Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting?.
Wang AZ, Schaffer JT, Holt DB, Morgan KL, Hunter BR. | Acad Emerg Med. 2020 Jan;27(1):6-14
Introduction : Elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs) often undergo troponin testing to assess for atypical acute coronary syndrome (ACS). However, the rate of ACS and utility of troponin testing in this population is unknown. We sought to determine the rate of ACS and diagnostic yield of troponin testing in elderly patients with NSCs.
Méthode : We retrospectively identified all patients aged ≥ 65 years triaged in the ED with NSCs from January 1, 2017, to June 30, 2017. NSCs were defined a priori and included complaints such as weakness, dizziness, or fatigue. NSCs were verified in ED provider notes by trained abstractors blind to testing results. Exclusions were focal chief complaint in provider notes, fever, and no troponin ordered. ACS was strictly defined and independently adjudicated by two trained physician researchers blind to the study hypothesis. We calculated the proportion of patients with ACS within 30 days and the test characteristics of troponin to diagnose ACS.
Résultats : Screening identified 1,146 encounters, and 552 were excluded for fever or focal chief complaints in the provider notes. Of the remaining 594 patients, troponin was ordered in 412 (69%), comprising the study cohort. The mean (±SD) age was 78.7 (±8.3) years, with 58% female and 75% admitted. Troponin elevation occurred in 81 patients (20%). ACS occurred in 5 of 412 (1.2%). Troponin was 100% sensitive (95% confidence interval [CI] = 48% to 100%) and 81% specific (95% CI = 77% to 85%) for ACS. Of patients with elevated troponin, 93.8% were false positives (no ACS). All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy.
Conclusion : While consideration for ACS is prudent in selected elderly patients with NSCs, ACS was rare and no patients received reperfusion therapy. Given the false-positive rate in our study, our results may not support routine troponin testing for ACS in this population.
Conclusion (proposition de traduction) : Bien qu'il soit prudent d'envisager un syndrome coronarien aigu chez certains patients âgés présentant des troubles non spécifiques, le syndrome coronarien aigu était rare et aucun patient n'a reçu de traitement de reperfusion. Étant donné le taux de faux positifs dans notre étude, nos résultats pourraient ne pas être favorables à un test de troponine de routine pour le syndrome coronarien aigu dans cette population.
Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study.
Solbiati M, Dipaola F, Villa P, Seghezzi S, Casagranda I, Rabajoli F, Fiorini E, Porta L, Casazza G, Voza A, Barbic F, Montano N, Furlan R, Costantino G. | Acad Emerg Med. 2020 Jan;27(1):15-23
Introduction : Arrhythmia is one of the most worrisome causes of syncope. Electrocardiographic (ECG) monitoring is crucial for the management of non-low-risk patients in the emergency department (ED). However, its diagnostic accuracy and optimal duration are unknown. We aimed to assess the diagnostic accuracy of ECG monitoring in non-low-risk patients with syncope in the ED.
Méthode : This prospective multicenter observational study included adult patients presenting to the ED after syncope. Patients without an obvious etiology after ED evaluation who were classified by ED physicians as being at non-low risk of adverse events underwent ECG monitoring. We assessed sensitivity, specificity, and diagnostic yield (defined as the proportion of patients with true-positive ECG monitoring findings) of ECG monitoring in the identification of 7- and 30-day adverse and arrhythmic events according to monitoring duration.
Résultats : Of 242 patients included in the study, 29 patients had 7-day serious outcomes. Ten additional patients had serious outcomes at 30 days. The overall sensitivity, specificity, and diagnostic yield of ECG monitoring in the identification of 7-day adverse events were 0.55 (95% confidence interval [CI] = 0.36 to 0.74], 0.93 (95% CI = 0.89 to 0.96), and 0.07 (95% CI = 0.04 to 0.10), respectively. The sensitivity, specificity, and diagnostic yield of >12-hour ECG monitoring in the identification of 7-day adverse events were 0.89 (95% CI = 0.65 to 0.99), 0.78 (95% CI = 0.67 to 0.87), and 0.18 (95% CI = 0.12 to 0.28), respectively. Similar results were observed for 30-day adverse events. The median (interquartile range) ECG monitoring time was 6.5 (6 to 15) hours. ECG monitoring findings were positive in 31 patients.
Conclusion : Although the overall diagnostic accuracy of ECG monitoring is fair, its sensitivity at >12 hours' duration is substantially higher. These results suggest that prolonged (>12 hours) monitoring is a safe alternative to hospital admission in the management of non-low-risk patients with syncope in the ED.
Conclusion (proposition de traduction) : Bien que la précision diagnostique globale de la surveillance par ECG soit assez bonne, sa sensibilité à une durée supérieure à 12 heures est nettement plus élevée. Ces résultats suggèrent qu'une surveillance prolongée (> 12 heures) est une alternative sûre à l'hospitalisation dans la prise en charge des patients à risque non faible souffrant de syncope aux urgences.
Can Emergency Physician Gestalt "Rule In" or "Rule Out" Acute Coronary Syndrome: Validation in a Multicenter Prospective Diagnostic Cohort Study.
Oliver G, Reynard C, Morris N, Body R. | Acad Emerg Med. 2020 Jan;27(1):24-30
Introduction : Chest pain is a common problem presenting to the emergency department (ED). Many decision aids and accelerated diagnostic protocols have been developed to help clinicians differentiate those needing admission from those who can be safely discharged. Some early evidence has suggested that clinician judgment or gestalt alone could be sufficient.
Objectives : Our aim was to externally validate whether emergency physician's gestalt could "rule in" or "rule out" acute coronary syndromes (ACS).
Méthode : We performed a multicenter prospective diagnostic accuracy study including consenting patients presenting to the ED in whom the physician suspected ACS. At the time of arrival, clinicians recorded their perceived probability of ACS using a 5-point Likert scale. The primary outcome was a diagnosis of ACS, defined as acute myocardial infarction or major adverse cardiac events within 30 days.
Résultats : A total of 1,391 patients were included; 240 (17.3%) had ACS. Overall, gestalt had fair diagnostic accuracy with a C-statistic of 0.75 (95% confidence interval = 0.72 to 0.79). If ACS was "ruled out" in the 60 (4.3%) patients where clinicians perceived that the diagnosis was "definitely not" ACS, a sensitivity of 98.0% and negative predictive value of 95.0% could have been achieved. If ACS was only ruled out in patients who also had no electrocardiographic (ECG) ischemia and a normal initial cardiac troponin (cTn) concentration, 100.0% sensitivity and NPV could be achieved. However, this strategy only applied to 4.1% of patients. If patients with "probably not" ACS who had normal ECG and cTn were also ruled out (n = 418, 30.8%), sensitivity fell to 86.2% with 99.2% NPV. Using gestalt "definitely" ACS to rule in ACS gave a specificity of 98.5% and positive predictive value of 71.2%.
Conclusion : Clinician gestalt is not sufficiently accurate or safe to either rule in or rule out ACS as a decision-making strategy. This study will enable emergency physicians to understand the limitations of our clinical judgment.
Conclusion (proposition de traduction) : L'expérience des cliniciens n'est pas suffisamment précise ou sûre pour permettre d'exclure ou de confirmer un syndrome coronarien aigs comme stratégie de prise de décision. Cette étude permettra aux médecins urgentistes de comprendre les limites de notre jugement clinique.
The Equivalence of Video Self-review Versus Debriefing After Simulation: Can Faculty Resources Be Reallocated?.
Tudor GJ, Podolej GS, Willemsen-Dunlap A, Lau V, Svendsen JD, McGarvey J, Vozenilek JA, Barker LT. | AEM Educ Train. 2020 January;4(1):36–42
DOI: https://doi.org/10.1002/aet2.10372 | Télécharger l'article au format
Introduction : Traditional simulation debriefing is both time- and resource-intensive. Shifting the degree of primary learning responsibility from the faculty to the learner through self-guided learning has received greater attention as a means of reducing this resource intensity. The aim of the study was to determine if video-assisted self-debriefing, as a form of self-guided learning, would have equivalent learning outcomes compared to standard debriefing.
Méthode : This randomized cohort study consisting of 49 PGY-1 to -3 emergency medicine residents compared performance after video self-assessment utilizing an observer checklist versus standard debriefing for simulated emergency department procedural sedation (EDPS). The primary outcome measure was performance on the second EDPS scenario.
Résultats : Independent-samples t-test found that both control (standard debrief) and intervention (video self-assessment) groups demonstrated significantly increased scores on Scenario 2 (standard-t(40) = 2.20, p < 0.05; video-t(45) = 3.88, p < 0.05). There was a large and significant positive correlation between faculty and resident self-evaluation (r = 0.70, p < 0.05). There was no significant difference between faculty and residents self-assessment mean scores (t(24) = 1.90, p = 0.07).
Conclusion : Residents receiving feedback on their performance via video-assisted self-debriefing improved their performance in simulated EDPS to the same degree as with standard faculty debriefing. Video-assisted self-debriefing is a promising avenue for leveraging the benefits of simulation-based training with reduced resource requirements.
Conclusion (proposition de traduction) : Les résidents recevant un retour d'information sur leur performance par le biais d'un autodébriefing assisté par vidéo ont amélioré leur performance dans la simulation de sédation procédurale au service des urgences identique qu'avec le débriefing standard des professeurs. L'auto-débriefing assisté par vidéo est une voie prometteuse pour tirer parti des avantages de la formation par simulation avec des ressources réduites.
Defining “Swarming” as a New Model to Optimize Efficiency and Education in an Academic Emergency Department.
Perniciaro JL, Schmidt AR, Pham PK, Liu DR. | AEM Educ Train. 2020 January;4(1):43–53
DOI: https://doi.org/10.1002/aet2.10388 | Télécharger l'article au format
Introduction : Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model.
Objectives: To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model.
Méthode : This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori.
Résultats : From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5).
Conclusion : Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.
Conclusion (proposition de traduction) : L'essaimage est actuellement mis en œuvre avec une grande variabilité, mais il se traduit par une grande satisfaction des prestataires et des familles. Les médecins s'accordent également à dire que l'essaimage améliore la formation des stagiaires dans le cadre des urgences. Les avantages et les obstacles à l'essaimage sont soulignés par la nature imprévisible du service d'urgence et la variabilité observée dans la mise en œuvre. Nos conclusions constituent une base essentielle pour nos efforts visant à affiner, normaliser et évaluer notre modèle d'essaimage.
Commentaire : L'« intelligence en essaim », trouve des applications dans le domaine de la simulation : un collectif d’humains qui doit résoudre un problème peut devenir une sources d’inspiration pour concevoir un système dont l’« intelligence » provient d’un ensemble d’entités – des « agents » – en interaction.
Contenti J, Occelli C, Lemoel F, Levraut J. | Ann Fr Med Urgence. 2020 Janvier;10(1):3-8
Keywords: Lactate; Agreement; Sepsis
Introduction : La mesure du lactate est une étape cruciale dans l’évaluation des patients septiques aux urgences. Bien que la référence soit le prélèvement artériel, celui-ci est inadapté à la médecine d’urgence, et le prélèvement veineux semble être une alternative potentielle. Ce travail s’est intéressé à décrire la concordance entre Lact-A et Lact-V, et à comparer l’apport pronostique du Lact-A comparativement au Lact-V chez les patients infectés aux urgences.
Méthode : Étude de cohorte prospective observationnelle menée au centre hospitalier universitaire de Nice entre 2015 et 2017. Ont été inclus les patients présentant une suspicion d’infection avec au moins deux critères cliniques de SIRS. Le lactate a été mesuré de manière concomitante par prélèvement veineux et artériel.
Résultats : Au total, 354 couples Lact-A/Lact-V ont été analysés. Le biais moyen entre les valeurs artérielles et veineuses était de 0,65 ± 0,89 mmol/l, avec des limites d’agrément à 95 % de –2,4 + 1,1 mmol/l. Un Lact-V supérieur à 2,3 mmol/l permettait de confirmer un Lact-A supérieur à 2 mmol/l avec une sensibilité de 94,1 % (IC 95 % : [87,8– 97,3]) et une spécificité de 91,7 % (IC 95 % : [87,6–94,5]). De plus, un Lact-V inférieur à 2 mmol/l permettait de confirmer un Lact-A inférieur à 2 mmol/l avec une VPP de 99 %. L’apport pronostique du Lact-V était globalement similaire au Lact-A mais restait relativement faible.
Conclusion (proposition de traduction) : La lactatémie veineuse apporte des arguments équivalents pour l’évaluation pronostique des patients infectés aux urgences. Par ailleurs, un Lact-V inférieur à 2 mmol/l permet d’affirmer un Lact-A normal permettant de surseoir au prélèvement artériel.
Bobbia X, Claret PG, Perrin-Bayard R, de La Coussaye JE. | Ann Fr Med Urgence. 2020 Janvier;10(1);31-37
Keywords: Point-of-care; Ultrasound; Emergency medicine
Mise au point / Update
Editorial : L’échographie clinique en médecine d’urgence (ECMU) devient une pratique intégrée à l’exercice de la spécialité. Quatre étapes semblent nécessaires au déploiement de cet outil : l’existence de preuves scientifiques sur sa pertinence clinique, l’implantation d’échographes dans les structures d’urgences (SU), la formation des médecins et l’objectivation d’un impact secondaire à son utilisation. Les preuves sur la pertinence diagnostique des techniques utilisées datent des années 1990 pour la majorité des applications utilisées aujourd’hui. La disponibilité d’un échographe adapté est également nécessaire. Si la majorité des SU disposent aujourd’hui d’un échographe, selon les recommandations françaises, toutes le devraient. Des échographes de mieux en mieux adaptés à la pratique de l’ECMU arrivent sur le marché. L’objectif doit être de permettre des examens rapides et fiables. Pour cela, une ergonomie épurée et l’implication de techniques d’intelligence artificielle semblent être l’avenir. Les médecins doivent également être formés. En France, l’utilisation de l’ECMU va se généraliser grâce à la formation de tous les nouveaux internes de médecine d’urgence. Cependant, beaucoup d’urgentistes exerçant actuellement doivent encore être formés. Pour répondre à cette demande, de nombreuses formations sont aujourd’hui accessibles. Enfin, peu de données sur l’impact clinique secondaire à l’utilisation de cet outil dans les SU sont disponibles. Après avoir défini l’ECMU, l’objectif de ce texte est d’expliquer la place de l’échographie clinique dans la spécialité de médecine d’urgence. Des perspectives d’évolution de l’ECMU sont également proposées.
Conclusion (proposition de traduction) : L’échographie clinique en médecine d’urgence (ECMU) est un outil permettant d’améliorer la pertinence diagnostique du médecin urgentiste et de sécuriser ses procédures. Les preuves sur sa pertinence ne sont pas récentes. Des recherches doivent être menées sur des techniques spécifiques à la médecine d’urgence. La progression de l’équi- pement en échographes des SU en France est significative, bien que ne respectant pas encore les recommandations, en particulier en préhospitalier. Des échographes conçus pour répondre aux Sp de l’ECMU apparaissent. Des formations courtes, longues, initiales ou continues existent, mais tous les médecins titulaires du DES de médecine d’urgence auront reçu une formation. Cependant, il n’existe actuellement pas de preuves permettant d’affirmer que la pratique de l’ECMU améliore le devenir des patients.
Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest After Traffic Accidents and Termination of Resuscitation.
Shibahashi K, Sugiyama K, Hamabe Y. | Ann Emerg Med. 2020 Jan;75(1):57-65
Introduction : We describe the characteristics and outcomes of pediatric traumatic out-of-hospital cardiac arrest after traffic accidents and validate the termination of resuscitation clinical criteria for adult traumatic out-of-hospital cardiac arrest in pediatrics.
Méthode : We analyzed the records of pediatric (≤18 years) traumatic out-of-hospital cardiac arrest cases after traffic accidents in a prospectively collected nationwide database (2012 to 2016). Endpoints were 1-month favorable neurologic outcomes and 1-month survival. Validation of termination of resuscitation criteria, cardiac arrest at the scene, and unsuccessful resuscitation after cardiopulmonary resuscitation (CPR) greater than 15 minutes was performed based on specificity and positive predictive value.
Résultats : Of the 582 patients who were eligible for analyses, 8 (1.4%) and 20 (3.4%) had 1-month favorable neurologic outcome and survival, respectively. All patients with favorable neurologic outcomes had out-of-hospital return of spontaneous circulation, and the duration of CPR was significantly shorter than for those with unfavorable neurologic outcomes (4 versus 23 minutes; absolute difference -21.9 minutes; 95% confidence interval -36.3 to -7.4 minutes). The duration of out-of-hospital CPR beyond which the possibility of favorable neurologic outcomes and survival diminished to less than 1% was 15 minutes. For predicting unfavorable neurologic outcomes, the termination of resuscitation criteria provided a specificity of 1.00 (95% confidence interval 0.52 to 1.00) and a positive predictive value of 1.00 (95% confidence interval 0.99 to 1.00).
Conclusion : The outcomes of pediatric patients with traumatic out-of-hospital cardiac arrest after traffic accidents were as poor as those of adults in previous studies. Out-of-hospital return of spontaneous circulation was a significant indicator of favorable outcomes, and the duration of out-of-hospital CPR beyond which the possibility of favorable neurologic outcomes and survival diminished to less than 1% was 15 minutes. Termination of resuscitation criteria provided an excellent positive predictive value for 1-month unfavorable neurologic outcomes after out-of-hospital cardiac arrest.
Conclusion (proposition de traduction) : Les résultats des patients pédiatriques ayant subi un arrêt cardiaque traumatique extra-hospitalier après un accident de la route étaient aussi mauvais que ceux des adultes dans les études précédentes. Le retour de la circulation spontanée (RACS) en extra-hospitalier était un indicateur significatif de résultats favorables, et la durée de la RCP en dehors de l'hôpital au-delà de laquelle la possibilité de résultats neurologiques favorables et de survie diminuait à moins de 1 % était de 15nbsp;minutes. Les critères de fin de réanimation ont fourni une excellente valeur prédictive positive pour les résultats neurologiques défavorables à un mois après un arrêt cardiaque hors hôpital.
