus aux urgences, le système informatisé d'aide à la décision a diminué le taux de demande de TDM crânienne, mais le rendement diagnostique ne s'est pas amélioré.

Intestinal Injury in Heat Stroke.
Ye N, Yu T, Guo H, Li J. | J Emerg Med. 2019 Dec;57(6):791–797
DOI: https://doi.org/10.1016/j.jemermed.2019.08.033
Keywords: heat stroke; intestinal injury; intestinal mucosal barrier

Clinical Reviews

Introduction : Heat stroke is a life-threatening syndrome that is characterized by its severe clinical symptoms, rapid progression, and high rate of mortality. Recently, research has indicated that a dysfunctional intestinal epithelia barrier plays an important role in the pathophysiology of heat stroke. Protecting the intestines from heat stress had been identified as a potentially effective treatment for patients with heat stroke and may reduce the innate immune response caused by endotoxins in circulation.
Objectives: The aim of this review is to discuss this key event in heat stroke and to describe the mechanism during progression.

Discussion : Direct injuries and secondary impairments of the intestine induced by heat stress are discussed; recent studies that refer to intestine-specific prevention and treatment in heat stroke and heat stress-induced injuries are also summarized.

Conclusion : A more detailed pathogenesis of heat stroke needs to be elucidated so that potentially effective means of treatment and prevention of heat stroke can be developed and studied.

Conclusion (proposition de traduction) : Une pathogenèse plus détaillée du coup de chaleur doit être élucidée afin que des moyens potentiellement efficaces de traitement et de prévention du coup de chaleur puissent être développés et étudiés.

Postcontrast Acute Kidney Injury After Computed Tomography Pulmonary Angiography for Acute Pulmonary Embolism.
Cho A, Kim MJ, You JS, Shin HJ, Lee EJ, Park I, Chung SP, Kim JH. | J Emerg Med. 2019 Dec;57(6):798–804
DOI: https://doi.org/10.1016/j.jemermed.2019.09.006
Keywords: acute kidney injury; acute pulmonary embolism; computed tomography pulmonary angiography; postcontrast acute kidney injury; renal function

Selected Topics: Emergency Radiology

Introduction : Despite the widespread use of computed tomography pulmonary angiography with contrast media for the diagnosis of acute pulmonary embolism, high-quality evidence on risk factors for postcontrast acute kidney injury related to its use is lacking.
Objective: The present study aimed to investigate whether the level of estimated glomerular filtration rate observed in the emergency department (ED) is significantly associated with the occurrence of postcontrast acute kidney injury in patients undergoing computed tomography pulmonary angiography.

Méthode : We performed a retrospective observational study using data automatically collected by a clinical data retrieval system from 1300 patients who underwent computed tomography pulmonary angiography for suspected acute pulmonary embolism in the ED. A total of 632 patients were selected for the study after exclusion. Univariate analyses were performed to identify significant risk factors for postcontrast acute kidney injury (the primary outcome). Multivariate logistic regression analysis was used to confirm the effect of estimated glomerular filtration rate in the ED on the occurrence of postcontrast acute kidney injury after adjustment for confounding variables.

Résultats : The total incidence rate of postcontrast acute kidney injury was 6.49% (41/632 patients). No statistically significant association between estimated glomerular filtration rate and the risk of postcontrast acute kidney injury was observed.

Conclusion : Our study findings could serve as useful reference for physicians who are concerned about performing computed tomography pulmonary angiography for fear of renal function deterioration.

Conclusion (proposition de traduction) : Les résultats de notre étude pourraient servir de référence utile aux médecins qui souhaitent réaliser un angioscanner pulmonaire par crainte d'une détérioration de la fonction rénale.

Implementing the Lever Sign in the Emergency Department: Does It Assist in Acute Anterior Cruciate Ligament Rupture Diagnosis? A Pilot Study.
McQuivey KS, Christopher ZK, Chung AS, Makovicka J, Guettler J, Levasseur K. | J Emerg Med. 2019 Dec;57(6):805–811
DOI: https://doi.org/10.1016/j.jemermed.2019.09.003
Keywords: ACL; anterior cruciate ligament; lever sign; lever test

Selected Topics: Sports Medicine

Introduction : Within the emergency department (ED) setting, anterior cruciate ligament (ACL) rupture is commonly misdiagnosed, leading to improper treatment and potential meniscal injury and total joint replacement. Utilizing traditional clinical tests to diagnosis ACL rupture leads to the correct diagnosis in about 30% of cases. The lever sign is a new and effective clinical test used to diagnose ACL rupture with 100% sensitivity.
Objective : We aim to study if the lever sign used in the ED setting is more sensitive to diagnose ACL rupture than traditional tests.

