Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study.
Brown CA 3rd, Kaji AH, Fantegrossi A, Carlson JN, April MD, Kilgo RW, Walls RM; National Emergency Airway Registry (NEAR) Investigators. | Acad Emerg Med. 2020 Feb;27(2):100-108
Introduction : The objective was to compare first-attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A-DL) with unaided video laryngoscopy (VL) in adult emergency department (ED) intubations.
Méthode : This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A-DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA-VL) and standard-geometry VL (SG-VL). We report differences in first-attempt intubation success and peri-intubation adverse events with cluster-adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI.
Résultats : We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A-DL or unaided VL on first attempt. A-DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A-DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First-attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A-DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry-recorded difficult airway predictors revealed first-attempt success was higher with all unaided VL compared with any A-DL (adjusted OR [AOR] = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA-VL and SG-VL compared with any A-DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score-adjusted odds for first-attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5).
Conclusion : Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first-attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.
Conclusion (proposition de traduction) : La vidéolaryngoscopie utilisée sans aucune manœuvre ni dispositif ou technique d'amélioration des conditions de visualisation de la glotte entraîne un succès à la première tentative plus élevé que le laryngoscopie directe qui nécessite d'être amélioré par l'utilisation d'une bougie, d'une manoeuvre de manipulation externe du larynx, d'un positionnement proclive avec tête surélevée (« ramp position ») ou de leur combinaison.
Commentaire : Ramping position
Randomized Controlled Trial of Adult Therapeutic Coloring for the Management of Significant Anxiety in the Emergency Department.
Rajendran N, Mitra TP, Shahrestani S, Coggins A. | Acad Emerg Med. 2020 Feb;27(2):92-99
Introduction : Anxiety and acute distress are significant concerns in the emergency department (ED). Adult coloring books are often utilized as an effective means of relaxation in waiting rooms and newsstands, but there are no reported randomized trials examining their effectiveness as a treatment for anxiety.
Méthode : We set out to examine the effectiveness of adult coloring books using a randomized placebo-controlled trial at a university-affiliated tertiary ED. Anxiety was measured using a validated self-reporting score, the Hospital Anxiety and Depression Scale (HADS-A), with a range of 0 to 21. Patients with HADS-A ≥ 7 were randomly assigned to either an adult coloring pack (n = 26) or placebo pack (n = 27). The primary outcome measure was the within-patient change in HADS-A scores following 2 hours of exposure.
Résultats : A convenience sample of 117 patients were screened, and 53 patients were randomized. Characteristics of allocated groups were similar in terms of sex, diagnosis, and ethnicity. A higher proportion of intervention subjects spent ≥1 hour engaged with their activity (46.2% vs. 4.0%, p = 0.01). For the primary outcome measure, the mean within-patient decrease in HADS-A score at 2 hours for intervention subjects was 3.7 (95% confidence interval [CI] = 2.4 to 5.1, p < 0.001) versus a decrease of 0.3 (95% CI = -0.6 to 1.2, p = 0.51) in the placebo group.
Conclusion : Among ED patients, exposure to adult coloring books resulted in lower self-reported levels of anxiety at 2 hours compared to placebo.
Conclusion (proposition de traduction) : Chez les patients des urgences, l'utilisation de livres à colorier pour adultes a entraîné des niveaux d'anxiété plus faibles à 2 heures que le placebo.
Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score.
Probst MA, Gibson T, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Hollander JE, Nicks BA, Nishijima DK, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. | Ann Emerg Med. 2020 Feb;75(2):147-158
Introduction : Older adults with syncope are commonly treated in the emergency department (ED). We seek to derive a novel risk-stratification tool to predict 30-day serious cardiac outcomes.
Méthode : We performed a prospective, observational study of older adults (≥60 years) with unexplained syncope or near syncope who presented to 11 EDs in the United States. Patients with a serious diagnosis identified in the ED were excluded. We collected clinical and laboratory data on all patients. Our primary outcome was 30-day all-cause mortality or serious cardiac outcome.