Which Ultrasonographic Characteristics Predict Miscarriage Risk?.
Mishoe JM, Shah KH. | Ann Emerg Med. 2020 Jan;75(1):111-112
Introduction : The authors searched MEDLINE (1946 to June 2017), EMBASE (1980 to June 2017), the Cumulative Index of Nursing and Allied Health (1981 to June 2017), and the Cochrane Library. The reference lists of all recent reviews and primary articles were also examined for articles not captured by the initial search.
Méthode : Prospective cohort studies using combination or individual ultrasonographic markers to predict miscarriage in women with a viable intrauterine pregnancy with gestational age between 6 weeks and 15 weeks and 6 days, with or without vaginal bleeding, were included. Studies with Doppler ultrasonographic criteria were excluded. Two authors performed independent literature searches to identify relevant articles, and disagreements were resolved by consensus.
Résultats : Predetermined forms were used during data extraction and quality assessment was performed with the Quality Assessment of Diagnostic Accuracy Studies–2. Statistical analysis of ultrasonographic markers was performed by plotting hierarchic receiver operating characteristic model graphs.
Conclusion : In pregnant patients with gestational age between 6 weeks and 15 weeks and 6 days with threatened abortion, a fetal pulse rate of less than or equal to 110 beats/min indicates a high likelihood of progressing to miscarriage.
Conclusion (proposition de traduction) : Chez les patientes enceintes dont l'âge gestationnel se situe entre 6 et 15 semaines et 6 jours avec menace d'avortement, un pouls fœtal inférieur ou égal à 110 battements/min indique une forte probabilité de progression vers une fausse couche.
Prevalence of Intracranial Injury in Adult Patients With Blunt Head Trauma With and Without Anticoagulant or Antiplatelet Use.
Probst MA, Gupta M, Hendey GW, Rodriguez RM, Winkel G, Loo GT, Mower WR. | Ann Emerg Med. 2020 Jan 17:S0196-0644(19)31284-3
Article in press
Introduction : We determine the prevalence of significant intracranial injury among adults with blunt head trauma who are receiving preinjury anticoagulant or antiplatelet medications.
Méthode : This was a multicenter, prospective, observational study conducted from December 2007 to December 2015. Patients were enrolled in 3 emergency departments (EDs) in the United States. Adults with blunt head trauma who underwent neuroimaging in the ED were included. Use of preinjury aspirin, clopidogrel, and warfarin was recorded. Data on direct oral anticoagulants were not specifically recorded. The primary outcome was prevalence of significant intracranial injury on neuroimaging. The secondary outcome was receipt of neurosurgical intervention.
Résultats : Among 9,070 patients enrolled in this study, the median age was 53.8 years (interquartile range 34.7 to 74.3 years) and 60.7% were men. A total of 1,323 patients (14.6%) were receiving antiplatelet medications or warfarin, including 635 receiving aspirin alone, 109 clopidogrel alone, and 406 warfarin alone. Compared with that of patients without any coagulopathy, the relative risk of significant intracranial injury was 1.29 (95% confidence interval [CI] 0.88 to 1.87) for patients receiving aspirin alone, 0.75 (95% CI 0.24 to 2.30) for those receiving clopidogrel alone, and 1.88 (95% CI 1.28 to 2.75) for those receiving warfarin alone. The relative risk of significant intracranial injury was 2.88 (95% CI 1.53 to 5.42) for patients receiving aspirin and clopidogrel in combination.
Conclusion : Patients receiving preinjury warfarin or a combination of aspirin and clopidogrel were at increased risk for significant intracranial injury, but not those receiving aspirin alone. Clinicians should have a low threshold for neuroimaging when evaluating patients receiving warfarin or a combination of aspirin and clopidogrel.
Conclusion (proposition de traduction) : Les patients traités par warfarine ou une combinaison d'aspirine et de clopidogrel, avant le traumatisme crânien, présentaient un risque accru de lésion intracrânienne grave, mais pas ceux recevant de l'aspirine seule.
Les cliniciens devraient avoir un seuil bas pour la demande de neuroimagerie lorsqu'ils évaluent des patients traités par warfarine ou une combinaison d'aspirine et de clopidogrel.
NAXOS: Healthcare resource use among patients with non-valvular atrial fibrillation newly treated with apixaban in France, and comparison with other oral anticoagulants.
Hanon O, Mahé I, Danchin N, Steg PG, Falissard B, Belhassen M, Jacoud F, Nolin M, Ginoux M, Dalon F, Lefevre C, Gollety S, F.Cotte FE, Van Ganse E.. | Arch Cardiol Diseases Suppl. 2020 January;2(1):104
Introduction : Describe and compare healthcare resource utilization (HCRU) among non-valvular atrial fibrillation (NVAF) patients newly treated with apixaban vs. VKA (vitamin K antagonist), rivaroxaban or dabigatran.
Méthode : All adult patients with NVAF newly initiating apixaban, VKA, rivaroxaban or dabigatran between January 2014 and December 2016 (absence of OAC use in the previous 24 months) were identified using the SNIIRAM database. Different types of HCRU were described: medical visits, nurse visits, concomitant drugs, biology dosings, medical procedures and hospital stays. HCRU were compared between groups with generalized linear model adjusted on propensity score, taking account of the follow-up time of patients as offset.
Résultats : Final cohorts included 87,565 apixaban, 112,628 VKA, 100,063 rivaroxaban, and 21,245 dabigatran patients. Over the follow-up period, apixaban patients had an average of 1.8 medical visits per month (SD: 1.9), mostly with general practitioners (89.9%) and cardiologists (52.2%). Mean number of nurse visits was 4.5 per month (SD: 8.5) for 66.3% of patients treated with apixaban. Mean number of concomitant drugs packages was 13.4 per month (SD: 18.0), and most frequent drug classes were antiarrhythmics, beta-blocking agents, analgesics in 68.2%, 64.1%, 60.5% respectively. Half of patients treated with apixaban had monthly dosing of creatinine, glucose and transaminases (56.5%, 55.5%, and 53.1%). Most frequent medical procedures were Doppler, thorax radiography and electrocardiography, 48.5%, 27.6%, and 26.8% and 47.7% of patients had at least one hospitalization. For all HCRU types, apixaban patients had significantly fewer HCRU than VKA patients. For drug claims, biology, and medical procedures, apixaban patients had significantly fewer HCRU than rivaroxaban and dabigatran patients.
Conclusion : This large real-world study found lower adjusted HCRU for apixaban compared to VKA and, to a lesser extent, compared to rivaroxaban and dabigatran.
Conclusion (proposition de traduction) : Cette grande étude dans la vrai vie a révélé une utilisation ajustée des ressources de soins de santé inférieure pour l'apixaban par rapport aux AVK et, dans une moindre mesure, par rapport au rivaroxaban et au dabigatran.
Commentaire : Abstract présenté au cours d’une session des Journées Européennes de la Société Française de Cardiologie (JESFC2020).
Voir l'analyse de l'article sur le site Medscape : Prise en charge de la FA : l’essentiel de 2019 . Rédigé par le Dr Vincent Richeux le 21 janvier 2020.
Patient Characteristics, Triage Utilisation, Level of Care, and Outcomes in an Unselected Adult Patient Population Seen by the Emergency Medical Services: A Prospective Observational Study.
Magnusson C, Herlitz J, Axelsson C. | BMC Emerg Med. 2020 Jan 30;20(1):7
DOI: https://doi.org/10.1186/s12873-020-0302-x | Télécharger l'article au format
Introduction : Crowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions.
Méthode : A prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher's exact test, and Spearman's rank correlation were used for statistical analysis.
Résultats : The median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an 'unspecific condition' more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274).
Conclusion : Age, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.
Conclusion (proposition de traduction) : L'âge, le sexe, les antécédents médicaux et le motif d'admission semblent tous influencer l'évaluation initiale. Un certain nombre de patients transportés aux urgences pourraient être pris en charge à un niveau de soins inférieur. Une petite partie des patients non transportés ont été diagnostiqués plus tard comme souffrant d'une maladie à délai de guérison critique, ce qui a justifié l'amélioration des outils d'évaluation sur place et la formation du personnel en se concentrant sur la population âgée. Ces résultats peuvent être utiles pour résoudre les problèmes d'affectation des ressources visant à accroître la sécurité des patients.
To Strengthen Self-Confidence as a Step in Improving Prehospital Youth Laymen Basic Life Support.
Abelsson A, Odestrand P, Nygårdh A. | BMC Emerg Med. 2020 Jan 30;20(1):8
DOI: https://doi.org/10.1186/s12873-020-0304-8 | Télécharger l'article au format
Keywords: Adult basic life support; Cardio pulmonary resuscitation CPR; First aid; Intervention; Layman; Self-confidence; Simulation.
Introduction : A rapid emergency care intervention can prevent the cardiac arrest from resulting in death. In order for Cardio Pulmonary Resuscitation (CPR) to have any real significance for the survival of the patient, it requires an educational effort educating the large masses of people of whom the youth is an important part. The aim of this study was to investigate the effect of a two-hour education intervention for youth regarding their self-confidence in performing Adult Basic Life Support (BLS).
Méthode : A quantitative approach where data consist of a pre- and post-rating of seven statements by 50 participants during an intervention by means of BLS theoretical and practical education.
Résultats : The two-hour training resulted in a significant improvement in the participants' self-confidence in identifying a cardiac arrest (pre 51, post 90), to perform compressions (pre 65, post 91) and ventilations (pre 64, post 86) and use a defibrillator (pre 61, post 81). In addition, to have the self-confidence to be able to perform, and to actually perform, first aid to a person suffering from a traumatic event was significantly improved (pre 54, post 89).
Conclusion : By providing youth with short education sessions in CPR, their self-confidence can be improved. This can lead to an increased will and ability to identify a cardiac arrest and to begin compressions and ventilations. This also includes having the confidence using a defibrillator. Short education sessions in first aid can also lead to increased self-confidence, resulting in young people considering themselves able to perform first aid to a person suffering from a traumatic event. This, in turn, results in young people perceiveing themselves as willing to commence an intervention during a traumatic event. In summary, when the youth believe in their own knowledge, they will dare to intervene.
Conclusion (proposition de traduction) : En proposant aux jeunes de courtes séances de formation à la RCP, on peut améliorer leur confiance en soi. Cela peut conduire à une volonté et une capacité accrues d'identifier un arrêt cardiaque et de commencer les compressions thoraciques et les ventilations. Cela implique également d'avoir la confiance nécessaire pour utiliser un défibrillateur. De courtes séances de formation aux premiers secours peuvent également renforcer la confiance en soi, les jeunes se considérant alors capables de prodiguer les premiers secours à une personne souffrant d'un événement traumatisant. Cela a pour conséquence que les jeunes se perçoivent comme prêts à commencer une intervention lors d'un événement traumatisant. En résumé, lorsque les jeunes croient en leurs propres connaissances, ils osent intervenir.
The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis.
Champagne N, Eadie L, Regan L, Wilson P. | BMC Emerg Med. 2019 Jan 28;19(1):17
DOI: https://doi.org/10.1186/s12873-019-0226-5 | Télécharger l'article au format
Keywords: Adults; Bone; Diagnostic imaging; Fracture; Radiology; Sonography; Trauma; Ultrasonography; Ultrasound.
Introduction : The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI).
Méthode : The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups.
Résultats : Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 - 100% and 65.0 - 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I2 = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I2 = 90.1 % ; 83.5%).
Conclusion : Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use.
Conclusion (proposition de traduction) : L'échographie a une bonne précision diagnostique dans la détection des fractures osseuses des membres supérieurs et inférieurs chez l'adulte, en particulier dans les fractures du pied et de la cheville. Ceci est étayé par une analyse groupée des sous-groupes de fractures des membres supérieurs et inférieurs. Des recherches supplémentaires sur des populations plus importantes sont nécessaires pour valider et renforcer la qualité des preuves disponibles avant de recommander l'échographie comme modalité d'imagerie de première intention pour une utilisation préhospitalière.
Long-term Outcomes in Syncope Patients Presenting to the Emergency Department: A Systematic Review.
Leafloor CW, Hong PJ, Mukarram M, Sikora L, Elliott J, Thiruganasambandamoorthy V. | CJEM. 2020 Jan;22(1):45-55
Keywords: Emergency medicine; clinical practice guidelines; syncope
Introduction : Long-term outcomes among syncope patients are not well studied to guide physicians regarding outpatient testing and follow-up. The objective of this study was to conduct a systematic review for outcomes at 1-year or later among ED syncope patients.
Méthode : We searched Cochrane Central, Medline, Medline in Process, PubMed, Embase, and the Cumulative Index to Nursing databases from inception to December 2018. We included studies that reported long-term outcomes among ED syncope patients. We excluded studies on patients <16 years old, studies that included syncope mimickers (pre-syncope, seizure, intoxication, loss of consciousness after head trauma), case reports, letters to the editor, non-English and review articles. Outcomes included death, syncope recurrence requiring hospitalization, arrhythmias and procedural interventions for arrhythmias. Meta-analysis was performed by pooling the outcomes using random effects model.
Résultats : Initial literature search generated 2,094 articles duplicate removal. Of the 50 articles selected for full-text review, 19 articles with 98,211 patients were included in this review: of which 12 were included in the 1-year outcome meta-analysis. Pooled analysis showed : 7.0% mortality; 16.0% syncope recurrence requiring hospitalization; 6.0% with device insertion. 1-year arrhythmias reported in two studies were 1.1 and 26.4%. Pooled analysis for outcome at 31 to 365 days showed: 5.0% mortality and 1% device insertion. Two studies reported 4.9% and 21% mortality at 30 months and 4.2 years follow-up.
Conclusion : An important proportion of ED syncope patients suffer long-term morbidity and mortality. Appropriate follow-up is needed and future research to identify patients at risk is needed.
Conclusion (proposition de traduction) : Une proportion importante des patients souffrant d'une syncope aux urgences souffre de morbidité et de mortalité à long terme. Un suivi approprié est nécessaire et de futures recherches pour identifier les patients à risque sont nécessaires.
Interventions to Reduce Emergency Department Consultation Time: A Systematic Review of the Literature.
Beckerleg W, Wooller K, Hasimjia D. | CJEM. 2020 Jan;22(1):56-64
Keywords: Education; quality improvement; research methods; residents and fellows; systematic review
Introduction : Overcrowding in the emergency department (ED) is associated with increased morbidity and mortality. Studies have shown that consultation to decision time, defined as the time when a consultation has been accepted by a specialty service to the time when disposition decision is made, is one important contributor to the overall length of stay in the ED.The primary objective of this review is to evaluate the impact of workflow interventions on consultation to decision time and ED length of stay in patients referred to consultant services in teaching centres, and to identify barriers to reducing consultation to decision time.
Méthode : This systematic review was performed in accordance with the PRISMA guidelines. An electronic search was conducted to identify relevant studies from MEDLINE, EMBASE, Cochrane Central, and CINAHL databases. Study screening, data extraction, and quality assessment were carried out by two independent reviewers.
Résultats : A total of nine full text articles were included in the review. All studies reported a decrease in consultation to decision time post intervention, and two studies reported cost savings. Interventions studied included short messaging service (SMS) messaging, education with audit and feedback, standardization of the admission process, implementation of institutional guideline, modification of the consultation process, and staffing schedules. Overall study quality was fair to poor.
Conclusion : The limited evidence suggests that audit and feedback in the form of SMS messaging, direct consultation to senior physicians, and standardization of the admission process may be the most effective and feasible interventions. Additional high-quality studies are required to explore sustainable interventions aimed at reducing consultation to decision time.
Conclusion (proposition de traduction) : Les preuves limitées suggèrent que l'audit et le retour d'information sous la forme de messages SMS, la consultation directement par des médecins seniors et la normalisation du processus d'admission pourraient être les interventions les plus efficaces et réalisables. Des études supplémentaires de haute qualité sont nécessaires pour explorer des interventions durables visant à réduire le temps de consultation à la prise de décision.
Decreasing Time to First Shock: Routine Application of Defibrillation Pads in Prehospital STEMI.
Felder S, VanAarsen K, Davis M. | CJEM. 2020 Jan;22(1):82-85
Keywords: Cardiac arrest; prehospital/EMS
Introduction : Four percent of ST-elevation myocardial infarctions (STEMIs) are complicated by an out-of-hospital cardiac arrest (OHCA). Research has shown that shorter time to initial defibrillation in patients with ventricular fibrillation/tachycardia (VF/VT) arrests increases favourable neurologic survival. The purpose of this study is to determine whether routine application of defibrillation pads in patients with prehospital STEMI decreases the time to initial defibrillation in those who suffer OHCA.
Méthode : This was a health records review for adult patients diagnosed with STEMI in the prehospital setting from January 2012 to July 2016. Patients were included if they had a 12 lead ECG indicative of STEMI and subsequently suffered VF/VT OHCA while in paramedic care. This study was designed to evaluate the effects of the "pads-on" protocol in a pre (Jan 2012-May 2014) /post implementation fashion (Jun 2014- Jul 2016). Records were reviewed for relevant patient and event features. T-test was used to measure the difference between mean times to defibrillation.
Résultats : 446 patients were diagnosed with prehospital STEMI. 11 suffered OHCA while in paramedic care. The mean (SD) age was 66.0 (9.3) and 55% were female. In the 4 patients treated with the "pads-on" protocol, the mean time to initial defibrillation was 17.7 seconds, compared to 72.7 seconds in patients who had pads applied following arrest (Δ 55.0 sec [95% CI 22.7-87.2 s]).