Méthode : Patients between 12 and 55 years of age were examined utilizing either traditional methods or the lever sign. Diagnostic findings in the ED were compared with those of a sports medicine specialist using magnetic resonance imaging as the diagnostic standard. A survey was given to ED providers to collect data on diagnosis and physician confidence in diagnosis.

Résultats : The sensitivity of the lever sign was 100% (94.7% accuracy, 93.75% specificity), whereas the sensitivity of the anterior drawer/Lachman test was 40% (87.5% accuracy, 100% specificity). Physician confidence in diagnosis was higher utilizing the lever sign vs. the anterior drawer/Lachman test at 8.45 (±1.82) compared with 7.72 (±1.82) out of 10, respectively. There was no statistically significant association between diagnostic accuracy with either test and level of training of the ED provider.

Conclusion : Implementation of the lever sign in the ED setting resulted in a higher sensitivity, higher physician confidence in screening test diagnosis, and a decrease in the number of undiagnosed ACL ruptures.

Conclusion (proposition de traduction) : La mise en œuvre du signe de levier dans le service des urgences a entraîné une sensibilité plus élevée, une plus grande confiance des médecins dans le diagnostic du test de dépistage et une diminution du nombre de ruptures du ligament croisé antérieur non diagnostiquées.

Commentaire : 
Trouvé sur : Koster CH, Harmsen AM, Lichtenberg MC, Bloemers FW. ACL injury: How do the physical examination tests compare? J Fam Pract. 2018;67(3):130–134  .

Delayed Intracranial Hemorrhage in Anticoagulated Geriatric Patients After Ground Level Falls.
Cocca AT, Privette A, Leon SM, Crookes BA, Hall G, Lena J, Eriksson EA. | J Emerg Med. 2019 Dec;57(6):812-816
DOI: https://doi.org/10.1016/j.jemermed.2019.09.011
Keywords: NOAC; apixaban; dabigatran; geriatric; intracranial hemorrhage; rivaroxaban; traumatic brain injury; warfarin.

Selected Topics: Neurological Emergencies

Introduction : The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined.
Objective : We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs.

Méthode : A retrospective review of our trauma registry was performed on geriatric patients (age older than 64 years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March 2018.

Résultats : Seventy-seven patients met inclusion criteria. The mean age was 80 ± 7.7 years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p = 0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3-15] vs. 5 [1-9]; p = 0.030) and Abbreviated Injury Scale-Head score (median [interquartile range]: 1 [0-3] vs. 1 [0-2]; p = 0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ = -0.064; p = 0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs.

Conclusion : A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted.

Conclusion (proposition de traduction) : Une chute de la position debout, ou de plus bas, chez les patients gériatriques anticoagulés est un mécanisme important de blessure entraînant une hémorragie intracrânienne. L'absence de perte de conscience n'élimine pas la possibilité d'hémorragie intracrânienne. Il existe un risque important d'hémorragie intracrânienne retardée pour les patients sous AOD et des évaluations répétées doivent être effectuées. Une évaluation prospective multicentrique de ce résultat est justifiée.

Commentaire : AOD : Anticoagulants Oraux Directs

Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared With Vitamin K Antagonists.
Turcato G, Zannoni M, Zaboli A, Zorzi E, Ricci G, Pfeifer N, Maccagnani A, Tenci A, Bonora A. | J Emerg Med. 2019 Dec;57(6):817–824
DOI: https://doi.org/10.1016/j.jemermed.2019.09.007
Keywords: anticoagulation; direct oral anticoagulants; intracranial hemorrhage; mild traumatic brain injury; warfarin

Selected Topics: Neurological Emergencies

Introduction : The risk of intracranial hemorrhage (ICH) in patients taking direct oral anticoagulants (DOACs) after mild traumatic brain injury (MTBI) is unclear.
OBJECTIVES : To assess the differences in the risk of developing early, delayed, and comprehensive bleeding after MTBI among patients treated with DOACs as compared with those treated with vitamin K antagonists (VKAs).