Résultats : We enrolled 3,177 older adults with unexplained syncope or near syncope between April 2013 and September 2016. Mean age was 73 years (SD 9.0 years). The incidence of the primary outcome was 5.7% (95% confidence interval [CI] 4.9% to 6.5%). Using Bayesian logistic regression, we derived the FAINT score: history of heart failure, history of cardiac arrhythmia, initial abnormal ECG result, elevated pro B-type natriuretic peptide, and elevated high-sensitivity troponin T. A FAINT score of 0 versus greater than or equal to 1 had sensitivity of 96.7% (95% CI 92.9% to 98.8%) and specificity 22.2% (95% CI 20.7% to 23.8%), respectively. The FAINT score tended to be more accurate than unstructured physician judgment: area under the curve 0.704 (95% CI 0.669 to 0.739) versus 0.630 (95% CI 0.589 to 0.670).
Conclusion : Among older adults with syncope or near syncope of potential cardiac cause, a FAINT score of zero had a reasonably high sensitivity for excluding death and serious cardiac outcomes at 30 days. If externally validated, this tool could improve resource use for this common condition.
Conclusion (proposition de traduction) : Chez les adultes âgés présentant une syncope ou une quasi-syncope de possible cause cardiaque, un score FAINT à zéro avait une sensibilité raisonnablement élevée pour exclure le décès et les conséquences cardiaques graves à 30 jours. S'il est validé en externe, cet outil pourrait améliorer l'utilisation des ressources pour cette situation courante.
Commentaire : Sheldon R, Rose S, Connolly S, Ritchie D, Koshman ML, Frenneaux M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur Heart J. 2006 Feb;27(3):344-50 .
Demystifying Lactate in the Emergency Department.
Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. | Ann Emerg Med. 2020 Feb;75(2):287-298
Editorial : The role of lactic acid and its conjugate base, lactate, has evolved during the past decade in the care of patients in the emergency department (ED). A recent national sepsis quality measure has led to increased use of serum lactate in the ED, but many causes for hyperlactatemia exist outside of sepsis. We provide a review of the biology of lactate production and metabolism, the many causes of hyperlactatemia, and evidence on its use as a marker in prognosis and resuscitation. Additionally, we review the evolving role of lactate in sepsis care. We provide recommendations to aid lactate interpretation in the ED and highlight areas for future research.
Conclusion : Lactate measurement is an important tool for clinicians in the ED. Significant advances have occurred in our understanding of the physiology and interpretation of lactate level, and it is now clear that lactate participates in many different physiologic processes. An oversimplified interpretation may mislead providers, but the savvy provider may recognize that lactate level may be the result of overproduction, impaired elimination, or both, which may guide him or her toward appropriate interventions. With a more nuanced understanding of lactate level interpretation, this important diagnostic and prognostic tool becomes even more beneficial.
Conclusion (proposition de traduction) : La mesure du taux de lactate est un outil important pour les cliniciens des services d'urgence. Des progrès significatifs ont été réalisés dans notre compréhension de la physiologie et de l'interprétation du taux de lactate, et il est maintenant clair que le lactate participe à de nombreux processus physiologiques différents. Une interprétation trop simplifiée peut induire en erreur les praticien, mais le praticien avisé peut reconnaître que le taux de lactate peut être le résultat d'une surproduction, d'une mauvaise élimination, ou des deux, ce qui peut le guider vers des interventions appropriées. Avec une compréhension plus nuancée de l'interprétation des niveaux de lactate, cet important outil de diagnostic et de pronostic devient encore plus utile.
Commentaire : Articles similaires :
• Lee SW, Hong YS, Park DW, Choi SH, Moon SW, Park JS, Kim JY, Baek KJ. Lactic acidosis not hyperlactatemia as a predictor of in hospital mortality in septic emergency patients. Emerg Med J. 2008 Oct;25(10):659-65 .
• Kushimoto S, Akaishi S, Sato T, Nomura R, Fujita M, Kudo D, Kawazoe Y, Yoshida Y, Miyagawa N. Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients. Acute Med Surg. 2016 May 16;3(4):293-297 .
• an den Nouland DP, Brouwers MC, Stassen PM. Prognostic value of plasma lactate levels in a retrospective cohort presenting at a university hospital emergency department. BMJ Open. 2017 Jan 30;7(1):e011450 .