Conclusion : Routine application of defibrillation pads in STEMI patients who suffer OHCA decreases time to initial defibrillation, which has previously been demonstrated to increase favourable neurologic survival.
Conclusion (proposition de traduction) : La mise en place systématique de palettes de défibrillation chez les patients souffrant d'un syndrome coronarien avec sus-décalage du segment ST qui font un arrêt cardiaque en préhospitalier réduit le temps nécessaire à la défibrillation initiale, dont il a été démontré précédemment qu'elle augmentait la survie neurologique favorable.
Frailty and Adverse Outcomes in Older Adults Being Discharged From the Emergency Department: A Prospective Cohort Study.
Afilalo J, Mottillo S, Xue X, Colacone A, Morais JA, Delaney JS, Afilalo M. | CJEM. 2020 Jan;22(1):65-73
Keywords: Disability; emergency department; frailty
Introduction : A growing number of frail older adults are treated in the emergency department (ED) and discharged home. There is an unmet need to identify older adults that are predisposed to functional decline and repeat ED visits so as to target them with proactive interventions.
Méthode : A prospective cohort study was conducted in patients 75 years or older who were being discharged from the ED. The objective was to test the value of frailty screening tests, namely 5-meter gait speed and handgrip strength, to predict repeat ED visits at 1 and 6 months and functional decline at 1 month using multivariable logistic regression.
Résultats : After excluding 7 patients lost to follow-up, 150 patients were available for analysis. The mean age was 81.1 ± 4.9 years with 51% females, 13% arriving by ambulance, and 67% having at least two comorbid conditions. At ED discharge, 41% of patients were found to have slow gait speed, whereas 23% had weak handgrip strength. After adjustment, only slow gait speed was independently associated with functional decline at 1 month (odds ratio [OR] 1.39 per 0.1 meters/second decrement, 95% confidence interval [CI], 1.12 to 1.72) and repeat ED visits at 6 months (OR 1.20 per 0.1 meters/second decrement, 95% CI, 1.01 to 1.42).
Conclusion : Gait speed can be feasibly measured at the time of ED discharge to identify frail older adults at risk for early functional decline and subsequent return to the ED. Conversely, grip strength was not found to be associated with functional decline or ED visits.
Conclusion (proposition de traduction) : La vitesse de marche peut être mesurée au moment de la sortie des urgences pour identifier les personnes âgées fragiles qui risquent un déclin fonctionnel précoce et un retour ultérieur aux urgences. Inversement, la force de préhension n'a pas été associée à un déclin fonctionnel ou à des reconsultation aux urgences.
Factors influencing physician risk estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome.
Greenslade JH, Sieben N, Parsonage WA, Knowlman T, Ruane L, Than M, Pickering JW, Hawkins T, Cullen L. | Emerg Med J. 2020 Jan;37(1):2-7
DOI: https://doi.org/10.1136/emermed-2019-208916 | Télécharger l'article au format
Keywords: acute coronary syndrome; cardiac care, diagnosis; clinical assessment
Introduction : Emergency physicians frequently assess risk of acute cardiac events (ACEs) in patients with undifferentiated chest pain. Such estimates have been shown to have moderate to high sensitivity for ACE but are conservative. Little is known about the factors implicitly used by physicians to determine the pretest probability of risk. This study sought to identify the accuracy of physician risk estimates for ACE in patients presenting to the ED with chest pain and to identify the demographic and clinical information emergency physicians use in their determination of patient risk.
Méthode : This study used data from two prospective studies of consenting adult patients presenting to the ED with symptoms of possible acute coronary syndrome. ED physicians estimated the pretest probability of ACE. Multiple linear regression analysis was used to identify predictors of physician risk estimates. Logistic regression was used to determine whether there was a correlation between physicians' estimated risk and ACE.
Résultats : Increasing age, male sex, abnormal ECG features, heavy/crushing chest pain and risk factors were correlated with physician risk estimates. Physician risk estimates were consistently found to be higher than the expected proportion of ACE from the sampled population.
Conclusion : Physicians systematically overestimate ACE risk. A range of factors are associated with physician risk estimates. These include factors strongly predictive of ACE, such as age and ECG characteristics. They also include other factors that have been shown to be unreliable predictors of ACE in an ED setting, such as typicality of pain and risk factors.
Conclusion (proposition de traduction) : Les médecins surestiment systématiquement le risque de SCA. Une série de facteurs sont associés aux estimations de risque des médecins. Ces facteurs comprennent des facteurs fortement prédictifs de SCA, tels que l'âge et les caractéristiques de l'ECG. Ils comprennent également d'autres facteurs qui se sont avérés des prédicteurs non fiables de SCA dans un contexte de service d'urgence, comme la typicité de la douleur et les facteurs de risque.
Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department.
Body R, Morris N, Reynard C, Collinson PO. | Emerg Med J. 2020 Jan;37(1):8-13
Keywords: acute coronary syndrome; cardiac care, diagnosis; diagnosis
Introduction : To directly compare the diagnostic accuracy of four decision aids (Troponin-only Manchester Acute Coronary Syndromes (T-MACS), History, ECG, Age, Risk factors and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI) and Emergency Department Assessment of Chest Pain (EDACS)) used to expedite the early diagnosis of acute coronary syndromes (ACS) in the ED.
Méthode : We prospectively included patients who presented to 14 EDs in England (February 2015 to June 2017) with suspected ACS within 12 hours of symptom onset. Data to enable evaluation of the T-MACS, HEART, TIMI and EDACS decision aids (without recalibration) were prospectively collected, blinded to patient outcome. We tested admission blood samples for high-sensitivity cardiac troponin I (hs-cTnI; Siemens ADVIA Centaur). Patients also underwent serial cardiac troponin testing over 3-12 hours. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We also evaluated the incidence of major adverse cardiac events (including death, AMI or coronary revascularisation) at 30 days. Diagnostic accuracy of each decision aid and hs-cTnI alone (using the limit of quantification cut-off, 3 ng/L) was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).
Résultats : Of 999 included patients, 132 (13.2%) had AMI. C-statistics were 0.96 for T-MACS, 0.78 for HEART and 0.69 for TIMI. The sensitivities of T-MACS, HEART, TIMI, EDACS and hs-cTnI <3 ng/L for AMI were 99.2% (95% CI 95.7% to 100.0%), 91.8% (85.0% to 96.2%), 97.5% (92.9% to 99.5%), 96.2% (92.2% to 99.4%) and 99.2% (95.9% to 100.0%), respectively. The respective strategies would have ruled out 46.5%, 34.9%, 19.4%, 48.3% and 28.8% patients. PPVs for the decision aids that identify 'high-risk' patients were 80.4% (T-MACS), 51.9% (TIMI) and 37.2% (HEART).
Conclusion : In this study, T-MACS could rule out AMI in 46.5% patients with 99.2% sensitivity. EDACS could rule out AMI in 48.3% patients with lower sensitivity, although the difference was not statistically significant. The HEART and TIMI scores had lower diagnostic accuracy.
Conclusion (proposition de traduction) : Dans cette étude, le T-MACS pouvait exclure un infarctus aigu du myocarde chez 46,5% des patients avec une sensibilité de 99,2%. EDACS pouvait exclure un infarctus aigu du myocarde chez 48,3% des patients avec une sensibilité plus faible, bien que la différence ne soit pas statistiquement significative. Les scores HEART et TIMI avaient une précision diagnostique plus faible.
The incidence of airway haemorrhage in manual versus mechanical cardiopulmonary resuscitation.
Asha SE, Doyle S, Paull G, Hsieh V. | Emerg Med J. 2020 Jan;37(1):14-18
Keywords: Trauma; airway; cardiac arrest; chest; resuscitation
Introduction : The aim of this study was to compare the incidence of airway haemorrhage between participants who received manual cardiopulmonary resuscitation (CPR) and those who had received mechanical CPR using the LUCAS device.
Méthode : A retrospective cohort study was conducted by means of a medical chart review. All non-traumatic cardiac arrest patients that presented to the ED, from May 2014 to February 2018, were recruited. The groups were stratified according to those who had the majority of CPR performed using the LUCAS and those who had the majority of CPR performed manually. The primary outcome was the proportion of participants with airway haemorrhage, defined as blood observed in the endotracheal tube, pharynx, trachea or mouth, and documented in the doctor or nursing notes. Logistic regression analysis was performed to adjust for confounders.
Résultats : 12 of 54 (22%) participants in the majority LUCAS CPR group had airway haemorrhage, compared with 20 of 215 (9%) participants in the majority manual CPR group, a difference of 13% (95% CI 3% to 26%, p=0.02). The unadjusted odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.8 (95% CI 1.3 to 6.1). After adjusting for confounders, the odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.5 (95% CI 1.1 to 5.7).
Conclusion : The LUCAS mechanical CPR device is associated with a higher incidence of airway haemorrhage compared with manual CPR. Limitations in the study design mean this conclusion is not robust.
Conclusion (proposition de traduction) : Le dispositif de RCP mécanique LUCAS est associé à une incidence plus élevée d'hémorragie des voies aériennes par rapport à la RCP manuelle. Des limites dans la conception de l'étude signifient que cette conclusion n'est pas solide.
Blood glucose reduction in patients treated with insulin and dextrose for hyperkalaemia.
Aljabri A, Perona S, Alshibani M, Khobrani 4, Jarrell D, Patanwala AE. | Emerg Med J. 2020 Jan;37(1):31-35
Keywords: dextrose; hyperkalaemia; hypoglycaemia; insulin
Introduction : Dextrose is commonly administered with insulin during the management of hyperkalaemia to avoid hypoglycaemia. Previous research has evaluated the incidence of hypoglycaemia; however, none have reported the extent of blood glucose reduction after this regimen. The aim of this study was to better characterise the changes in blood glucose and to identify patients who may have an increased response to insulin.
Méthode : This was a multicentre retrospective study evaluating adult patients who received a regimen of 10 units of intravenous regular insulin plus 25 g of intravenous dextrose to manage hyperkalaemia between January 2014 and September 2016. The primary outcome was to evaluate the extent of blood glucose reduction (milligram per decilitre) up to 6 hours following the above regimen. Secondary outcomes included incidence of hypoglycaemia (blood glucose <70 mg/dL) and severe hypoglycaemia (blood glucose <40 mg/dL), and predictors of the extent of blood glucose reduction.
Résultats : A total of 90 patients were included. The median blood glucose change over 6 hours was -24 mg/dL (IQR -53 to 6 mg/dL). Hypoglycaemia developed in 20 patients (22.2%, 95% CI 14.1% to 32.2%) and five patients (5.6%, 95% CI 1.8% to 12.5%) had severe hypoglycaemia. Patients who developed hypoglycaemia had a median baseline blood glucose of 110 mg/dL (IQR 80 to 127 mg/dL), which decreased to a median value of 52 mg/dL (IQR 40 to 60 mg/dL). Higher baseline blood glucose was significantly associated with greater blood glucose reduction (coefficient -0.36, 95% CI -0.55 to -0.18, p<0.001).
Conclusion : The extent of blood glucose reduction is variable and hypoglycaemia is common. The high incidence of hypoglycaemia highlights the importance of frequent blood glucose monitoring.
Conclusion (proposition de traduction) : L'ampleur de la baisse de la glycémie est variable et l'hypoglycémie est courante. L'incidence élevée d'hypoglycémie met en évidence l'importance d'une surveillance fréquente de la glycémie.
Thromboprophylaxis in lower limb immobilisation after injury (TiLLI).
Horner D, Goodacre S, Pandor A, Nokes T, Keenan J, Hunt B, Davis S, Stevens JW, Hogg K. | Emerg Med J. 2020 Jan;37(1):36-41
DOI: https://doi.org/10.1136/emermed-2019-208944 | Télécharger l'article au format
Keywords: cost effectiveness; musculo-skeletal, fractures and dislocations; pulmonary embolism; risk management; thrombo-embolic disease
Editorial : Venous thromboembolic disease is a major global cause of morbidity and mortality. An estimated 10 million episodes are diagnosed yearly; over half of these episodes are provoked by hospital admission/procedures and result in significant loss of disability adjusted life years. Temporary lower limb immobilisation after injury is a significant contributor to the overall burden of venous thromboembolism (VTE). Existing evidence suggests that pharmacological prophylaxis could reduce overall VTE event rates in these patients, but the proportional reduction of symptomatic events remains unclear. Recent studies have used different pharmacological agents, dosing regimens and outcome measures. Consequently, there is wide variation in thromboprophylaxis strategies, and international guidelines continue to offer conflicting advice for clinicians. In this review, we provide a summary of recent evidence assessing both the clinical and cost effectiveness of thromboprophylaxis in patients with temporary immobilisation after injury. We also examine the evidence supporting stratified thromboprophylaxis and the validity of widely used risk assessment methods.
Conclusion : In patients with temporary lower limb immobilisation after trauma, the absolute risk of symptomatic VTE is low, at approx- imately 2%. Current evidence suggests that pharmacological prophylaxis can significantly reduce this risk. The benefits of thromboprophylaxis are achieved mainly through reduction of morbidity rather than lives saved. Pharmacological prophylaxis appears to be cost-effective.
Risk assessment can help inform SDM and individually tailor thromboprophylaxis, but there is limited evidence of external validation for any specific method at present. A key aspect of the risk assessment process is the sharing of information; clinicians must inform patients that there is an increased risk of VTE with temporary immobilisation and what the common presenting features are, even if the absolute risk is low.
Conclusion (proposition de traduction) : Chez les patients présentant une immobilisation temporaire des membres inférieurs après un traumatisme, le risque absolu de TVP symptomatique est faible, à environ 2%. Les preuves actuelles suggèrent que la prophylaxie pharmacologique peut réduire considérablement ce risque. Les avantages de la thromboprophylaxie sont obtenus principalement par la réduction de la morbidité plutôt que par les de vies sauvées. La prophylaxie pharmacologique semble rentable.
L'évaluation des risques peut aider à éclairer la prise de décision partagée et à adapter individuellement la thromboprophylaxie, mais il existe actuellement des preuves limitées de validation externe pour une méthode spécifique. Un aspect clé du processus d'évaluation des risques est le partage d'informations ; les cliniciens doivent informer les patients qu'il existe un risque accru de TVP lors d'une immobilisation temporaire et quelles sont les caractéristiques de présentation courantes, même si le risque absolu est faible.
BET 1: Does inhaled tranexamic acid reduce morbidity in adults with haemoptysis?.
Mervau J, Jason S, Jones JS. | Emerg Med J. 2020 Jan;37(1):45-46
BEST EVIDENCE TOPIC REPORTS
Editorial : A short cut review was carried out to establish whether inhaled tranexamic acid is more effective than placebo at controlling bleeding in patients with haemoptysis. Thirty-four papers were found using the reported searches, of which one presented the best available evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper is tabulated. It is concluded that in patients with non-massive haemoptysis, management with nebulised TXA leads to fast resolution.
Conclusion : Now, one small RCT provides evidence that nebulised tranexamic acid (500 mg three times a day) is an effective and safe option for patients with non-massive haemoptysis. It can be used as a sole therapy, or as an adjunct to other interventions in patients with haemoptysis of various causes.
Conclusion (proposition de traduction) : Maintenant, un petit essai contrôlé randomisé fournit la preuve que l'acide tranexamique nébulisé (500 mg trois fois par jour) est une option efficace et sûre pour les patients présentant une hémoptysie non massive. L'acide tranexamique peut être utilisé comme thérapie unique ou comme complément à d'autres interventions chez des patients présentant une hémoptysie de diverses causes.
Acute Headache Management in Emergency Department. A Narrative Review.
Giamberardino MA, Affaitati G, Costantini R, Guglielmetti M, Martelletti P. | Intern Emerg Med. 2020 Jan;15(1):109-117
Keywords: Drugs; Emergency department; Headache; Management; Migraine; Secondary headache.
EM - REVIEW
Editorial : Headache is a significant reason for access to Emergency Departments (ED) worldwide. Though primary forms represent the vast majority, the life-threatening potential of secondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture. Once secondary forms are excluded, distinction among primary forms should be performed, based on the international headache classification criteria. Most frequent primary forms motivating ED observation are acute migraine attacks, particularly status migrainous, and cluster headache. Though universally accepted guidelines do not exist for headache management in an emergency setting, pharmacological parenteral treatment remains the principal approach worldwide, with NSAIDs, neuroleptic antinauseants, triptans and corticosteroids, tailored to the specific headache type. Opioids should be avoided, for their scarce effectiveness in the acute phase, while IV hydration should be limited in cases of ascertained dehydration. Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED. More controlled studies are needed to establish specific protocols of management for the headache patient in the ED.
Conclusion : In synthesis, optimal management of a patient with headache in an ED necessarily passes through correct diagnosis at the beginning, but also to adequate referral of the patient to a specialist after treatment of the acute phase has been performed. As underlined by Pari et al., a strict interaction of the ED with a Headache Center, with shared algorithms and collaborative network is key for an effective improved management of the patient, also in the light of the new available options for headache prophylaxis, which should ultimately lead to a reduced recurrence of the patient to the ED. Concluding, it must always be considered that headache in ED covers is present in a huge number of clinical situations of secondary headaches, as Subarachnoid Hemorrhage, Reversible Cerebral Vasoconstriction Syndrome, and also the following post-concussion syndrome, which include post-traumatic headache. All these situations must be carefully considered by the physicians working in the ED.