Méthode : All MTBI patients taking oral anticoagulants in our emergency department between June 2017 and August 2018 were included. All patients on oral anticoagulants underwent immediate cerebral computed tomography (CT) and a second CT scan after 24 h of clinical observation.

Résultats : There were 451 patients enrolled: 268 were on VKAs and 183 on DOACs. Of the DOAC-treated patients, 7.7% (14/183) presented overall intracranial bleeding, compared with 14.9% (40/268) of VKA-treated patients (p = 0.026). Early bleeding was present in 5.5% (10/183) of DOAC-treated patients and in 11.6% (31/268) of VKA-treated patients (p = 0.030). Multivariable analysis showed that VKA therapy (odds ratio [OR] 2.327), high-energy impact (OR 11.229), amnesia (OR 2.814), loss of consciousness (OR 5.286), Glasgow Coma Scale score < 15 (OR 4.719), and the presence of lesion above the clavicles (OR 2.742) were associated with significantly higher risk of global ICH. A nomogram was constructed to predict ICH using these six variables. Discrimination of the nomogram revealed good predictive abilities (area under the receiver operating characteristic curve: 0.817).

Conclusion : DOAC-treated patients seem to have lower risk of posttraumatic intracranial bleeding compared with VKA-treated patients.

Conclusion (proposition de traduction) : Les patients traités par AOD semblent présenter un risque plus faible de saignement intracrânien post-traumatique par rapport aux patients traités par AVK.

Commentaire : Les résultats montrent que les saignements retardés, bien que non négligeables, ne semblent pas être associés à une intervention neurochirurgicale ou à un décès.

A Low-Fidelity, High-Functionality Ultrasound-Guided Serratus Plane Block Model.
Odom M, Byrnes J, Herrman NWC, Micheller D, Seleno N, Majkrzak A. | J Emerg Med. 2019 Dec;57(6):844-847
DOI: https://doi.org/10.1016/j.jemermed.2019.09.004
Keywords: education; nerve block; regional anesthesia; simulation; ultrasound

Ultrasound in Emergency Medicine

Introduction : Thoracic injuries present many challenges for management in the acute and inpatient settings, including achieving appropriate pain control. Traditional modalities, such as opioids and spinal epidural anesthesia, are associated with multiple complications. Ultrasound-guided regional nerve blocks are becoming more prevalent, and they have been shown to be an effective modality of pain control for other traumatic injuries. Models comprised of animal tissue to simulate human anatomy are widely utilized to facilitate training of needle-guided procedures, but no such model for the serratus anterior plane block has yet been defined in the literature.
Objectives

Discussion : We describe the creation of an inexpensive high-functionality serratus anterior plane block model from common materials, including pork ribs and chicken breasts, to realistically simulate human anatomy, including multiple muscle and fascial planes, as well as to allow hydrodissection.

Conclusion : This model will facilitate training and can improve success when caring for patients with thoracic trauma.

Conclusion (proposition de traduction) : Ce modèle facilitera la formation et peut améliorer la réussite des soins aux patients souffrant de traumatismes thoraciques.

Commentaire : Le « Serratus Plane Block » est une technique de bloc anesthésique de réalisation facile ; son approche échoguidée permet d’injecter un volume d’anesthésique local, de part et d’autre du muscle serratus antérieur, afin d’anesthésier les structures nerveuses participant à l’innervation sensitive du thorax. Ce bloc comportant peu de risque semble être une bonne alternative au bloc paravertébral.
 
Voir le Flash Communication sur Urgences Direct Info (06/06/2019) :
Analgésie du traumatisé thoracique - Réalisation du Serratus plane block par des médecins non spécialisés en anesthésie-réanimation : étude de faisabilité sur cadavre  .