Oxygen Therapy in Patients With ST Elevation Myocardial Infarction Based on the Culprit Vessel: Results From the Randomized Controlled SOCCER Trial.
Mokhtari A, Akbarzadeh M, Sparv D, Bhiladvala P, Arheden H, Erlinge D, Khoshnood A. | BMC Emerg Med. 2020 Feb 18;20(1):12
DOI: https://doi.org/10.1186/s12873-020-00309-y | Télécharger l'article au format
Keywords: Cardiac magnetic resonance imaging; High-sensitive troponin T; Infarct size; Left anterior descending artery; Myocardial infarction; Myocardial salvage index; Myocardium at risk; Oxygen; Randomized controlled trials; ST elevation myocardial infarction.
Introduction : Oxygen (O2) treatment has been a cornerstone in the treatment of patients with myocardial infarction. Recent studies, however, state that supplemental O2 therapy may have no effect or harmful effects in these patients. The aim of this study was thus to evaluate the effect of O2 therapy in patients with ST Elevation Myocardial Infarction (STEMI) based on the culprit vessel; Left Anterior Descending Artery (LAD) or Non-LAD.
Méthode : This was a two-center, investigator-initiated, single-blind, parallel-group, randomized controlled trial at the Skåne university hospital, Sweden. A simple computer-generated randomization was used. Patients were either randomized to standard care with O2 therapy (10 l/min) or air until the end of the primary percutaneous coronary intervention. The patients underwent a Cardiac Magnetic Resonance Imaging (CMRI) days 2-6. The main outcome measures were Myocardium at Risk (MaR), Infarct Size (IS) and Myocardial Salvage Index (MSI) as measured by CMRI, and median high-sensitive troponin T (hs-cTnT).
Résultats : A total of 229 patients were assessed for eligibility, and 160 of them were randomized to the oxygen or air arm. Because of primarily technical problems with the CMRI, 95 patients were included in the final analyses; 46 in the oxygen arm and 49 in the air arm. There were no significant differences between patients with LAD and Non-LAD as culprit vessel with regard to their allocation (oxygen or air) with regards to MSI, MaR, IS and hs-cTnT.
Conclusion : The results indicate that the location of the culprit vessel has probably no effect on the role of supplemental oxygen therapy in STEMI patients.
Conclusion (proposition de traduction) : Les résultats indiquent que le territoire coronaire occlue n'a probablement aucun effet sur le rôle d'une supplémentation en oxygéne chez les patients présentant un syndrome coronarien avec sus-décalage du segment ST (STEMI).
Serum Copeptin levels in the emergency department predict major clinical outcomes in adult trauma patients.
Salvo F, Luppi F, Lucchesi DM, Canovi S, Franchini S, Polese A, Santi F, Trabucco L, Fasano T, Ferrari AM. | BMC Emerg Med. 2020 Feb 24;20(1):14
DOI: https://doi.org/10.1186/s12873-020-00310-5 | Télécharger l'article au format
Keywords: Copeptin; Lactate; Multiple trauma; Trauma severity index; Triage; Vasopressin
Introduction : Early prognostication in trauma patients is challenging, but particularly important. We wanted to explore the ability of copeptin, the C-terminal fragment of arginine vasopressin, to identify major trauma, defined as Injury Severity Score (ISS) > 15, in a heterogeneous cohort of trauma patients and to compare its performances with lactate. We also evaluated copeptin performance in predicting other clinical outcomes: mortality, hospital admission, blood transfusion, emergency surgery, and Intensive Care Unit (ICU) admission.
Méthode : This single center, pragmatic, prospective observational study was conducted at Arcispedale Santa Maria Nuova, a level II trauma center in Reggio Emilia, Italy. Copeptin determination was obtained on Emergency Department (ED) arrival, together with venous lactate. Different outcomes were measured including ISS, Revised Trauma Score (RTS), hospital and ICU admission, blood transfusion, emergency surgery, and mortality.