Conclusion (proposition de traduction) : En synthèse, la prise en charge optimale d'un patient souffrant de céphalée aux urgences passe nécessairement par un diagnostic correct initial, mais aussi par une orientation adéquate du patient vers un spécialiste après le traitement de la phase aiguë. Comme le soulignent Pari et al, une interaction stricte entre le service des urgences et un centre spécialisé de la céphalée, avec des algorithmes partagés et un réseau de collaboration, est essentielle pour une meilleure gestion efficace du patient, compte tenu également des nouvelles options disponibles pour la prophylaxie des céphalées, ce qui devrait en fin de compte conduire à une réduction de la reconsultation du patient au service des urgences. En conclusion, il faut toujours considérer que les céphalées dans la prise en charge des urgences sont présentes dans un très grand nombre de situations cliniques de céphalées secondaires, comme l'hémorragie sous-arachnoïdienne, le syndrome de vasoconstriction cérébrale réversible, et aussi le syndrome cérébral post-traumatique, qui inclut la céphalée post-traumatique. Toutes ces situations doivent être soigneusement examinées par les médecins exerçant au service des urgences.
Reduced Utility of Early Procalcitonin and Blood Culture Determination in Patients With Febrile Urinary Tract Infections in the Emergency Department.
Covino M, Manno A, Merra G, Simeoni B, Piccioni A, Carbone L, Forte E, Ojetti V, Franceschi F, Murri R. | Intern Emerg Med. 2020 Jan;15(1):119-125
EM - ORIGINAL
Editorial : To investigate the prognostic role of procalcitonin (PCT) assessment and blood culture (BC) acquisition in the emergency department (ED) in patients with urinary tract infection (UTI) or urosepsis. We enrolled patients admitted for UTI to our ED over a 10-year period. Mortality and in hospital length of stay (LOS) were compared between patients with UTI or urosepsis who had sampling for PCT levels and BC taken in the ED (ePCT group-eBC group) and those who had not (no-ePCT group-no-eBC group). 1029 patients were analyzed, 52.7% of which were female. Median age was 77 [65-83]; 139 patients (13.5%) had complicated UTI. Median LOS was 10 [7-17] days. In the ePCT group, LOS was 10 [7-16] days, vs. 10 [7-17] (p = 0.428) in the no-ePCT group. In the eBC group, LOS was 10 [6-16] days vs. 10 [7-17] days (p = 0.369) in the no-eBC group. The overall mortality rate was 6.6%. The mortality rate was not affected by early PCT determination (6% in the ePCT group vs. 6.9% in the no-ePCT group, p = 0.584). Similarly, the mortality rate was not different in the eBC group as compared to the no-eBC group (5.4% vs. 6.9%, p = 0.415). Performance of ePCT or eBC testing made no significant difference in terms of improvement of mortality rates in septic patients (11.4% vs. 7.2%; p = 0.397 and 8.8% vs. 9.8%; p = 0.845, respectively). The prognostic relevance of early evaluation of PCT and BC in the ED of patients with febrile UTI appears limited. In complicated UTI patients, PCT and BC testing may be more appropriate in the context of improving antibiotic stewardship, or as an integral component of PCT-guided standardized protocols.
Conclusion : In complicated urinary tract infection, the determination of certified scores of severity of illness, such as APACHE II, SOFA or qSOFA, appears to still be the most reliable method of identifying urinary tract infection patients with poor prognosis. In these cases, PCT and blood culture sampling in the Emergency Department may be justified, but the utility of these tests is increased by the involvement of an antibiotic stewardship unit to optimize antibiotic therapy.
Conclusion (proposition de traduction) : En cas d'infection urinaire compliquée, la détermination de scores certifiés de gravité de la maladie, tels que APACHE II, SOFA ou qSOFA, semble encore être la méthode la plus fiable pour identifier les patients souffrant d'une infection urinaire avec un mauvais pronostic. Dans ces cas, le prélèvement de la PCT et d'hémocultures au service des urgences peut être justifié, mais l'utilité de ces tests est accrue par l'intervention d'une unité de gestion des antibiotiques pour optimiser l'antibiothérapie.
Urgent Intubation Without Neuromuscular Blocking Agents and the Risk of Tracheostomy.
Fujinaga J, Suzuki E, Kuriyama A, Onodera M, Doi H. | Intern Emerg Med. 2020 Jan;15(1):127-134
Keywords: Airway management; Emergency patients; Neuromuscular blocking agents; Tracheostomy
EM - ORIGINAL
Editorial : Neuromuscular blocking agents play a significant role in improving the success rate for urgent intubation, although there is limited evidence about the effect on subsequent outcomes, such as the incidence of tracheostomy. In this retrospective cohort study, we aimed to examine the association between avoidance of neuromuscular blocking agents for urgent tracheal intubation and incidence of tracheostomy among patients in the intensive care unit (ICU). The setting of this study was an eight-bed ICU at a tertiary-care hospital in Okayama, Japan. We included patients who underwent urgent tracheal intubation at the emergency department or the ICU and were admitted to the ICU between April 2013 and November 2017. We extracted data on methods and medications of intubation, predictors for difficult intubation, Cormack-Lehane grade, patient demographics, primary diagnoses, reintubation. We estimated odds ratios and their 95% confidence intervals for elective tracheostomy during the ICU stay using logistic regression models. Of 411 patients, 46 patients underwent intubation without neuromuscular blocking agents and 61 patients underwent tracheostomy. After adjusting for potential confounders, patients who avoided neuromuscular blocking agents had more than double the odds of tracheostomy (odds ratio 2.59, 95% confidence interval 1.06-6.34, p value = 0.04). When stratifying the subjects by risk status for tracheostomy, the association was more pronounced in high-risk group, while we observed less significant association in the low-risk group. Avoidance of neuromuscular blocking agents for urgent intubation increases the risk of tracheostomy among emergency patients, especially those who have a higher risk for tracheostomy.
Conclusion : Our study suggests that the avoidance of neuromuscular blocking agent for urgent intubation increases the risk of subsequent tracheostomy among emergency patients, especially among those who have a higher risk for tracheostomy. This finding is vital because NMBA can be easily implemented as a modifiable intervention for urgent intubation and can improve longer-term outcomes. Further studies are warranted to examine this hypothesis in larger and prospective settings, by determining whether the dose and effect of neuromuscular blocking agent was optimal, the time required for intubation, the patient’s position at the time of intubation, and vocal cord dysfunction or laryngeal edema after extubation.
Conclusion (proposition de traduction) : Notre étude suggère que le fait d'éviter l'utilisation d'un curare pour une intubation en urgence augmente le risque de trachéotomie ultérieure chez les patients des urgences, en particulier chez ceux qui présentent un risque plus élevé de trachéotomie. Ce constat est vital car le curare peut être facilement mise en œuvre comme une intervention modifiable pour une intubation urgente et peut améliorer les résultats à plus long terme. D'autres études sont nécessaires pour confirmer cette hypothèse dans des contextes plus larges et prospectifs, en déterminant si la dose et l'effet du curare étaient optimaux, le temps nécessaire à l'intubation, la position du patient au moment de l'intubation et le dysfonctionnement des cordes vocales ou l'œdème laryngé après l'extubation.
Cohort Retrospective Study: The Neutrophil to Lymphocyte Ratio as an Independent Predictor of Outcomes at the Presentation of the Multi-Trauma Patient.
Soulaiman SE, Dopa D, Raad AT, Hasan W, Ibrahim N, Hasan AY, Sulaiman HA, Darwich M. | Int J Emerg Med. 2020 Feb 4;13(1):5
DOI: https://doi.org/10.1186/s12245-020-0266-3 | Télécharger l'article au format
Keywords: Intensive care; Mortality; Neutrophil to lymphocyte ratio; Trauma.
Introduction : Although the association of neutrophil to lymphocyte ratio (NLR) with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. Recent studies suggest that the NLR has a predictive value of mortality in trauma patients during various times of admission. This study aimed to determine the prognostic impact of NLR at the presentation in critically ill trauma patients.
Méthode : A retrospective cohort study of adult trauma patients between July 2017 and November 2017 in Tishreen Hospital. All patients who had arrived at the emergency department with multi-trauma injury within the age category (14-80 years) were included in this analysis. The prophetical capability of NLR on mortality was assessed by the receiver operative characteristics (ROC) curve. To identify the impact of the NLR on survival, a separate log-rank test was used. Multivariable Cox proportional hazard modeling was used to identify independent predictors of mortality.
Résultats : Throughout the time of the study, 566 patients met the inclusion criteria. Of these, 98.8% were male, 75.8% sustained penetrating trauma, and median age [IQR25-IQR75] was 26 [23-32]. Ninety-seven patients (17.1%) had major trauma, with an Injury Severity Score (ISS) ≥ 15. Using the ROC curve analyses hospitalization day 1, optimal NLR cutoff values of 4.00 were calculated by maximizing the Youden index. Kaplan-Meier curves revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality (p = 0.020, log-rank test). The Cox regression model demonstrated significant collinearity among the predictive variables (all VIF results < 2). Only ISS > 15 has a significant statistical relation with elevated NLR on day 1 (p = 0.010).
Conclusion : Elevated NLR on day 1 has high predictive power for overall survival during the first 30 days after trauma, but it was not independent of other factors.
Conclusion (proposition de traduction) : Un rapport neutrophiles/lymphocytes élevé, le premier jour, a un pouvoir prédictif élevé pour la survie globale au cours des 30 premiers jours après le traumatisme, mais il n'était pas indépendant d'autres facteurs.
Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma.
Stengel D, Mutze S, Güthoff C, Weigeldt M, von Kottwitz K, Runge D, Razny F, Lücke A, Müller D, Ekkernkamp A, Kahl T. | JAMA Surg. 2020 Jan 15:e195468
Introduction : Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. Objective: To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. Design, setting, and participants: This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. Interventions: Standard- or low-dose WBCT.
Méthode : The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy.
Résultats : Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, -2.0% [95% CI, -7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001).
Conclusion : Low-dose whole-body computed tomography using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.
Conclusion (proposition de traduction) : La reconstruction itérative en scanner corps entier à faible dose ne semble pas augmenter le risque de diagnostics de blessures méconnues au point d'intervention par rapport aux protocoles à dose standard, tout en réduisant presque de moitié l'exposition aux rayonnements pour le diagnostic.
Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review.
Chiabrando JG, Bonaventura A, Vecchié A, Wohlford GF, Mauro AG, Jordan JH, Grizzard JD, Montecucco F, Berrocal DH, Brucato A, Imazio M, Abbate A. | J Am Coll Cardiol. 2020 Jan 7;75(1):76-92
Keywords: acute pericarditis; cardiac tamponade; constrictive pericarditis; recurrent pericarditis; treatment.
THE PRESENT AND FUTURE
Editorial : Pericarditis refers to the inflammation of the pericardial layers, resulting from a variety of stimuli triggering a stereotyped immune response, and characterized by chest pain associated often with peculiar electrocardiographic changes and, at times, accompanied by pericardial effusion. Acute pericarditis is generally self-limited and not life-threatening; yet, it may cause significant short-term disability, be complicated by either a large pericardial effusion or tamponade, and carry a significant risk of recurrence. The mainstay of treatment of pericarditis is represented by anti-inflammatory drugs. Anti-inflammatory treatments vary, however, in both effectiveness and side-effect profile. The objective of this review is to summarize the up-to-date management of acute and recurrent pericarditis.
Conclusion : Acute pericarditis remains the most common pre- sentation of pericardial diseases. Although generally benign, pericarditis can be fraught by a significant number of complications and recurrences. Accord- ing to geographical differences, the etiology varies and so do its prognosis and treatments. The awareness of the diagnostic and etiologic features of pericarditis is key for a proper treatment and the prevention of complications. Imaging studies are essential in the diagnosis and guidance for tailored treatment. In patients with recurrent or constrictive pericarditis or in those dependent on corticosteroids, targeted therapies with IL-1 blockers or other immunomodulators represent promising therapies.
Conclusion (proposition de traduction) : La péricardite aiguë reste la présentation la plus courante des maladies péricardiques. Bien que généralement bénigne, la péricardite peut être lourde de complications et de récidives. Selon les différences géographiques, l'étiologie varie ainsi que son pronostic et ses traitements. La prise de conscience des caractéristiques diagnostiques et étiologiques de la péricardite est essentielle pour un traitement approprié et la prévention des complications. Les études d'imagerie sont essentielles pour le diagnostic et l'orientation d'un traitement personnalisé. Chez les patients atteints de péricardite récurrente ou constrictive ou chez ceux qui dépendent des corticostéroïdes, les thérapies ciblées avec des bloqueurs de l'IL-1 ou d'autres immunomodulateurs représentent des thérapies prometteuses.
Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest.
Matsuyama T, Komukai S, Izawa J, Gibo K, Okubo M, Kiyohara K, Kiguchi T, Iwami T, Ohta B, Kitamura T. | J Am Coll Cardiol. 2020 Jan 21;75(2):194-204
Keywords: epinephrine; out-of-hospital cardiac arrest; pediatrics; time-dependent propensity score-sequential matching analysis.
Introduction : There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs).
OBJECTIVES : This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical- service (EMS) personnel for pediatric OHCA.
Méthode : This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC).
Résultats : During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54]).
Conclusion : In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine.
Conclusion (proposition de traduction) : Dans cette étude, l'administration pré-hospitalière d'épinéphrine était associée à la RACS, alors qu'il n'y avait pas de différence significative dans la survie à 1 mois et les résultats neurologiques favorables entre ceux avec et sans épinéphrine.
Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.
Clase CM, Carrero JJ, Ellison DH, Grams ME, Hemmelgarn BR, Jardine MJ, Kovesdy CP, Kline GA, Lindner G, Obrador GT, Palmer BF, Cheung M, Wheeler DC, Winkelmayer WC, Pecoits-Filho R; Conference Participants. | Kidney Int. 2020 Jan;97(1):42-61
KDIGO Executive Conclusions
Editorial : Potassium disorders are common in patients with kidney disease, particularly in patients with tubular disorders and low glomerular filtration rate. A multidisciplinary group of researchers and clinicians met in October 2018 to identify evidence and address controversies in potassium management. The issues discussed encompassed our latest understanding of the regulation of tubular potassium excretion in health and disease; the relationship of potassium intake to cardiovascular and kidney outcomes, with increasing evidence showing beneficial associations with plant-based diet and data to suggest a paradigm shift from the idea of dietary restriction toward fostering patterns of eating that are associated with better outcomes; the paucity of data on the effect of dietary modification in restoring abnormal serum potassium to the normal range; a novel diagnostic algorithm for hypokalemia that takes into account the ascendency of the clinical context in determining cause, aligning the educational strategy with a practical approach to diagnosis; and therapeutic approaches in managing hyperkalemia when chronic and in the emergency or hospital ward. In sum, we provide here our conference deliberations on potassium homeostasis in health and disease, guidance for evaluation and management of dyskalemias in the context of kidney diseases, and research priorities in each of the above areas.
Conclusion : We summarized here the evidence and controversies in the physiology, identification, and management of disturbances of potassium in the context of kidney diseases and hope that this report serves as a useful reference and outlines research priorities that will further strengthen the evidence base in this area.
Conclusion (proposition de traduction) : Nous avons résumé ici les preuves et les controverses dans la physiologie, l'identification et la gestion des perturbations du potassium dans le contexte des maladies rénales et espérons que ce rapport servira de référence utile et exposera les priorités de recherche qui renforceront davantage la base de données probantes dans ce domaine.
Commentaire : Algorithme de prise en charge d'une hypokaliémie proposé par Rafique Zubaid :
Composition and Associated Factors of Radiological Examination in Major Trauma Patients: A Prospective Observational Study.
Shanshou L, Wei Z, Xianqi W, Jiangang X, Chaojuan Z, Qianmei W, Wen Y, Junjie L. | Pediatr Emerg Care. 2020 Jan;36(1):34-38
DOI: https://doi.org/10.1097/pec.0000000000001363 | Télécharger l'article au format
Editorial : The care of major trauma patients continues to be a challenge for emergency physicians and trauma surgeons. We found that the total number of radiological examinations for major trauma patients in this study was high and mainly comprised radiography and computed tomography (CT), with CT being more commonly adopted. The number of CT scans was positively correlated with severity of injury and intensive care unit length of stay. Further study is warranted to optimize radiological examinations involving major trauma patients.
Conclusion : In conclusion, the total number of radiological examinations undergone by major trauma patients in our study was high and mainly comprised radiography and CT, with CT being more commonly adopted. The number of CT scans was positively correlated with the severity of injury and ICU LOS. Further study is warranted to enable optimization of radiological examinations in major trauma patients.
Conclusion (proposition de traduction) : En conclusion, le nombre total d'examens radiologiques subis par des patients traumatisés majeurs dans notre étude était élevé et comprenait principalement la radiographie et le TDM, le TDM étant plus couramment utilisé. Le nombre de scanner était corrélé positivement avec la gravité des blessures et la durée de vie en soins intensifs. Une étude plus approfondie est justifiée pour permettre l'optimisation des examens radiologiques chez les patients traumatisés majeurs.
Determination of the Pretibial Soft Tissue Thickness in Children: Are Intraosseous Infusion Needles Long Enough?.
Al-Shibli A, Lim R, Poonai N, Istasy V, Lin K, Kilgar J. | Pediatr Emerg Care. 2020 Jan;36(1):39-42
Introduction : The EZ-IO intraosseous (IO) needle is available in 2 needle sizes for children based on the patient weight. To date, there is no published evidence validating the use of weight-based scaling in children. We hypothesized that pretibial subcutaneous tissue thickness (PSTT) does not correspond with patient weight but rather with age and body mass index (BMI). Our objective was to describe the relationship of a patient's PSTT to their weight, age, and BMI in children less than 40 kg.
Méthode : One hundred patients who weighed less than 40 kg were recruited prospectively from October 2013 to April 2015 at a tertiary care pediatric emergency department. All sonographic assessments were performed by 1 of 2 emergency physicians certified in point-of-care ultrasound. A single sonographic image was taken over the proximal tibia corresponding to the site of IO insertion. In patients where both sonographers performed independent measurements, a Pearson correlation coefficient was determined. Univariate linear regression was performed to determine the relationship between age, weight, and BMI with PSTT.