An Alternate In-Plane Technique of Ultrasound-Guided Internal Jugular Vein Cannulation.
Haji Sani HS, Shindhe S, Manap NBA, Vadaje KS, Dato Paduka Buntar WS, Daiwajna RG. | J Emerg Med. 2019 Dec;57(6):852-858
DOI: https://doi.org/10.1016/j.jemermed.2019.08.029
Keywords: APSAX; cannulation; in-plane; internal jugular; ultrasonography

Ultrasound in Emergency Medicine

Introduction : Commonly used ultrasound-guided internal jugular vein (IJV) cannulation techniques, short axis out of plane and long axis in-plane, have significantly reduced complications but failed to eliminate them because of technical difficulties.
Objective : This article describes a new anteroposterior short axis in-plane technique that combines advantage of in-plane technique to track the needle tip and short axis view of visualizing nearby anatomical structures by placing the probe on the side of the neck, oriented anteroposteriorly, perpendicular to the long axis of neck. This view visualizes IJV and its relationship to the carotid artery in short axis. The puncture needle is passed in-plane anteroposteriorly from the anterior aspect of the neck. Visualizing the needle, carotid artery, and IJV in single frame minimizes complications.

Méthode : A prospective evaluative clinical trial was conducted in patients who require IJV cannulation for various reasons by performers experienced in ultrasound-guided IJV cannulations. The efficacy of the technique is indicated by 3 primary outcome measures: access time, number of attempts and success rate, and safety by secondary outcome measure, which is the incidence of mechanical complications.

Résultats : Seventy-five patients were enrolled. The average number of attempts was 1.17 (standard deviation 0.44), the access time was 27.12 s (standard deviation 21.47), and the success rate was 100%. This technique had 12% incidence of posterior venous wall punctures and 2.66% misplacements and no other complications.

Conclusion : Anteroposterior short axis in-plane technique is relatively novel and could be alternatively used safely and effectively in place of existing techniques for IJV cannulation.

Conclusion (proposition de traduction) : La technique de canulation dans le plan antéro-postérieur à axe court est relativement nouvelle et pourrait être utilisée en remplacement des techniques existantes de canulation de la veine jugulaire interne, de manière sûre et efficace.

Commentaire : 
Dans cette incidence, l’aiguille est entièrement visible dans le plan d’exploration de la sonde ce qui facilite sa localisation tridimensionnelle.
On place l’aiguille dans le plan principal de la sonde pour qu’elle soit visible sur toute sa longueur et surtout pour qu’il voie l’écho de la pointe de l’aiguille qui est généralement un peu plus marqué que le reste de l’aiguille en raison des artefacts produits par l’extrémité de l’aiguille et son biseau (tip-écho).
 

Pour mieux distinguer l’aiguille du tissu qui l’environne, on peut réaliser de petits mouvements de va et vient qui sont plus facilement repérés sur l’écran d’échographie.
Il ne faut faire progresser une aiguille qu’à condition d’être certain d’avoir identifié sa position et son extrémité.

Natural History of Subclinical Atrial Fibrillation Detected by Implanted Loop Recorders.
Diederichsen SZ, Haugan KJ, Brandes A, Lanng MB, Graff C, Krieger D, Kronborg C, Holst AG, Køber L, Højberg S, Svendsen JH. | J Emerg Med. 2019 Dec 3;74(22):2771-2781
DOI: https://doi.org/10.1016/j.jemermed.2019.09.007
Keywords: atrial fibrillation burden; atrial fibrillation progression; continuous monitoring; heart rate; symptoms.

ORIGINAL INVESTIGATION

Introduction : As new heart rhythm monitoring technologies emerge, subclinical atrial fibrillation (AF) signifies a future challenge to health care systems. The pathological characteristics of this condition are largely unknown.
Objectives : This study sought to characterize the natural history of subclinical AF in at-risk patients from the general population.

Méthode : The authors studied 590 individuals ≥70 years of age with ≥1 of hypertension, diabetes, previous stroke, or heart failure, without history of AF, undergoing long-term implantable loop recorder monitoring as part of the LOOP (Atrial Fibrillation Detected by Continuous ECG Monitoring Using Implantable Loop Recorder to Prevent Stroke in High-risk Individuals) study. Baseline assessments included N-terminal pro-B-type natriuretic peptide (NT-proBNP). All day-to-day heart rhythm and symptom data were extracted from the device. Endpoints included AF burden, AF progression, symptom reports, and heart rate during AF.