Résultats : One hundred participants were recruited and ranged in age from 10 days to 14 years (mean [SD], 5.01 [3.14] years). Fifty-seven percent of participants were male. Patients' weights ranged from 3.5 to 39.3 kg (mean [SD], 21.42 [9.12] kg), and BMI ranged from 12.1 to 45.0 kg/m (mean [SD], 17.31 [4.00]). The mean (SD) PSTT across participants was 0.68 (0.2) cm. The intraclass correlation coefficient for agreement between the 2 sonographers was moderate (intraclass correlation coefficient, 0.602 [confidence interval, 0.385-0.757]). There were significant positive correlations between BMI and PSTT (r = 0.562, P = <0.001) as well as weight and PSTT (r = 0.293, P < 0.003). There was a weak correlation between age and PSTT (0.065, P = 0.521).
Conclusion : Pretibial subcutaneous tissue thickness correlates most strongly with BMI, followed by weight, and weakly with age. Our findings suggest that current IO needle length recommendations should be based on BMI rather than weight. This would suggest that clinicians need to be aware that young patients in particular with large BMIs may pose problems with current weight-based needle length recommendations.
Conclusion (proposition de traduction) : L'épaisseur du tissu sous-cutané prétibial correspond le plus fortement à l'IMC, suivi du poids et faiblement à l'âge. Nos résultats suggèrent que les recommandations actuelles sur la longueur des aiguilles intraosseuses devraient être basées sur l'IMC plutôt que sur le poids. Cela suggérerait que les cliniciens doivent être conscients que les jeunes patients en particulier avec de grands IMC peuvent poser des problèmes avec les recommandations actuelles de longueur d'aiguille basées sur le poids.
Commentaire : Les résultats de l'étude suggèrent que les recommandations de longueur des aiguilles intraosseuses basée sur le poids pourrait poser des problèmes chez l'enfant avec un IMC > 20 kg/m2.
(Le lien DOI: 10.1097/PEC.0000000000002019 génère une erreur de destination… Utiliser le lien de la revue Pediatr Emerg Care. 2020 Jan;36(1):39-42 )
Early Diagnosis of Sepsis in Emergency Departments, Time to Treatment, and Association With Mortality: An Observational Study.
Husabø G, Nilsen RM, Flaatten H, Solligård E, Frich JC, Bondevik GT, Braut GS, Walshe K, Harthug S, Hovlid E. | PLoS One. 2020 Jan 22;15(1):e0227652
DOI: https://doi.org/10.1371/journal.pone.0227652 | Télécharger l'article au format
Introduction : Early recognition of sepsis is critical for timely initiation of treatment. The first objective of this study was to assess the timeliness of diagnostic procedures for recognizing sepsis in emergency departments. We define diagnostic procedures as tests used to help diagnose the condition of patients. The second objective was to estimate associations between diagnostic procedures and time to antibiotic treatment, and to estimate associations between time to antibiotic treatment and mortality.
Méthode : This observational study from 24 emergency departments in Norway included 1559 patients with infection and at least two systemic inflammatory response syndrome criteria. We estimated associations using linear and logistic regression analyses.
Résultats : Of the study patients, 72.9% (CI 70.7-75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (42.4-47.4) were examined by a physician in accordance with the triage priority, 44.4% (41.4-46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (23.2-27.7) received antibiotics within 1 hour. Delay or non-completion of these key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (10.1-17.1), in the timespan 2 to 3 hours after admission 5.9% (2.8-9.1), and 4 hours or later after admission 10.5% (5.7-15.3).
Conclusion : Key procedures for recognizing sepsis were delayed or not completed in a substantial proportion of patients admitted to the emergency department with sepsis. Delay or non-completion of key diagnostic procedures was associated with prolonged time to treatment with antibiotics. This suggests a need for systematic improvement in the initial management of patients admitted to emergency departments with sepsis.
Conclusion (proposition de traduction) : Les procédures clés de reconnaissance du sepsis ont été retardées ou non terminées chez une proportion importante de patients admis aux urgences pour une septicémie. Le retard ou l'inachèvement des principales procédures de diagnostic était associé à une durée prolongée du traitement par les antibiotiques. Cela suggère la nécessité d'une amélioration systématique de la prise en charge initiale des patients admis aux urgences pour sepsis.
Predictors of Hypothermia Upon Trauma Center Arrival in Severe Trauma Patients Transported to Hospital via EMS.
Forristal C, Van Aarsen K, Columbus M, Wei J, Vogt K, Mal S. | Prehosp Emerg Care. 2020 Jan-Feb;24(1):15-22
Keywords: hypothermia; prehospital emergency care; trauma.
Introduction : Hypothermia in severe trauma patients can increase mortality by 25%. Active warming practices decrease mortality and are recommended in the Advanced Trauma Life Support (ATLS) guidelines. Despite this, many emergency medical services (EMS) vehicles do not carry equipment necessary to perform active warming. The intent of this study was to determine the rate of hypothermia in severe trauma patients upon major trauma center (MTC) arrival, as well as to characterize factors associated with hypothermia in trauma in order to devote potential resources to those at highest risk.
Méthode : This single-center retrospective chart review included adults (age ≥ 18) in the local trauma registry (trauma team activation or injury severity score ≥12) from January 2009 to June 2016. Logistic regression was used to identify predictors of hypothermia on MTC arrival.
Résultats : A total of 3,070 patient charts were reviewed, of which 159 (5.2%) were hypothermic. Multivariate logistic regression identified 7 factors that were significantly associated with hypothermia on MTC arrival in severe trauma. Risk factors for hypothermia on MTC arrival after severe trauma included: intubation pre-MTC, increased number of co-morbidities, and increased injury severity. Conversely, protective factors against hypothermia were: higher initial systolic blood pressure (SBP), penetrating injury, referral to MTC, and higher ambient outdoor temperatures. Median length of stay in hospital was 7 days for hypothermic patients compared to 4 days for normothermic patients (Δ 3 days; p < 0.001). Only 69.2% of hypothermic patients survived to discharge compared to 93.9% of normothermic patients (Δ 24.7%; χ2 = 133.4, p < 0.001).
Conclusion : This retrospective study of hypothermia in major trauma patients found a rate of hypothermia of 5%. Factors associated with higher risk of hypothermia include pre-MTC intubation, high ISS, multiple comorbidities, low SBP, non-penetrating mechanism of injury, and being transferred directly to MTC, and colder outdoor temperature. Avoidance of hypothermia is imperative to the management of major trauma patients. Prospective studies are required to determine if prehospital warming in these high-risk patients decreases the rate of hypothermia in major trauma and improves patient outcomes.
Conclusion (proposition de traduction) : Cette étude rétrospective sur la constatation d'une hypothermie à l'admission de patients ayant subi un traumatisme sévère a révélé un taux d'hypothermie de 5 %.
Les facteurs associés à un risque plus élevé d'hypothermie comprenaient une intubation avant l'admission dans le major trauma center (MTC), un ISS élevé, des comorbidités multiples, une pression artérielle systolique basse, un mécanisme de lésion non pénétrant, et le fait d'être transféré directement dans le major trauma center (MTC), et une température extérieure plus froide. Il est impératif d'éviter l'hypothermie dans la prise en charge des patients souffrant de traumatismes sévères. Des études prospectives sont nécessaires pour déterminer si le réchauffement préhospitalier chez ces patients à haut risque diminue le taux d'hypothermie lors de traumatismes sévères et améliore le devenir des patients.
Commentaire : Un « traumatisé sévère » est un blessé victime d'un traumatisme violent susceptible d'induire des lésions menaçant le pronostic vital (c'est la nouvelle définition du « polytraumatisé » dont la définition était : un blessé porteur d'une ou plusieurs lésions traumatiques, dont au moins une met en jeu le pronostic vital).
Les recommandations internationales en soins de santé proposent de constituer des centres experts de traumatologie (Trauma Center ou Major Trauma Center) pour prendre en charge ces patients souffrant de lésions multiples et complexes.
Effect of Specialized Critical Care Transport Unit on Short-Term Mortality of Critically ILL Patients Undergoing Interhospital Transport.
Kim TH, Song KJ, Shin SD, Ro YS, Hong KJ, Park JH. | Prehosp Emerg Care. 2020 Jan-Feb;24(1):46-54
Keywords: critical care transport unit; critically ill patients; interhospital transfer; mortality
Introduction : To minimize risk and prevent harmful incidents during interhospital transport, the critical care transport unit service called Seoul Mobile Intensive Care Unit (SMICU) was organized and initiated its service within the city of Seoul. We sought to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport in Seoul.
Méthode : A retrospective observational case-control study was designed to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport. ED patients transported from other hospitals in Seoul during 2016 were identified in the National Emergency Department Information System (NEDIS) and according to use of the SMICU. One-to-one propensity matching was performed to balance covariates between groups. The association of SMICU transport on survival outcome was calculated in a multivariable logistic regression model.
Résultats : Among 42,188 ED patients transported from other hospitals in 2016, 482 (1.1%) of patients were transported by SMICU. Patients transported by SMICU had a higher proportion of severe emergency disease and use of a mechanical ventilator. The adjusted odds ratio for 24-hour mortality after interhospital transport was 0.45 (95% CI: 0.26-0.81) in total cohort and was 0.34 (95% CI: 0.16-0.71) in a one-to-one propensity-matched cohort.
Conclusion : Transport by specialized critical care transport unit for patients undergoing interhospital transport was associated with lower 24-hour mortality, demonstrating the benefits of the SMICU.
Conclusion (proposition de traduction) : Le transport par une unité de transport spécialisée dans les soins intensifs pour les patients en transport interhospitalier a été associé à une baisse de la mortalité sur 24 heures, démontrant ainsi les avantages de l'unité mobile de soins intensifs de Séoul.
CaRdiac Arrest Survival Score (CRASS) — A tool to predict good neurological outcome after out-of-hospital cardiac arrest.
Seewald S, Wnent J, Lefering R, Fischer M, Bohn A, Jantzen T, Brenner S, Masterson S, Bein B, Scholz J, Gräsner JT. | Resuscitation. 2020 Jan 1;146:66-73
Keywords: German Resuscitation Registry, CaRdiac Arrest Survival Score, Out of hospital cardiac arrest
Introduction : The aim of this study was to develop a score to predict the outcome for patients brought to hospital following out-of-hospital cardiac arrest (OHCA).
Méthode : All patients recorded in the German Resuscitation Registry (GRR) who suffered OHCA 2010-2017, who had ROSC or ongoing CPR at hospital admission were included. The study population was divided into development (2010-2016: 7985) and validation dataset (2017: 1806). Binary logistic regression analysis was used to derive the score. The probability of hospital discharge with good neurological outcome was defined as 1/(1 + e-X), where X is the weighted sum of independent variables.
Résultats : The following variables were found to have a significant positive (+) or negative (-) impact: age 61-70 years (-0·5), 71-80 (-0·9), 81-90 (-1·3) and > = 91 (-2·3); initial PEA (-0·9) and asystole (-1·4); presumable trauma (-1·1); mechanical CPR (-0·3); application of adrenalin > 0 - < 2 mg (-1·1), 2 - <4 mg (-1·6), 4 - < 6 mg (-2·1), 6 - < 8 mg (-2·5) and > = 8 mg (-2·8); pre emergency status without previous disease (+0·5) or minor disease (+0·2); location at nursing home (-0·6), working place/school (+0·7), doctor's office (+0·7) and public place (+0·3); application of amiodarone (+0·4); hospital admission with ongoing CPR (-1·9) or normotension (+0·4); witnessed arrest (+0·6); time from collapse until start CPR 2 - < 10 min (-0·3) and > = 10 min (-0·5); duration of CPR <5 min (+0·6). The AUC in the development dataset was 0·88 (95% CI 0·87-0·89) and in the validation dataset 0·88 (95% CI 0·86-0·90).
Conclusion : The CaRdiac Arrest Survival Score (CRASS) represents a tool for calculating the probability of survival with good neurological function for patients brought to hospital following OHCA.
Conclusion (proposition de traduction) : Le CaRdiac Arrest Survival Score (CRASS) est un outil permettant de calculer la probabilité de survie avec une bonne fonction neurologique pour les patients amenés à l'hôpital suite à un arrêt cardiaque extra-hospitalier.
Commentaire : Voir l'article :
Balan P, Hsi B, Thangam M and al. The cardiac arrest survival score: A predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest. Resuscitation. 2019 Nov;144:46-53 .
Identifying Out-Of-Hospital Cardiac Arrest Patients With No Chance of Survival: An Independent Validation of Prediction Rules.
Hreinsson JP, Thorvaldsson AP, Magnusson V, Fridriksson BT, Libungan BG, Karason S. | Resuscitation. 2020 Jan 1;146:19-25
Keywords: Futility score in OHCA; Out-of-hospital cardiac arrest; Resuscitation; Termination of resuscitation prediction rules
Introduction : The Basic life support (BLS) and Advanced life support (ALS) are known prediction rules for termination of resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA). Recently, a new rule was developed by Jabre et al. We aimed to independently validate and compare the predictive accuracy of these rules.
Méthode : OHCA cases in Iceland from 2008 to 2017 from a population-based, prospectively registered database. Primary outcome was survival to discharge among patients that met all conditions of abovementioned rules: BLS (not witnessed by EMS personnel, no defibrillation nor ROSC before transport), ALS (BLS criteria plus not witnessed nor CPR by bystander) and Jabre (not witnessed by EMS personnel, initial rhythm non-shockable, no sustainable ROSC before third dose of adrenaline).
Résultats : Overall, 568 OHCA patients were included in validation of TOR rules. Mean age 67, males 74%, witnessed by EMS 11%, by bystander 66% that attempted CPR in 50%, transported to hospital 60%, overall survival 20%. All rules had high specificity for mortality, 99.6-100% (95%CI 95-100). The Jabre and BLS rules had similar sensitivity 47% (43-52) vs. 44% (40-49), respectively, the sensitivity of ALS was lower, 8% (5-11). Combined use of positive BLS and Jabre rules performed the best, identifying 88/226 (39%) of futile cases transported to hospital, specificity 100% (97-100) and sensitivity 59% (55-64).
Conclusion : The accuracy of the BLS and Jabre TOR rules to predict mortality after OHCA is very good and their combined use may be superior to the use of either one.
Conclusion (proposition de traduction) : La précision des règles de réanimation de base (BLS : Basic Life Support) et d’abandon de la réanimation (TOR : Termination Of Resuscitation) de Jabre pour prédire la mortalité après un arrêt cardiaque extra-hospitalier est très bonne et leur utilisation combinée peut être supérieure à l'utilisation de l'une ou l'autre.
Commentaire : Jabre P, Bougouin W, Dumas F, Carli P, Antoine C, Jacob L, Dahan B, Beganton F, Empana JP, Marijon E, Karam N, Loupy A, Lefaucheur C, Jost D, Cariou A, Adnet F, Rea TD, Jouven X. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016 Dec 6;165(11):770-778 . Epub 2016 Sep 13. PMID: 27618681.
• Critères d'abandon de la réanimation (TOR) de Jabre et al. :
Arrêt cardiaque extra-hospitalier pour lequel le personnel des services médicaux d'urgence n'a pas été témoin du moment de l'arrêt cardiaque, avec un rythme cardiaque initial non choquable et pas de récupération d'activité cardiaque spontanée (RACS) avant l'administration d'une troisième dose d'un milligramme d'adrénaline.
• L'ajout d'autres critères (un intervalle de temps d'intervantion supérieur à huit minutes ou un arrêt cardiaque non observé par un témoin) améliorerait encore la spécificité et la valeur prédictive positive de la règle (ndlr : de Jabre) mais entraînerait le transport d'une plus grande proportion de patients. Morrison LJ, Visentin LM, Kiss A, Theriault R, Eby D, Vermeulen M, Sherbino J, Verbeek PR; TOR Investigators. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006 Aug 3;355(5):478-87 . PMID: 16885551.
• Morrison LJ. Prehospital termination of resuscitation rule. Curr Opin Crit Care. 2019 Jun;25(3):199-203 . PMID: 31026236.
Improving Emergency Call Detection of Out-of-Hospital Cardiac Arrests in the Greater Paris Area: Efficiency of a Global System With a New Method of Detection.
Derkenne C, Jost D, Thabouillot O, Briche F, Travers S, Frattini B, Lesaffre X, Kedzierewicz R, Roquet F, de Charry F, Prunet B; Paris Fire Brigade Cardiac Arrest Task Force. | Resuscitation. 2020 Jan 1;146:34-42
Keywords: Cardiac arrest; Dispatch-assisted cardiopulmonary resuscitation; Telephone cardio-pulmonary resuscitation.
Introduction : The detection of cardiac arrests by dispatchers allows telephone-assisted cardiopulmonary resuscitation (t-CPR) and improves Out-of-Hospital Cardiac Arrest (OHCA) survival. To enhance the OHCA detection rate, in 2012, the Paris Fire Brigade dispatch center created an original technique called "Hand On Belly" (HoB). The new algorithm that resulted has become a central point in a broader program for dispatch-assisted cardiac arrests.
Méthode : This is a repeated cross-sectional study with retrospective data of four 15-day call samples recorded from 2012 to 2018. We included all calls from OHCAs cared for by Basic Life Support (BLS) teams and excluded calls where the dispatcher was not in contact directly with a witness. The primary endpoint was the successful detection of an OHCA by the dispatcher; the secondary endpoints were successful t-CPR and measurements of the different time intervals related to the call. Logistic regressions were performed to assess parameters associated with detecting OHCAs and initiating t-CPR.