Résultats : A total of 685,445 monitoring days were available for analysis. Adjudicated AF episodes lasting ≥6 min were detected in 205 participants (35%). The AF burden was median 0.13% (interquartile range: 0.03% to 1.05%) of the monitoring time and changed by a factor of 1.31 (95% CI: 1.02 to 1.68) per doubling of NT-proBNP. AF episodes were present 2.7% (interquartile range: 1.0% to 15.7%) of monitoring days after debut. Progression to 24-h episodes was seen in 33 of the AF patients (16%), whereas 46 (22%) had no AF episodes in the last 6 months of monitoring or longer. Symptoms were absent in 185 (90%) at debut, and 178 (87%) never reported AF-related symptoms during follow-up. The averaged heart rate during AF was 96 (interquartile range: 83 to 114) beats/min, 24 (interquartile range: 9 to 41) beats/min faster than daytime sinus rates.

Conclusion : Although previously unknown AF was highly prevalent, the burden was low, and progression was limited. In addition, symptoms were scarce, and the heart rate was only modestly elevated.

Conclusion (proposition de traduction) : Bien que la FA auparavant inconnue était très répandue, le poids imputable était faible et la progression était limitée. De plus, les symptômes étaient rares et la fréquence cardiaque n'était que modérément élevée.

Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction.
Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP, Pinto FJ, Ibrahim R, Gamra H, Kiwan GS, Berry C, López-Sendón J, Ostadal P, Koenig W, Angoulvant D, Grégoire JC, Lavoie MA, Dubé MP, Rhainds D, Provencher M, Blondeau L, Orfanos A, L'Allier PL, Guertin MC, Roubille F. | N Engl J Med. 2019 Dec 26;381(26):2497-2505
DOI: https://doi.org/10.1056/NEJMoa1912388
Keywords: Aucun

Original article

Introduction : Experimental and clinical evidence supports the role of inflammation in atherosclerosis and its complications. Colchicine is an orally administered, potent antiinflammatory medication that is indicated for the treatment of gout and pericarditis.

Méthode : We performed a randomized, double-blind trial involving patients recruited within 30 days after a myocardial infarction. The patients were randomly assigned to receive either low-dose colchicine (0.5 mg once daily) or placebo. The primary efficacy end point was a composite of death from cardiovascular causes, resuscitated cardiac arrest, myocardial infarction, stroke, or urgent hospitalization for angina leading to coronary revascularization. The components of the primary end point and safety were also assessed.

Résultats : A total of 4745 patients were enrolled; 2366 patients were assigned to the colchicine group, and 2379 to the placebo group. Patients were followed for a median of 22.6 months. The primary end point occurred in 5.5% of the patients in the colchicine group, as compared with 7.1% of those in the placebo group (hazard ratio, 0.77; 95% confidence interval [CI], 0.61 to 0.96; P = 0.02). The hazard ratios were 0.84 (95% CI, 0.46 to 1.52) for death from cardiovascular causes, 0.83 (95% CI, 0.25 to 2.73) for resuscitated cardiac arrest, 0.91 (95% CI, 0.68 to 1.21) for myocardial infarction, 0.26 (95% CI, 0.10 to 0.70) for stroke, and 0.50 (95% CI, 0.31 to 0.81) for urgent hospitalization for angina leading to coronary revascularization. Diarrhea was reported in 9.7% of the patients in the colchicine group and in 8.9% of those in the placebo group (P = 0.35). Pneumonia was reported as a serious adverse event in 0.9% of the patients in the colchicine group and in 0.4% of those in the placebo group (P = 0.03).

Conclusion : Among patients with a recent myocardial infarction, colchicine at a dose of 0.5 mg daily led to a significantly lower risk of ischemic cardiovascular events than placebo.

Conclusion (proposition de traduction) : Chez les patients présentant un infarctus du myocarde récent, la colchicine à la dose de 0,5 mg par jour a entraîné un risque significativement plus faible d'événements cardiovasculaires ischémiques que le placebo.