Résultats : From 2012 to 2018, among the detectable OCHAs, the proportion correctly identified increased from 54% to 93%; the rate of t-CPRs from 51% to 84%. OHCA detection and t-CPR initiation were both associated with HoB breathing assessments (adjustedOR: 89, 95%CI: 31-299, and adjustedOR: 11.2, 95%CI: 1.4-149, respectively). Over the study period, the times to answering calls and the time to sending BLS teams were shorter than those recommended by international guidelines; however, the times to OHCA recognition and starting t-CPR delivery were longer.
Conclusion : The HoB effectively facilitated OHCA detection in our system, which has achieved very high performance levels.
Conclusion (proposition de traduction) : La technique appelée « Hand On Belly » a efficacement facilité la détection des arrêts cardiaques extra-hospitaliers dans notre système avec des niveaux de performance très élevés.
Commentaire : La technique appelée « Hand On Belly » (HoB) ou la « main sur le ventre » quantifie la fréquence respiratoire pour vérifier les mouvements de l'abdomen en posant la main sur le ventre, au-dessus du nombril.
La procédure pour la détection téléphonique des arrêts cardiaques extrahospitaliers repose sur l'évaluation de la fréquence respiratoire : l'alertant est invité à poser sa main sur le ventre de la victime et à dire un « top » à chaque mouvement perçu. Au-delà de 7 secondes entre deux « tops », l'opérateur fait initier un massage cardiaque guidé par téléphone.
Voir l'article sur le site de la SFMU : Intérêt de la détection des arrêts cardiaques extrahospitaliers et du massage cardiaque guidés par téléphone publié le 06/06/2019.
Advanced Airway Management Success Rates in a National Cohort of Emergency Medical Services Agencies.
Nwanne T, Jarvis J, Barton D, Donnelly JP, Wang HE. | Resuscitation. 2020 Jan 1;146:43-49
Keywords: Airway management; Cardiac arrest; Emergency medical services; Intubation (intratracheal); Paramedics; Pediatrics; Rapid sequence intubation; Trauma.
Introduction : Despite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies.
Méthode : We used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011-2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years).
Résultats : AAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8-89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5-77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9-90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5-90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4-88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4-23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8-88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4-92.0), medical non-arrest (n = 17,086; 84.7%, 84.2-85.2%); trauma (n = 4341; 84.3%, 83.1-85.3%); pediatric (n = 1223; 73.7%, 71.2-76.2%).
Conclusion : AAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.
Conclusion (proposition de traduction) : Les taux de réussite de la gestion des voies aériennes avancées variaient selon la technique de gestion des voies aériennes et le sous-ensemble de patients. Dans cette cohorte nationale, ces résultats offrent des perspectives sur les pratiques avancées de gestion des voies respiratoires des services médicaux d'urgence.
A Smartphone Application With Augmented Reality for Estimating Weight in Critically Ill Paediatric Patients.
Scquizzato T, Landoni G, Carenzo L, Forti A, Zangrillo A. | Resuscitation. 2020 Jan 1;146:3-4
Letters to the Editor
Editorial : Knowing child weight is critical while managing paediatric emergencies because dosing resuscitation drugs is generally based on weight. However, in many out-of-hospital and emergency department settings the child weight is unknown to the treating team and often it is not possible to weight the patients. Some of the conditions which make challenging to obtain a rapid and reliable measurement of the weight include on-going cardiopulmonary resuscitation, spinal immobilization, emergency airway management, and emergency delirium or agitation. Calculation of emergency drug doses, choosing the most appropriate equipment size and defibrillation energy level requires knowing or accurately estimating the child weight.
Conclusion : Like the available physical tapes, our app estimates weight using only the smartphone camera. Internal tests were executed but the app was not formally validated and a clinical study is needed before clinical use. There is the possibility to obtain a demo of the app by contacting the authors.
Conclusion (proposition de traduction) : Comme les bandes (bandes Broselow d'urgence pédiatrique) physiques disponibles, notre application estime le poids en utilisant uniquement la caméra du smartphone. Des tests internes ont été exécutés mais l'application n'a pas été officiellement validée et une étude clinique est nécessaire avant utilisation clinique. Il est possible d'obtenir une démo de l'application en contactant les auteurs.
Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review.
Considine J, Gazmuri RJ, Perkins GD, Kudenchuk PJ, Olasveengen TM, Vaillancourt C, Nishiyama C, Hatanaka T, Mancini ME, Chung SP, Escalante-Kanashiro R, Morley P. | Resuscitation. 2020 Jan 1;146:188-202
Keywords: Advanced life support; Basic life support; CPR; Cardiopulmonary resuscitation; Chest compression; Resuscitation; Scoping review.
Introduction : To understand whether the science to date has focused on single or multiple chest compression components and identify the evidence related to chest compression components to determine the need for a full systematic review.
Méthode : This review was undertaken by members of the International Liaison Committee on Resuscitation and guided by a specific methodological framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Studies were eligible for inclusion if they were peer-reviewed human studies that examined the effect of different chest compression depths or rates, or chest wall or leaning, on physiological or clinical outcomes. The databases searched were MEDLINE complete, Embase, and Cochrane.
Résultats : Twenty-two clinical studies were included in this review: five observational studies involving 879 patients examined both chest compression rate and depth; eight studies involving 14,285 patients examined chest compression rate only; seven studies involving 12001 patients examined chest compression depth only, and two studies involving 1848 patients examined chest wall recoil. No studies were identified that examined chest wall leaning. Three studies reported an inverse relationship between chest compression rate and depth.
Conclusion : This scoping review did not identify sufficient new evidence that would justify conducting new systematic reviews or reconsideration of current resuscitation guidelines. This scoping review does highlight significant gaps in the research evidence related to chest compression components, namely a lack of high-level evidence, paucity of studies of in-hospital cardiac arrest, and failure to account for the possibility of interactions between chest compression components.
Conclusion (proposition de traduction) : Cette étude de portée n'a pas identifié de nouvelles preuves suffisantes qui justifieraient la réalisation de nouvelles revues systématiques ou le réexamen des lignes directrices actuelles en matière de réanimation. Cette étude de portée met en évidence des lacunes importantes dans les preuves concernant la recherche liées aux composantes du massage cardiaque, à savoir un manque de preuves de haut niveau, la rareté des études sur l'arrêt cardiaque à l'hôpital et la non-prise en compte de la possibilité d'interactions entre les composantes du massage cardiaque.
Commentaire : Quelques information sur les étude de portée sur le site Internet : Rédaction Médicale et Scientifique
Interrater Reliability of Pediatric Point-Of-Care Lung Ultrasound Findings.
Gravel CA, Monuteaux MC, Levy JA, Miller AF, Vieira RL, Bachur RG. | Am J Emerg Med. 2020 Jan;38(1):1-6
Keywords: Lung ultrasound; Pediatrics; Pneumonia; Point-of-care ultrasound
Introduction : We sought to assess interrater reliability (IRR) of lung point-of-care ultrasound (POCUS) findings among pediatric patients with suspected pneumonia.
Méthode : A convenience sample of patients between the ages of 6 months and 18 years with a clinical suspicion of pneumonia had a lung ultrasound performed by a POCUS-credentialed emergency medicine physician with subsequent expert review. Each lung zone was assessed as either normal or abnormal, and specific ultrasound findings were recorded. IRR was assessed by intraclass correlation coefficient (ICC) and kappa statistics.
Résultats : Seventy-one patients, with a total of 852 lung zones imaged, were included. The sonographer assessment of normal versus abnormal, across each of the zones, demonstrated moderate agreement with ICC 0.46 (95% CI: 0.41, 0.52) and kappa 0.56. Right-sided zones demonstrated moderate agreement [0.43 (CI 0.35, 0.51)] while left-sided zones, specifically left-sided anterior zones, showed only fair agreement [0.36 (0.28, 0.44)]. IRR varied between specific findings: ICC for B-lines 0.52 (95% CI: 0.46, 0.57), pleural effusion 0.40 (0.34, 0.45), consolidation 0.39 (0.33, 0.44), subpleural consolidation 0.31 (0.25, 0.37), and pleural line irregularity 0.16 (0.10, 0.23). A composite indicator of typical pneumonia findings (consolidation, B-lines, and pleural effusion) demonstrated moderate [ICC 0.52 (0.46, 0.57)] reliability.
Conclusion : We found moderate interrater reliability of lung POCUS findings for the assessment of pediatric patients with suspected pneumonia. B-lines had the highest reliability. Further assessment of lung POCUS is necessary to guide proper training and optimal scanning techniques to ensure adequate reliability of ultrasound findings in the assessment of pediatric pneumonia.
Conclusion (proposition de traduction) : Nous avons constaté une fiabilité interopérateur modérée pour les résultats d'échographie pulmonaire au point d'intervention pour l'évaluation des patients pédiatriques suspectés de pneumopathie. Les lignes B avaient la plus grande fiabilité. Une évaluation plus approfondie de l'échographie pulmonaire au point d'intervention est nécessaire pour guider la formation appropriée et les techniques de balayage optimales afin de garantir une fiabilité adéquate des résultats de l'échographie dans l'évaluation de la pneumopathie pédiatrique.
A New Marker Identification of High Risk Stroke Patients: Jugular Saturation.
Guven M, Akilli NB, Koylu R, Oner V, Guven M, Ozer MR. | Am J Emerg Med. 2020 Jan;38(1):7-11
Keywords: Jugular saturation; Mortality; Stroke
Introduction : The aim of this prospective study; to investigate in emergency patients with stroke the relationship between jugular saturation and National Institutes of Health Stroke Scale (NIHSS), lesion volume and mortality score.
Méthode : In this prospective study, 82 patients who fulfilling the criteria for inclusion in diagnosed with were enrolled in the study. Patients' demographic data, comorbid conditions and stroke type were recorded. The arterial blood pressure, heart rate, and consciousness were recorded at the emergency department. Glasgow Coma Score (GCS) and National Health Institutions Stroke Scale (NIHSS) scores were calculated. Complete Blood Count (CBC) and biochemical values were obtained at the time of admission to the emergency department. Arterial blood gas and jugular venous blood gas were taken and pO2, SpO2 and lactate values were recorded. Patients were grouped according to jugular desaturation (<50%). After imaging, the lesion was located by a specialist radiologist and the lesion volume was calculated. Afterwards, it was followed up by means of the hospital registry system where the patients were followed up (service, intensive care), hospitalization time and whether in-hospital mortality occurred.
Résultats : 82 patients were included in the study. Of the 82 patients, 36 (43.9%) were male and 46 (56.1%) were female. The mean age was 69.8 ± 13.3. Patients were divided into two groups, jugular venous saturation <50% and ≥50%. 16 patients with J.SpO2 <50% were detected. There was no difference between the two groups in terms of age, sex, Glasgow Coma Scale (GCS), National Health Institutions Stroke Scale (NIHSS) score, laboratory data other than hemoglobin and lesion volume (p > 0,05). In-hospital mortality occurred in 9 (13.6%) of patients with J.SpO2 ≥% 50; In the group with J.SpO2 < % 50, 6 patients (37.5%) died within the hospital and this difference was statistically significant (p < 0,05).
Conclusion : SjVO2 measurement can be used to identify high-risk stroke patients and to direct critical interventions. However, no correlation was found between this value and lesion volume and NIHSS scale.
Conclusion (proposition de traduction) : La mesure de la SjVO2 peut être utilisée pour identifier les patients à haut risque d'accident vasculaire cérébral et pour orienter les interventions critiques. Cependant, aucune corrélation n'a été trouvée entre cette valeur et le volume de la lésion et l'échelle NIHSS.
A Checklist Manifesto: Can a Checklist of Common Diagnoses Improve Accuracy in ECG Interpretation?.
Nickerson J, Taub ES, Shah K. | Am J Emerg Med. 2020 Jan;38(1):18-22
Keywords: Checklist; Diagnostic aid; Electrocardiogram; Emergency medicine; Syncope
Introduction : To determine whether a checklist of possible etiologies for syncope provided alongside ECGs helps Emergency Medicine (EM) residents identify ECG patterns more accurately than with ECGs alone.
Méthode : We developed a test of ten ECGs with syncope-related pathology from ECG Wave-Maven. We reviewed the literature and used expert consensus to develop a checklist of syncope-related pathologies commonly seen and diagnosed on ECGs. We randomized residents from three New York EM residency programs to interpret ECGs with or without a checklist embedded into the test.
Résultats : We randomized 165 residents and received completed tests from 100 (60%). Of those who responded, 39% were interns, 23% PGY2s, and 38% were PGY3s or PGY4s. We found no significant difference in overall test scores between those who read ECGs with a checklist and those who read ECGs alone. In post-hoc analysis, residents given a checklist of syncoperelated etiologies were significantly more likely to recognize Brugada (96% vs. 78%, p = 0.007), long QT (86% vs. 68%, p = 0.03) and heart block (100% vs 78%, p = 0.003) as compared to those without a checklist. Those with a checklist were more likely to overread normal ECGs (72% vs 35%, p = 0.0001) compared to those without a checklist, finding pathology where there was none.
Conclusion : Using a checklist with common syncope-related pathology when interpreting an ECG for a patient with clinical scenario of syncope may improve residents' ability to recognize some clinically important pathologies; however it could lead to increased interpretation and suspicion of pathology that is not present.
Conclusion (proposition de traduction) : L'utilisation d'une check-list pour une pathologie commune liée à la syncope lors de l'interprétation d'un ECG pour un patient avec un scénario clinique de syncope peut améliorer la capacité des résidents à reconnaître certaines pathologies cliniquement importantes ; cependant, cela pourrait conduire à une interprétation accrue et à une suspicion de pathologie non présente.
Pentraxin 3 Level in Acute Migraine Attack With Aura: Patient Management in the Emergency Department.
Gokdemir MT, Nas C, Gokdemir GS. | Am J Emerg Med. 2020 Jan;38(1):38-42
Introduction : We investigated the state of inflammation, PTX3 level and other routine inflammatory markers (high sensitivity C-reactive protein [hsCRP], and white blood cells [WBC]), in patients who presented to the emergency department (ED) with migraine. We also investigated the relationship between the clinical presentation, PTX3 level, and other routine inflammatory markers in the emergency management of these patients.
Méthode : The study included 44 patients (group 1) who presented to the ED due to a migraine attack with aura and 44 controls (group 2) with similar demographic characteristics.
Résultats : The WBC count was 8.82 ± 2.10 × 109/L in group 1 and 7.85 ± 2.04 × 109/L in group 2. The mean PTX3 level was 11.57 ± 3.99 ng/mL in patients who presented at the ED with a migraine attack, and 4.59 ± 1.28 ng/mL in controls. The differences values of WBC and PTX3 between the two groups were significant (respectively; P = 0.031, P < 0.001). ROC analyses indicated significant results for PTX3 as a marker for acute migraine attack. It had a sensitivity of 93% and specificity of 84% at a cut-off value of 5.80 ng/mL.
Conclusion : This is the first study to investigate plasma levels of PTX3 in patients with acute migraine. PTX3 as a biomarker may be used as an additional examination to the current subjective criteria to support the diagnosis of patients presenting to the ED with an acute migraine attack.
Conclusion (proposition de traduction) : C'est la première étude à étudier les taux plasmatiques de PTX3 chez les patients souffrant de migraine aiguë. Le PTX3 en tant que biomarqueur peut être utilisé comme un examen supplémentaire aux critères subjectifs actuels pour appuyer le diagnostic des patients se présentant aux urgences pour une crise de migraine aiguë.
Commentaire : Le Pentraxin 3 (PTX 3) est une nouvelle molécule qui joue un rôle clé dans la régulation des TCD4 et la production d’IL‐17A, intervenant dans la régulation de l’inflammation allergique
Developing Neural Network Models for Early Detection of Cardiac Arrest in Emergency Department.
Park SM, Lee DK, Park I, Kim D, Chang H. | Am J Emerg Med. 2020 Jan;38(1):43-49
Keywords: Cardiac arrest; Deep learning; Early warning system; Emergency department; Monitoring
Introduction : Automated surveillance for cardiac arrests would be useful in overcrowded emergency departments. The purpose of this study is to develop and test artificial neural network (ANN) classifiers for early detection of patients at risk of cardiac arrest in emergency departments.
Méthode : This is a single-center electronic health record (EHR)-based study. The primary outcome was the development of cardiac arrest within 24 h after prediction. Three ANN models were trained: multilayer perceptron (MLP), long-short-term memory (LSTM), and hybrid. These were compared to other classifiers including the modified early warning score (MEWS), logistic regression, and random forest. We used AUROC, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the comparison.
Résultats : During the study period, there were a total of 374,605 ED visits and 2,910,321 patient status updates. The ANN models (MLP, LSTM, and hybrid) achieved higher AUROC (AUROC: 0.929, 0.933, and 0.936; 95% confidential interval: 0.926-0.932, 0.930-0.936, and 0.933-0.939, respectively) compared to the non-ANN models, and the hybrid model exhibited the best performance. The ANN classifiers displayed higher performance in most of the test characteristics when the threshold levels of the classifiers were fixed to display the same positive result as those at the three MEWS thresholds (score ≥ 3, ≥4, and ≥5), and when compared with each other.
Conclusion : The ANN improves upon MEWS and conventional machine learning algorithms for the prediction of cardiac arrests in emergency departments. The hybrid ANN model utilizing both baseline and sequence information achieved the best performance.
Conclusion (proposition de traduction) : Le réseau neuronal artificiel améliore le score d'alerte précoce modifié (MEWS) et les algorithmes d'apprentissage machine classiques pour la prédiction des arrêts cardiaques dans les services d'urgence. Le modèle de réseau neuronal artificiel hybride utilisant à la fois des informations de base et de séquence a obtenu les meilleures performances.
Comparing the Effects of 3 Oxygen Delivery Methods Plus Intravenous Ketorolac on Primary Headaches: A Randomized Clinical Trial.