Metoprolol for the Prevention of Acute Exacerbations of COPD.
Dransfield MT, Voelker H, Bhatt SP, Brenner K, Casaburi R, Come CE, Cooper JAD, Criner GJ, Curtis JL, Han MK, Hatipoğlu U, Helgeson ES, Jain VV, Kalhan R, Kaminsky D, Kaner R, Kunisaki KM, Lambert AA, Lammi MR, Lindberg S, Make BJ, Martinez FJ, McEvoy C, Panos RJ, Reed RM, Scanlon PD, Sciurba FC, Smith A, Sriram PS, Stringer WW, Weingarten JA, Wells JM, Westfall E, Lazarus SC, Connett JE; BLOCK COPD Trial Group. | N Engl J Med. 2019 Dec 12;381(24):2304-2314
DOI: https://doi.org/10.1056/nejmoa1908142
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Observational studies suggest that beta-blockers may reduce the risk of exacerbations and death in patients with moderate or severe chronic obstructive pulmonary disease (COPD), but these findings have not been confirmed in randomized trials.

Méthode : In this prospective, randomized trial, we assigned patients between the ages of 40 and 85 years who had COPD to receive either a beta-blocker (extended-release metoprolol) or placebo. All the patients had a clinical history of COPD, along with moderate airflow limitation and an increased risk of exacerbations, as evidenced by a history of exacerbations during the previous year or the prescribed use of supplemental oxygen. We excluded patients who were already taking a beta-blocker or who had an established indication for the use of such drugs. The primary end point was the time until the first exacerbation of COPD during the treatment period, which ranged from 336 to 350 days, depending on the adjusted dose of metoprolol.

Résultats : A total of 532 patients underwent randomization. The mean (±SD) age of the patients was 65.0±7.8 years; the mean forced expiratory volume in 1 second (FEV1) was 41.1±16.3% of the predicted value. The trial was stopped early because of futility with respect to the primary end point and safety concerns. There was no significant between-group difference in the median time until the first exacerbation, which was 202 days in the metoprolol group and 222 days in the placebo group (hazard ratio for metoprolol vs. placebo, 1.05; 95% confidence interval [CI], 0.84 to 1.32; P = 0.66). Metoprolol was associated with a higher risk of exacerbation leading to hospitalization (hazard ratio, 1.91; 95% CI, 1.29 to 2.83). The frequency of side effects that were possibly related to metoprolol was similar in the two groups, as was the overall rate of nonrespiratory serious adverse events. During the treatment period, there were 11 deaths in the metoprolol group and 5 in the placebo group.

Conclusion : Among patients with moderate or severe COPD who did not have an established indication for beta-blocker use, the time until the first COPD exacerbation was similar in the metoprolol group and the placebo group. Hospitalization for exacerbation was more common among the patients treated with metoprolol.

Conclusion (proposition de traduction) : Parmi les patients présentant une BPCO modérée ou grave qui n'avaient pas d'indication établie pour l'utilisation de bêta-bloquants, le temps écoulé avant la première exacerbation de BPCO était similaire dans le groupe métoprolol et le groupe placebo. L'hospitalisation pour exacerbation était plus fréquente chez les patients traités par le métoprolol.

Targeted Temperature Management for Cardiac Arrest With Nonshockable Rhythm.
Lascarrou JB, Merdji H, Le Gouge A, Colin G, Grillet G, Girardie P, Coupez E, Dequin PF, Cariou A, Boulain T, Brule N, Frat JP, Asfar P, Pichon N, Landais M, Plantefeve G, Quenot JP, Chakarian JC, Sirodot M, Legriel S, Letheulle J, Thevenin D, Desachy A, Delahaye A, Botoc V, Vimeux S, Martino F, Giraudeau B, Reignier J; CRICS-TRIGGERSEP Group. | N Engl J Med. 2019 Dec 12;381(24):2327-2337
DOI: https://doi.org/10.1056/nejmoa1906661
Keywords: Aucun

Randomized Controlled Trial

Introduction : Moderate therapeutic hypothermia is currently recommended to improve neurologic outcomes in adults with persistent coma after resuscitated out-of-hospital cardiac arrest. However, the effectiveness of moderate therapeutic hypothermia in patients with nonshockable rhythms (asystole or pulseless electrical activity) is debated.

Méthode : We performed an open-label, randomized, controlled trial comparing moderate therapeutic hypothermia (33°C during the first 24 hours) with targeted normothermia (37°C) in patients with coma who had been admitted to the intensive care unit (ICU) after resuscitation from cardiac arrest with nonshockable rhythm. The primary outcome was survival with a favorable neurologic outcome, assessed on day 90 after randomization with the use of the Cerebral Performance Category (CPC) scale (which ranges from 1 to 5, with higher scores indicating greater disability). We defined a favorable neurologic outcome as a CPC score of 1 or 2. Outcome assessment was blinded. Mortality and safety were also assessed.

Résultats : From January 2014 through January 2018, a total of 584 patients from 25 ICUs underwent randomization, and 581 were included in the analysis (3 patients withdrew consent). On day 90, a total of 29 of 284 patients (10.2%) in the hypothermia group were alive with a CPC score of 1 or 2, as compared with 17 of 297 (5.7%) in the normothermia group (difference, 4.5 percentage points; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). Mortality at 90 days did not differ significantly between the hypothermia group and the normothermia group (81.3% and 83.2%, respectively; difference, -1.9 percentage points; 95% CI, -8.0 to 4.3). The incidence of prespecified adverse events did not differ significantly between groups.

Conclusion : Among patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia.

Conclusion (proposition de traduction) : Parmi les patients dans le coma qui ont été réanimés après un arrêt cardiaque avec un rythme non choquable, une hypothermie thérapeutique modérée à 33° C pendant 24 heures a conduit à un pourcentage plus élevé de patients qui ont survécu avec une issue neurologique favorable au 90° jour que ce qui a été observé avec une normothermie ciblée.

Lay Responder Care for an Adult With Out-of-Hospital Cardiac Arrest.
Brady WJ, Mattu A, Slovis CM. | N Engl J Med. 2019 Dec 5;381(23):2242-2251
DOI: https://doi.org/10.1056/nejmra1802529
Keywords: Aucun

Review

Editorial : Out-of-hospital cardiac arrest is a major public health issue. In the United States, an estimated 155,000 persons per year are treated by emergency medical services (EMS) for out-of-hospital cardiac arrest, and approximately 8% survive. In Europe, annual occurrence is estimated to be 128,000 to 275,000 persons, and approximately 10% survive. Substantial variations exist, both within countries and across the globe, with respect to data collection and reporting methods and with respect to survival and neurologic outcome.

Conclusion : The report “Strategies to Improve Cardiac Arrest Survival: A Time to Act” of the Institute of Medicine (IOM, now the National Academy of Medicine) recommends that physicians “. . . foster a culture of action through public awareness and training” in cardiac arrest management. Physicians should support this approach by encouraging the public to participate in prearrival care, endorsing appropriate lay provider education, and advocating for placement of public-access AEDs. Physicians should also make the public aware of the substantial effect bystander care has on survival. The IOM report also refers to “The Power of Multiple Initiatives” — the benefit of approaching this major public health issue from multiple strategic directions simultaneously with education, training, and resource implementation.51 The multiple-initiatives approach emphasizes cardiac arrest recognition, call for assistance, CPR performance, and AED application. If these prearrival measures are initiated early in out-of-hospital cardiac arrest, they have the potential to significantly increase the likelihood of meaningful survival.

Conclusion (proposition de traduction) : Le rapport "Strategies to Improve Cardiac Arrest Survival : A Time to Act"; de l'Institut de médecine (IOM, aujourd'hui l'Académie nationale de médecine) recommande aux médecins "(...) de favoriser une culture de l'action par la sensibilisation et la formation du public"; à la gestion des arrêts cardiaques. Les médecins doivent soutenir cette approche en encourageant le public à participer aux soins avant l'arrivée, en soutenant la formation appropriée des prestataires non professionnels et en préconisant le placement de DEA d'accès public. Les médecins doivent également sensibiliser le public à l'effet considérable que les soins prodigués par les témoins ont sur la survie. Le rapport de l'IOM fait également référence au "Pouvoir des initiatives multiples"; - l'avantage d'aborder ce problème majeur de santé publique à partir de multiples directions stratégiques simultanément avec l'éducation, la formation et la mise en œuvre des ressources. L'approche des initiatives multiples met l'accent sur la reconnaissance des arrêts cardiaques, l'appel à l'aide, la performance de la RCP et l'utilisation d'un DEA. Si ces mesures préalables à l'arrivée sont mises en place dès le début de l'arrêt cardiaque survenu extra-hospitalier, elles peuvent augmenter considérablement la probabilité d'une survie significative.