Saeedi M, Shahvaran SM, Ramezani M, Rafiemanesh H, Karimialavijeh E. | Am J Emerg Med. 2020 Jan;38(1):55-59
Introduction : To compare three different oxygen therapy methods in primary headaches.
Méthode : The emergency department of a university-affiliated urban hospital in Tehran, Iran.
Participants : Adult patients (aged 18 years and above) with moderate and severe primary headaches (VAS score of 4 or more).
Interventions : Participants were allocated to one of four groups. Group A (n = 34) received 30 mg of intravenous ketorolac plus oxygen at 15 l/min (min) through a non-rebreather mask (NRB), group B (n = 34) received 30 mg of intravenous ketorolac plus 7 l/min of oxygen through a 60% venturi mask, group C (n = 34) received 30 mg of intravenous ketorolac plus 4 l/min of oxygen through a nasal cannula and group D (n = 34) received 30 mg of intravenous ketorolac and room air.
Main outcomes measured: Pain was assessed using the visual analog scale (VAS) at 0, 15, 30 and 60 min after admission.
Résultats : Altogether, 136 patients were included. The most significant VAS change occurred in the NRB group at 30 min (p-value = 0.001). At this point, pain reduction in the NRB group was clinically higher than for the venturi and nasal cannula groups, but this effect had disappeared at 60 min.
Conclusion : Although the non-rebreather mask was significantly more effective at 30 min, after 60 min, none of the groups met the endpoint criterion of a 1.3-cm difference on the VAS scale.
Conclusion (proposition de traduction) : Bien que le masque haute concentration ait été significativement plus efficace à 30 min, après 60 min, aucun des groupes n'a satisfait au critère d'évaluation d'une différence de 1,3 cm sur l'échelle EVA.
Commentaire : Le kétorolac est un anti-inflammatoire non stéroïdien (AINS) de la famille des dérivés de l'acide propionique possédant une activité antalgique. Il agit par inhibition de la synthèse des prostaglandines.
Articles sur les effets de l'oxygénothérapie dans la migraine :
• Singhal AB, Maas MB, Goldstein JN, Mills BB, Chen DW, Ayata C, Kacmarek RM, Topcuoglu MA. High-flow oxygen therapy for treatment of acute migraine: A randomized crossover trial. Cephalalgia. 2017 Jul;37(8):730-736 .
• Bennett MH, French C, Schnabel A, Wasiak J, Kranke P, Weibel S. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache. Cochrane Database Syst Rev. 2015 Dec 28;(12):CD005219 .
• Huber G, Lampl C. Oxygen therapy influences episodic cluster headache and related cutaneous brush and cold allodynia. Headache. 2009 Jan;49(1):134-6 .
• Bennett MH, French C, Schnabel A, Wasiak J, Kranke P. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005219 .
Quality Retention of Chest Compression After Repetitive Practices With or Without Feedback Devices: A Randomized Manikin Study.
Zhou XL, Wang J, Jin XQ, Zhao Y, Liu RL, Jiang C. | Am J Emerg Med. 2020 Jan;38(1):73-78
Keywords: Audiovisual feedback device; Bystander; Chest compression–only CPR; Quality; Repetitive practices
Introduction : This study was designed to investigate whether an audiovisual feedback (AVF) device is beneficial for quality retention of chest compression (CC) after repetitive practices (RP).
Méthode : After completion of a 45-min CC-only cardiopulmonary resuscitation (CPR) training, participants performed 3 sessions of practices on days 1, 3, and 7 under the guidance of an instructor with (RP + AVF) or without (RP) the AVF device. CC quality was determined after each session and was retested at 3 and 12 months.
Résultats : In total, ninety-seven third year university students participated in this study. CC quality was improved after 3 sessions in both the RP and RP + AVF groups. Retests at 3 months showed that the proportions of appropriate CC rate and correct hand position were significantly decreased in the RP group as compared with the last practice (p < 0.05). However, no significant changes in CC quality were observed in the RP + AVF group. However, the proportions of appropriate CC rate, depth, and complete recoil were significantly decreased after 12 months in both RP and RP + AVF groups (p < 0.05). There were no significant differences in these parameters between the RP and the RP + AVF groups at 12 months after RP.
Conclusion : With RP, the use of an AVF device further improves initial CC skill acquisition and short-term quality retention. However, long-term quality retention is not statistically different between rescuers who receive verbal human feedback only and those who receive additional AVF device feedback after RP.
Conclusion (proposition de traduction) : Dans le cas de pratiques répétitives, l'utilisation d'un dispositif de retour d'information audiovisuel améliore encore l'acquisition initiale des compétences en matière de compression thoracique et le maintien de la qualité à court terme. Cependant, la conservation de la qualité à long terme n'est pas statistiquement différente entre les sauveteurs qui reçoivent uniquement un retour d'information verbal humain et ceux qui reçoivent un retour d'information audiovisuel supplémentaire après des pratiques répétitives.
Effect of Infarct Site on the Clinical Endpoints of Thrombolytic-Treated ST-elevation Myocardial Infarction.
Gifft K, Dohrmann M, Eniezat M, Enezate T. | Am J Emerg Med. 2020 Jan;38(1):79-82
Introduction : Some studies suggest better outcomes after the use of thrombolytics in inferior ST-elevation myocardial infarction (STEMI) compared to other locations. The goal of this study is to compare the clinical endpoints of thrombolytic-treated STEMI based on coronary artery distribution.
Méthode : The study population was extracted from the 2014 Nationwide Readmissions Data using the International Classification of Diseases, Ninth Revision, Clinical Modifications codes for STEMI, thrombolytic infusion, and complications of STEMI. Primary study endpoints included in-hospital all-cause mortality, length of hospital stay (LOS), cardiogenic shock, and mechanical complications of STEMI.
Résultats : A principal diagnosis of thrombolytic-treated STEMI was identified for in 1231 patients (mean age 61.5 years; 26.5% female). Four hundred and thirty-one STEMIs occurred in the left anterior descending (LAD) artery distribution, 124 in the left circumflex (LCX) artery distribution, and 676 in the right coronary artery (RCA) distribution. In comparison to the LAD and LCX distributions, thrombolytic-treated STEMIs in the RCA distribution were associated with lower mortality (6.5% with LAD, 5.7% with LCX, and 3.6% with RCA; p = 0.02), fewer cardiogenic shock (12.3% with LAD, 12.1% with LCX, and 7.7% with RCA; p = 0.01), and shorter LOS (4.5 days with LAD, 3.9 with LCX, and 3.6 days with RCA; p < 0.01). Mechanical complications showed no significant difference based on coronary distribution (2.3% with LAD, 3.2% with LCX, and 1.2% with RCA; p = 0.17).
Conclusion : Thrombolytic-treated STEMIs in the RCA distribution were associated with lower in-hospital all-cause mortality, cardiogenic shock, and shorter LOS. Mechanical complications were not different based on coronary distribution.
Conclusion (proposition de traduction) : Les infarctus du myocarde avec surélévation du segment ST dans le territoire de l'artère coronaire droite traités par thrombolyse ont été associés à une diminution de la mortalité toutes causes confondues en milieu hospitalier, à un choc cardiogénique et à une durée d'hospitalisation plus courte. Les complications mécaniques n'étaient pas différentes selon le territoire coronaire.
The Difference of Subcutaneous Digital Nerve Block Method Efficacy According to Injection Location.
Choi S, Cho YS, Kang B, Kim GW, Han S. | Am J Emerg Med. 2020 Jan;38(1):95-98
Keywords: Digital anesthesia; Fear; Lidocaine; Phalanx; Volar block
Introduction : Finger injuries are commonly attended to in the emergency department, and digital nerve block is a frequently performed procedure for such injuries. This study compared the efficacy levels of the subcutaneous method according to the different injection sites.
Méthode : This was a simulation study for medical students who rendered medical service at the emergency department. One group performed subcutaneous injection of lidocaine at the volar side of the metacarpophalangeal (MCP) joint, while another group injected at the volar side of the proximal interphalangeal (PIP) joint. The time to anesthesia was measured at 30-s intervals. Pain at the injection site was measured using the numeric rating scale (NRS), while the length from the fingertip to the injection site and the circumference of the injection site were measured.
Résultats : A total of 82 participants were included, with 41 under the MCP joint group and the rest under the PIP joint group. The mean length from the fingertip to the needling point was 3.62 ± 0.63 cm in the PIP joint group and 5.90 ± 0.65 cm in the MCP joint group, while the mean circumference of the needling point was 4.93 ± 0.51 and 5.61 ± 0.58 cm, and the mean time to anesthesia was 2.55 ± 1.11 and 3.79 ± 1.28 min (p-value < 0.001), respectively. The median value of NRS was 4 in both groups (p-value = 0.921). Length was correlated with the time to anesthesia (p-value = 0.018).
Conclusion : Injection into the PIP joint showed the same anesthetic effect as injection into the MCP joint, but this effect occurred faster in the former.
Conclusion (proposition de traduction) : L'injection dans l'articulation interphalangienne proximale a montré le même effet anesthésique que l'injection dans l'articulation métacarpophalangienne, mais cet effet s'est produit plus rapidement dans la première.
Plasma Oxidative-Stress Parameters and Prolidase Activity in Patients With Various Causes of Abdominal Pain.
Albayrak L, Sogut O, Çakmak S, Gökdemir MT, Kaya H. | Am J Emerg Med. 2020 Jan;38(1):99-104
Keywords: Acute abdominal pain; OSI; Oxidative stress; Prolidase; TAS; TOS
Introduction : We aimed to investigate the predictive power of plasma prolidase activity and oxidative-stress parameters for distinguishing in patients with various causes of non-traumatic abdominal pain who presented to the emergency department.
Méthode : This study enrolled 100 consecutive adult patients and 100 age- and sex-matched healthy controls. The patients were divided into surgically treated patients (STP); medically treated patients (MTP) and nonspecific abdominal pain (NSAP) patients. As predictors of early oxidative changes, the plasma prolidase activity, total oxidant status (TOS), total antioxidant status (TAS), and oxidative stress index (OSI) were assessed using a novel automated method.
Résultats : No significant difference was observed between the patients and the controls with respect to age or sex (p = 0.837 and 0.188, respectively). The plasma TOS, OSI value, and prolidase activity were significantly higher in the patients with abdominal pain than in the controls (p < 0.001, p = 0.001, and p < 0.001, respectively); however, there was no significant difference in the TAS (p = 0.211). The mean plasma TOS, OSI value, and prolidase activity differed significantly among the three groups (p < 0.001, p = 0.001, and p < 0.001, respectively). The STP had the highest TOS and prolidase activity. However, there was no significant difference in the mean plasma TAS in either group of patients (p = 0.419).
Conclusion : The plasma prolidase activity and TOS level, as biomarkers of oxidative stress, enable discrimination of patients with NSAP from those with surgical abdominal pain that requires emergent surgical treatment.
Conclusion (proposition de traduction) : L'activité de la prolidase plasmatique et le niveau du statut d'oxydant total, en tant que biomarqueurs du stress oxydatif, permettent de distinguer les patients souffrant de douleurs abdominales non spécifiques de ceux qui souffrent de douleurs abdominales chirurgicales nécessitant un traitement chirurgical d'urgence.
Can Physicians Detect Hyperkalemia Based on the Electrocardiogram?.
Rafique Z, Aceves J, Espina I, Peacock F, Sheikh-Hamad D, Kuo D. | Am J Emerg Med. 2020 Jan;38(1):105-108
Introduction : Although there is no consensus on how to use an electrocardiogram (ECG) in patients with hyperkalemia, physicians often obtain it in the acute setting when diagnosing and treating hyperkalemia. The objective of this study is to evaluate if physicians are able to detect hyperkalemia based on the ECG.
Méthode : The study was conducted at a large county hospital with a population of end stage renal disease (ESRD) patients who received hemodialysis (HD) solely on an emergent basis. Five hundred twenty eight ECGs from ESRD patients were evaluated. The prevalence of hyperkalemia was approximately 60% in this cohort, with at least half of them in the severe hyperkalemia range (K ≥ 6.5 mEq/L).
Résultats : The mean sensitivity and specificity of the emergency physicians detecting hyperkalemia were 0.19 (± 0.16) and 0.97(± 0.04) respectively. The mean positive predictive value of evaluators for detecting hyperkalemia was 0.92 (±0.13) and the mean negative predictive value was 0.46 (± 0.05). In severe hyperkalemia (K ≥ 6.5 mEq/L), the mean sensitivity improved to 0.29 (± 0.20), while specificity decreased to 0.95 (±0.07).
Conclusion : An ECG is not a sensitive method of detecting hyperkalemia and should not be relied upon to rule it out. However, the ECG has a high specificity for detecting hyperkalemia and could be used as a rule in test.
Conclusion (proposition de traduction) : Un ECG n'est pas une méthode sensible de détection de l'hyperkaliémie et ne doit pas être utilisé pour l'exclure. Cependant, l'ECG a une grande spécificité pour détecter l'hyperkaliémie et pourrait être utilisé comme règle dans les tests.
Factors Associated With First-Pass Success of Emergency Endotracheal Intubation.
Jung W, Kim J. | Am J Emerg Med. 2020 Jan;38(1):109-113
Keywords: Advanced airway; Critical care; Emergency department; Endotracheal intubation
Introduction : Endotracheal intubation is frequently performed in emergency departments (EDs). First-pass success is important because repeated attempts are associated with poor outcomes. We sought to identify factors associated with first-pass success in emergency endotracheal intubation.
Méthode : We analyzed emergency orotracheal intubations on adult patients in an ED located in South Korea from Jan. 2013 to Dec. 2016. Various operator-, procedure- and patient-related factors were screened with univariable logistic regression. Using variables with P-values less than 0.2, a multiple logistic regression model was constructed to identify independent predictors.
Résultats : There were 1154 eligible cases. First-pass success was achieved in 974 (84.4%) cases. Among operator-related factors, clinical experience (OR: 2.93, 5.26, 3.80 and 5.71; 95% CI: 1.62-5.26, 2.80-9.84, 1.81-8.13 and 2.07-18.67 for PGY 3, 4 and 5 residents and EM specialists, respectively, relative to PGY 2 residents) and physician based outside the ED (OR: 0.10; 95% CI: 0.04-0.25) were independently associated with first-pass success. There was no statistically or clinically significant difference for first-pass success rate as determined by operator's gender (83.6% for female vs. 84.8% for male; 95% CI for difference: -3.1% to 5.8%). Among patient-related factors, restricted mouth opening (OR: 0.47; 95% CI: 0.31-0.72), restricted neck extension (OR: 0.57; 95% CI: 0.39-0.85) and swollen tongue (OR: 0.46; 95% CI: 0.28-0.77) were independent predictors of first-pass success.
Conclusion : Operator characteristics, including clinical experience and working department, and patient characteristics, including restricted mouth opening, restricted neck extension and swollen tongue, were independent predictors of first-pass success in emergency endotracheal intubation.
Conclusion (proposition de traduction) : Les caractéristiques de l'opérateur, notamment son expérience clinique et le service dans lequel il travaille, et les caractéristiques du patient, notamment la limitation de l'ouverture buccale, la mobilité restreinte du cou et le volume de la langue, étaient des critères prédictifs indépendants du succès du premier essai de l'intubation trachéale aux urgences.
Role of High-Dose Intravenous Nitrates in Hypertensive Acute Heart Failure.
Wang K, Samai K. | Am J Emerg Med. 2020 Jan;38(1):132-137
Keywords: Bolus-dose nitroglycerin; High-dose nitroglycerin; Hypertensive acute heart failure; Nitrates; Nitroglycerin; Pulmonary edema
Introduction : Patients with hypertensive acute heart failure (H-AHF) can decompensate rapidly and require immediate medical attention; the use of high-dose nitroglycerin is a topic of growing interest in this patient population.
Méthode : The purpose of this review is to provide an evidence-based approach for the utilization of high-dose nitrates in the emergent management of H-AHF.
Discussion : Two randomized controlled trials, three prospective studies, two retrospective cohorts, two case series, and one case report were evaluated. Level of robust evidence and heterogeneity limit the ability to draw strong conclusions regarding the use of high-dose nitrates. Despite these limitations, high-dose nitrates appeared to have an overall beneficial effect across all studies reviewed, including lower rates of mechanical ventilation, improvement in blood pressure, shorter LOS, and lower rates of ICU admission. Adverse effects were mild and infrequently reported.
Conclusion : High-dose nitrates are likely safe and may be effective, as demonstrated in the studies reviewed. High-dose NTG may be appropriate in H-AHF patients presenting with severe respiratory distress and SBP ≥160 mmHg or MAP ≥120 mmHg. Future well-designed randomized controlled trials are needed to elucidate optimal dosing strategies and confirm safety and efficacy of high-dose nitrates.
Conclusion (proposition de traduction) : Les dérivés nitrés à forte dose sont probablement sans danger et peuvent être efficaces, comme le démontrent les études examinées. Une dose élevée de nitroglycérine peut être appropriée chez les patients souffrant d'insuffisance cardiaque aiguë hypertensive et présentant une détresse respiratoire sévère et une pression artérielle systolique ≥ 160 mmHg ou une MAP ≥ 120 mmHg. De futurs essais contrôlés randomisés bien conçus sont nécessaires pour élucider les stratégies de dosage optimales et confirmer la sécurité et l'efficacité des dérivés nitrés à forte dose.
Can physicians detect hyperkalemia based on the electrocardiogram?.
Rafique Z, Aceves J, Espina I, Peacock F, Sheikh-Hamad D, Kuo D. | Am J Emerg Med. 2020 Jan;38(1):105-108
Introduction : Although there is no consensus on how to use an electrocardiogram (ECG) in patients with hyperkalemia, physicians often obtain it in the acute setting when diagnosing and treating hyperkalemia. The objective of this study is to evaluate if physicians are able to detect hyperkalemia based on the ECG.