Bedside ultrasound in cardiac standstill: a clinical review.
Hussein L, Rehman MA, Sajid R, Annajjar F, Al-Janabi T. | Ultrasound J. 2019 Dec 30;11(1):35
DOI: https://doi.org/10.1186/s13089-019-0150-7  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiac standstill; Echocardiography; Point-of-care ultrasound; Predictors of survival in cardiac arrest; Resuscitation; Transesophageal echocardiography; Ultrasound

REVIEW

Editorial : Patients with cardiac arrest present as a relatively frequent occurrence in the Emergency Department. Despite the advances in our understanding of the pathophysiology of cardiac arrest, managing the condition remains a stressful endeavor and currently implemented interventions, while beneficial, are still associated with a disappointingly low survivability. The majority of modern Advanced Life Support algorithms employ a standardized approach to best resuscitate the 'crashed' patient. However, management during resuscitation often encourages a 'one-size-fits-all' policy for most patients, with lesser attention drawn towards causality of the disease and factors that could alter resuscitative care. Life support providers are also often challenged by the limited bedside predictors of survival to guide the course and duration of resuscitation. Over the recent decades, point-of-care ultrasonography (PoCUS) has been gradually proving itself as a useful adjunct that could potentially bridge the gap in the recognition and evaluation of precipitants and end-points in resuscitation, thereby facilitating an improved approach to resuscitation of the arrested patient. Point-of-care ultrasound applications in the critical care field have tremendously evolved over the past four decades. Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process. This article reviews the current literature on cardiac standstill and the application of bedside ultrasound in cardiac arrests.

Conclusion : Cardiopulmonary resuscitation has had a humble evolution over the last decade, but remains to have rather unfruitful results. For the most part, the physician involved has little information about the reason of arrest and likelihood of survival. This is where bedside ultrasound shows promise as a fundamental tool that can provide the physician with valuable information mandating change in management. Ultrasound can guide the resuscitative process under direct vision rather than by blind adherence to resuscitation protocols. An important point evidenced by most of the studies referenced above is the fact that cardiac motion visualized on ultrasonography is the best predictor of survival, and its use can provide much needed prognostic information that aids resuscitation. On the other hand, patients shown to have cardiac standstill on ultrasound have been shown to have very low chances of survival. Still, it is important to remember that the decision to terminate resuscitation should never be taken based on ultrasound findings alone. In summary, current CPR guidelines should not involve a ‘one-size-fits-all’ strategy for arrest patients. The decision to terminate needs to be tailored on a case-by-case basis. Point-of-care ultrasound can support this decision and needs to be adopted as part of the standard of care.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire a connu une évolution modeste au cours de la dernière décennie, mais elle donne des résultats plutôt insuffisants. Dans la plupart des cas, le médecin concerné a peu d'information sur l’étiologie de l'arrêt et les chances de survie. C'est là que l'échographie au point d'intervention s'avère prometteuse en tant qu'outil fondamental pouvant fournir au médecin des informations précieux qui l'obligeront à modifier sa prise en charge. L'échographie peut guider le processus de réanimation en vision directe plutôt que par l'adhésion aveugle aux protocoles de réanimation. Un point important mis en évidence par la plupart des études est le fait que la visualisation de l’activité cardiaque à l'échographie est le meilleur prédicteur de survie, et son utilisation peut fournir des informations pronostiques indispensables pour faciliter la réanimation. D'autre part, il a été démontré que les patients dont le cœur est en arrêt à l'échographie ont de très faibles chances de survie. Néanmoins, il est important de se rappeler que la décision de mettre fin à la réanimation ne doit jamais être prise sur la seule base des résultats de l'échographie. En résumé, les lignes directrices actuelles sur la RCP ne devraient pas impliquer une stratégie « universelle » pour les patients en arrêt. La décision de mettre fin aux manœuvres de réanimation doit être adaptée au cas par cas. L'échographie au point d'intervention peut étayer cette prise de décision et doit être adoptée dans le cadre de la norme de soins.