Méthode : The study was conducted at a large county hospital with a population of end stage renal disease (ESRD) patients who received hemodialysis (HD) solely on an emergent basis. Five hundred twenty eight ECGs from ESRD patients were evaluated. The prevalence of hyperkalemia was approximately 60% in this cohort, with at least half of them in the severe hyperkalemia range (K ≥ 6.5 mEq/L).
Résultats : The mean sensitivity and specificity of the emergency physicians detecting hyperkalemia were 0.19 (± 0.16) and 0.97(± 0.04) respectively. The mean positive predictive value of evaluators for detecting hyperkalemia was 0.92 (±0.13) and the mean negative predictive value was 0.46 (± 0.05). In severe hyperkalemia (K ≥ 6.5 mEq/L), the mean sensitivity improved to 0.29 (± 0.20), while specificity decreased to 0.95 (±0.07).
Conclusion : An ECG is not a sensitive method of detecting hyperkalemia and should not be relied upon to rule it out. However, the ECG has a high specificity for detecting hyperkalemia and could be used as a rule in test.
Conclusion (proposition de traduction) : Un ECG n'est pas une méthode sensible de détection de l'hyperkaliémie et ne doit pas être invoqué pour l'exclure. Cependant, l'ECG a une spécificité élevée pour la détection de l'hyperkaliémie et pourrait être utilisé en règle générale dans le test.
Malpractice Liability and Health Care Quality: A Review.
Mello MM, Frakes MD, Blumenkranz E, Studdert DM. | JAMA. 2020 Jan 28;323(4):352-366
Introduction : The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients.
Objective : To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety.
Méthode : Systematic search of multiple databases for studies published between January 1, 1990, and November 25, 2019, examining the relationship between malpractice liability risk measures and health outcomes or structural and process indicators of health care quality.
Data extraction and synthesis: Information on the exposure and outcome measures, results, and acknowledged limitations was extracted by 2 reviewers. Meta-analytic pooling was not possible due to variations in study designs; therefore, studies were summarized descriptively and assessed qualitatively.
Main outcomes and measures: Associations between malpractice risk measures and health care quality and safety outcomes. Exposure measures included physicians' malpractice insurance premiums, state tort reforms, frequency of paid claims, average claim payment, physicians' claims history, total malpractice payments, jury awards, the presence of an immunity from malpractice liability, the Centers for Medicare & Medicaid Services' Medicare malpractice geographic practice cost index, and composite measures combining these measures. Outcome measures included patient mortality; hospital readmissions, avoidable admissions, and prolonged length of stay; receipt of cancer screening; Agency for Healthcare Research and Quality patient safety indicators and other measures of adverse events; measures of hospital and nursing home quality; and patient satisfaction.
Résultats : Thirty-seven studies were included; 28 examined hospital care only and 16 focused on obstetrical care. Among obstetrical care studies, 9 found no significant association between liability risk and outcomes (such as Apgar score and birth injuries) and 7 found limited evidence for an association. Among 20 studies of patient mortality in nonobstetrical care settings, 15 found no evidence of an association with liability risk and 5 found limited evidence. Among 7 studies that examined hospital readmissions and avoidable initial hospitalizations, none found evidence of an association between liability risk and outcomes. Among 12 studies of other measures (eg, patient safety indicators, process-of-care quality measures, patient satisfaction), 7 found no association between liability risk and these outcomes and 5 identified significant associations in some analyses.
Conclusion : In this systematic review, most studies found no association between measures of malpractice liability risk and health care quality and outcomes. Although gaps in the evidence remain, the available findings suggested that greater tort liability, at least in its current form, was not associated with improved quality of care.
Conclusion (proposition de traduction) : Dans cet examen systématique, la plupart des études n'ont trouvé aucune association entre les mesures du risque de responsabilité pour faute professionnelle et la qualité et les résultats des soins de santé. Bien que des lacunes subsistent dans les preuves, les résultats disponibles suggèrent qu'une responsabilité délictuelle accrue, du moins sous sa forme actuelle, n'est pas associée à une amélioration de la qualité des soins.
Evolving Issues in Oxygen Therapy in Acute Care Medicine.
Munshi L, Ferguson ND. | JAMA. 2020 Jan 24
Editorial : Oxygen therapy is one of the most ubiquitously applied therapies in modern medicine. Clinicians usually react rapidly to declining oxygen saturations. Although this response is appropriate in the setting of hypoxia, there are many circumstances in which excess oxygen is indiscriminately administered for extended periods.
Conclusion : Many important questions remain including thresholds and duration of oxygen that may induce harm, optimal ways to study excess oxygen (FIO2, saturation, or PaO2), interactions with acid-base disturbances, ventilator–induced lung injury or shock, and long- term consequences. It is likely that there are different clinical conditions in which liberal oxygen may induce harm when combined with some degree of exogenous stimuli that causes a proliferation of reactive oxygen species. The liberal oxygen threshold at which this occurs likely varies across different conditions and different intensities of the exogenous stimuli. To date, more than 70 clinical trials of oxygen therapy have been registered and are ongoing or recently completed. The results of these studies will further inform the degree to which inappropriately titrated oxygen has contributed to iatrogenic adverse events and will help define the appropriate use and dose of oxygen in acute care medicine.
Conclusion (proposition de traduction) : De nombreuses questions importantes restent en suspens, notamment les seuils et la durée de l'oxygènothérapie qui peuvent être nocifs, les moyens optimaux d'étudier l'excès d'administration de l'oxygène (FIO2, saturation ou PaO2), les interactions avec les perturbations acido-basiques, les lésions ou chocs pulmonaires induits par le respirateur et les conséquences à long terme.
Il est probable qu'il existe différentes conditions cliniques dans lesquelles l'oxygènothérapie libérale peut induire des dommages lorsqu'il est combiné à un certain degré de stimuli exogènes qui provoquent une prolifération de dérivés réactifs de l'oxygène. Le seuil d'oxygène libéral auquel cela se produit varie probablement en fonction des différentes conditions et des différentes intensités des stimuli exogènes.
À ce jour, plus de 70 essais cliniques d'oxygénothérapie ont été enregistrés et sont en cours ou récemment terminés. Les résultats de ces études permettront de mieux comprendre dans quelle mesure l'oxygène mal dosé a contribué aux effets indésirables iatrogènes et de définir l'utilisation et la dose appropriées d'oxygène en médecine de soins aigus.
Commentaire : Les dérivés réactifs de l'oxygène (DRO) ou espèces réactives de l'oxygène (ERO), en anglais reactive oxygen species ou ROS, sont des espèces chimiques oxygénées telles que des radicaux libres, des ions oxygénés et des peroxydes, rendus chimiquement très réactifs par la présence d'électrons de valence non appariés.
Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial.
Fujii T, Luethi N, Young PJ, Frei DR, Eastwood GM, French CJ, Deane AM, Shehabi Y, Hajjar LA, Oliveira G, Udy AA, Orford N, Edney SJ, Hunt AL, Judd HL, Bitker L, Cioccari L, Naorungroj T, Yanase F, Bates S, McGain F, Hudson EP, Al-Bassam W, Dwivedi DB, Peppin C, McCracken P, Orosz J, Bailey M, Bellomo R; VITAMINS Trial Investigators. | JAMA. 2020 Jan 17
Introduction : It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock.
Objective : To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock.
Méthode : Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019.
Interventions : Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days.
Main outcomes and measures: The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality.
Résultats : Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was -0.6 hours (95% CI, -8.3 to 7.2 hours; P = .83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69-2.00). No serious adverse events were reported.
Conclusion : In patients with septic shock, treatment with intravenous vitamin C, hydrocortisone, and thiamine, compared with intravenous hydrocortisone alone, did not significantly improve the duration of time alive and free of vasopressor administration over 7 days. The finding suggests that treatment with intravenous vitamin C, hydrocortisone, and thiamine does not lead to a more rapid resolution of septic shock compared with intravenous hydrocortisone alone.
Conclusion (proposition de traduction) : Chez les patients en état de choc septique, le traitement par vitamine C, hydrocortisone et thiamine par voie intraveineuse, comparé à l'hydrocortisone seule, n'a pas amélioré de manière significative la durée de vie et l'absence d'administration de vasopresseurs pendant 7 jours. Cette découverte suggère que le traitement par vitamine C, hydrocortisone et thiamine par voie intraveineuse ne permet pas une résolution plus rapide du choc septique que l'hydrocortisone par voie intraveineuse seule.
Oseltamivir Plus Usual Care Versus Usual Care for Influenza-Like Illness in Primary Care: An Open-Label, Pragmatic, Randomised Controlled Trial.
Butler CC, van der Velden AW, Bongard E, Saville BR, Holmes J, Coenen S, Cook J, Francis NA, Lewis RJ, Godycki-Cwirko M, Llor C, Chlabicz S, Lionis C, Seifert B, Sundvall PD, Colliers A, Aabenhus R, Bjerrum L, Jonassen Harbin N, Lindbæk M, Glinz D, Bucher HC, Kovács B, Radzeviciene Jurgute R, Touboul Lundgren P, Little P, Murphy AW, De Sutter A, Openshaw P, de Jong MD, Connor JT, Matheeussen V, Ieven M, Goossens H, Verheij TJ. | Lancet. 2020 Jan 4;395(10217):42-52
Introduction : Antivirals are infrequently prescribed in European primary care for influenza-like illness, mostly because of perceived ineffectiveness in real world primary care and because individuals who will especially benefit have not been identified in independent trials. We aimed to determine whether adding antiviral treatment to usual primary care for patients with influenza-like illness reduces time to recovery overall and in key subgroups.
Méthode : We did an open-label, pragmatic, adaptive, randomised controlled trial of adding oseltamivir to usual care in patients aged 1 year and older presenting with influenza-like illness in primary care. The primary endpoint was time to recovery, defined as return to usual activities, with fever, headache, and muscle ache minor or absent. The trial was designed and powered to assess oseltamivir benefit overall and in 36 prespecified subgroups defined by age, comorbidity, previous symptom duration, and symptom severity, using a Bayesian piece-wise exponential primary analysis model.
Résultats : Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20-1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74-1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30-1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00-5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group.
Conclusion : Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2-3 days sooner.
Conclusion (proposition de traduction) : Les patients en soins primaires présentant un syndrome grippal traités par l'oseltamivir ont récupéré un jour plus tôt en moyenne que ceux pris en charge par les seuls soins habituels. Les patients plus âgés et plus malades présentant des comorbidités et une durée des symptômes antérieure plus longue ont récupéré 2 à 3 jours plus tôt.
Alcohol Abstinence in Drinkers with Atrial Fibrillation.
Voskoboinik A, Kalman JM, De Silva A, Nicholls T, Costello B, Nanayakkara S, Prabhu S, Stub D, Azzopardi S, Vizi D, Wong G, Nalliah C, Sugumar H, Wong M, Kotschet E, Kaye D, Taylor AJ, Kistler PM. | N Engl J Med. 2020 Jan 2;382(1):20-28
Introduction : Excessive alcohol consumption is associated with incident atrial fibrillation and adverse atrial remodeling; however, the effect of abstinence from alcohol on secondary prevention of atrial fibrillation is unclear.
Méthode : We conducted a multicenter, prospective, open-label, randomized, controlled trial at six hospitals in Australia. Adults who consumed 10 or more standard drinks (with 1 standard drink containing approximately 12 g of pure alcohol) per week and who had paroxysmal or persistent atrial fibrillation in sinus rhythm at baseline were randomly assigned in a 1:1 ratio to either abstain from alcohol or continue their usual alcohol consumption. The two primary end points were freedom from recurrence of atrial fibrillation (after a 2-week "blanking period") and total atrial fibrillation burden (proportion of time in atrial fibrillation) during 6 months of follow-up.
Résultats : Of 140 patients who underwent randomization (85% men; mean [±SD] age, 62±9 years), 70 were assigned to the abstinence group and 70 to the control group. Patients in the abstinence group reduced their alcohol intake from 16.8±7.7 to 2.1±3.7 standard drinks per week (a reduction of 87.5%), and patients in the control group reduced their alcohol intake from 16.4±6.9 to 13.2±6.5 drinks per week (a reduction of 19.5%). After a 2-week blanking period, atrial fibrillation recurred in 37 of 70 patients (53%) in the abstinence group and in 51 of 70 patients (73%) in the control group. The abstinence group had a longer period before recurrence of atrial fibrillation than the control group (hazard ratio, 0.55; 95% confidence interval, 0.36 to 0.84; P = 0.005). The atrial fibrillation burden over 6 months of follow-up was significantly lower in the abstinence group than in the control group (median percentage of time in atrial fibrillation, 0.5% [interquartile range, 0.0 to 3.0] vs. 1.2% [interquartile range, 0.0 to 10.3]; P = 0.01).
Conclusion : Abstinence from alcohol reduced arrhythmia recurrences in regular drinkers with atrial fibrillation.
Conclusion (proposition de traduction) : L'abstinence chez l'éthylique chronique régulier avec fibrillation atriale réduit les récidives d'arythmie.
Conservative versus Interventional Treatment
for Spontaneous Pneumothorax.
Lee YCG, Nowitz M, Read CA, Simpson G, Smith JA, Summers QA, Weatherall M, Beasley R; PSP Investigators. | N Engl J Med. 2020 Jan 30;382(5):405-415
Randomized Controlled Trial
Introduction : Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown.
Méthode : In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks.
Résultats : A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management.
Conclusion : Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events.
Conclusion (proposition de traduction) : Bien que le résultat principal n'ait pas été statistiquement robuste pour les hypothèses conservatrices sur les données manquantes, l'essai fournit des preuves modestes que la gestion conservatrice du pneumothorax spontané primaire n'était pas inférieure à la gestion interventionnelle, avec un risque moindre d'événements indésirables graves.
Retrospective Analysis of eFAST Ultrasounds Performed on Trauma Activations at an Academic level-1 Trauma Center.
Shwe S, Witchey L, Lahham S, Kunstadt E, Shniter I, Fox JC. | World J Emerg Med. 2020;11(1):12-17
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2020.01.002 | Télécharger l'article au format
Keywords: Blunt trauma; Emergency medicine; Focused assessment with sonography in trauma; Point-of-care ultrasound; Trauma activation.
Introduction : Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients.
Méthode : This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was cross-referenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented.
Résultats : We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient's chart although an eFAST was recorded and reviewed during ultrasound quality assurance.
Conclusion : A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.
Conclusion (proposition de traduction) : Une proportion importante de patients victime de traumatismes ont bénéficié d'eFAST mais n'ont pas été documentés ni facturés. Le manque de documentation était multifactoriel. Les programmes d'échographie d'urgence nécessitent un remboursement approprié pour soutenir la formation, l'accréditation, l'équipement, l'assurance qualité et l'entretien des appareils. Notre étude démontre une absence significative de documentation adéquate, ce qui entraîne une perte potentielle de revenus pour un programme d'échographie d'urgence.
Commentaire : La mobilisation de l'équipe de traumatologie (trauma activations) consiste à appeler un certain nombre de membres du personnel hospitalier pour qu'ils se rendent aux urgences le plus rapidement possible.
Les personnes contactées peuvent être un chirurgien traitant, deux ou trois résidents en chirurgie, un anesthésiste ou un résident en anesthésie, un inhalothérapeute, une infirmière en soins intensifs, une infirmière de salle d'opération, un technicien en radiologie, un aumônier et divers autres. L'équipe de traumatologie évalue le patient et si des blessures graves sont présentes, elle diagnostique et traite rapidement le problème.
On constate une énorme variation dans les frais de mobilisation des moyens de traumatologie, allant de 1 112 $ dans un hôpital à un maximum de 50 659 $ dans un autre.
A Pulmonary Source of Infection in Patients With Sepsis-Associated Acute Kidney Injury Leads to a Worse Outcome and Poor Recovery of Kidney Function.
Pan SM, Gao CJ. | World J Emerg Med. 2020;11(1):18-26
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2020.01.003 | Télécharger l'article au format
Keywords: Acute kidney injury; Infection source; Lung injury; Renal function; Sepsis.
Introduction : Hospital mortality rates are higher among patients with sepsis-associated acute kidney injury (SA-AKI) than among patients with sepsis. However, the pathogenesis underlying SA-AKI remains unclear. We hypothesized that the source of infection affects development of SA-AKI. We aim to explore the relationship between the anatomical source of infection and outcome in patients with SA-AKI.
Méthode : Between January 2013 and January 2018, 113 patients with SA-AKI admitted to our Emergency Center were identified and divided into two groups: those with pulmonary infections and those with other sources of infection. For each patient, we collected data from admission until either discharge or death. We also recorded the clinical outcome after 90 days for the discharged patients.
Résultats : The most common source of infection was the lung (52/113 cases, 46%), followed by gastrointestinal (GI) (25/113 cases, 22.1%) and urinary (22/113, 19.5%) sources. Our analysis showed that patients with SA-AKI had a significantly worse outcome (30/52 cases, P<0.001) and poorer kidney recovery (P=0.015) with pulmonary sources of infection than those infected by another source. Data also showed that patients not infected by a pulmonary source more likely experienced shock (28/61 cases, P=0.037).
Conclusion : This study demonstrated that the source of infection influenced the outcome of SA-AKI patients in an independent manner. Lung injury may influence renal function in an as-yet undetermined manner as the recovery of kidney function was poorer in SA-AKI patients with a pulmonary source of infection.
Conclusion (proposition de traduction) : Cette étude a démontré que la source de l'infection influençait de manière indépendante le résultat des patients souffrant d'insuffisance rénales aiguës associées à une septicémie. Les lésions pulmonaires peuvent influencer la fonction rénale d'une manière encore indéterminée, car la récupération de la fonction rénale était plus faible chez les patients présentant une insuffisance rénale aiguë associée à une septicémie et présentant une infection pulmonaire.