Résultats : One hundred and twenty five adult trauma patients admitted to the ED between June 2017 and March 2018. Copeptin showed a good ability to identify patients with ISS > 15 (AUC 0.819). Similar good performances were recorded also in predicting other outcomes. Copeptin was significantly superior to lactate in identifying patients with ISS > 15 (P 0.0015), and in predicting hospital admission (P 0.0002) and blood transfusion (P 0.016). Comparable results were observed in a subgroup of patients with RTS 7.84.
Conclusion : In a heterogeneous group of trauma patients, a single copeptin determination at the time of ED admission proved to be an accurate biomarker, statistically superior to lactate for the identification of major trauma, hospital admission, and blood transfusion, while no statistical difference was observed for ICU admission and emergency surgery. These results, if confirmed, may support a role for copeptin during early management of trauma patients.
Conclusion (proposition de traduction) : Dans un groupe hétérogène de patients traumatisés, une seule détermination de la copeptine au moment de l'admission aux urgences s'est révélée être un biomarqueur précis, statistiquement supérieur au lactate pour l'identification des traumatismes majeurs, de l'admission à l'hôpital et de la transfusion sanguine, alors qu'aucune différence statistique n'a été observée pour l'admission aux soins intensifs et en chirurgie d'urgence. Ces résultats, s'ils sont confirmés, pourraient suggérer le rôle de la copeptine lors de la prise en charge précoce des patients traumatisés.
Blunt Chest Trauma in the Elderly: An Expert Practice Review.
Birse F, Williams H, Shipway D, Carlton E. | Emerg Med J. 2020 Feb;37(2):73-78
Keywords: analgesia/pain control; geriatrics; trauma, chest
Editorial : Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group.
Conclusion : Structured national guidelines for the assess- ment and management of such patients that include appropriate rib fracture assessment tools may improve outcomes. In the absence of such at present, EDs and associated acute specialties should examine their local practice to ensure they are providing consistently high standards of care to older patients with blunt thoracic injuries.
Conclusion (proposition de traduction) : Des directives nationales structurées pour l'évaluation et la prise en charge de ces patients qui incluent des outils appropriés d'évaluation des fracture de côtes peuvent améliorer les résultats. En l'absence de tels outils à l'heure actuelle, les urgentistes et les spécialités aiguës associées devraient examiner leur pratique locale pour s'assurer qu'elles fournissent des soins de haute qualité aux patients âgés souffrant de blessures thoraciques contondantes.
Incidence of Cervical Spine Fractures on CT: A Study in a Large Level I Trauma Center.
Khanpara S, Ruiz-Pardo D, Spence SC, West OC, Riascos R. | Emerg Radiol. 2020 Feb;27(1):1-8
Keywords: Cervical spine fractures; Incidence and cause of fractures; Level of fractures
Introduction : Though spinal fractures constitute a minority of all traumas, the financial burden imposed is immense especially following cervical spine trauma. There have been several papers in the past describing the incidence of cervical spine fractures. In this paper, we report the incidence of cervical spine fractures and correlate with demographic information and cause of injury and review the mechanism of fractures.
Méthode : We performed retrospective analysis of 934 patients who had undergone CT scan for cervical spine trauma at our institute which includes 16 hospitals and one level I trauma center over a period of 2 years. This list was created from a wider database of 13,512 patients imaged for suspected cervical spine injury. All patients who had at least one positive finding on CT were included in this study irrespective of any demographic difference. Each patient was analyzed by reviewing the medical records, and correlation was sought between demographics and cause of injury.
Résultats : In our study, the peak incidence of cervical spine trauma was in the age group of 21-30 years followed by 31-40 years with a male:female ratio of 2.1. The major cause of injury in the study population was motor vehicle accidents (66.1%), followed by fall from height of less than 8 ft (12.2%). With regard to the ethnic distribution, Caucasians (46.9%) constituted the major population followed by Hispanic population (23.3%). C1 and C2 were observed to be more frequently fractured as compared with the subaxial spine. Incidence of C2 fractures (188 levels) was higher as compared with C1 (102 levels). Incidence of body and lateral mass fractures was marginally higher as compared with odontoid fractures. C7 (50 levels) was the most fractured vertebral body in the subaxial spine followed by C6 (35 levels) and C5.
Conclusion : Spinal trauma is on the rise and it helps to know the factors which can guide us for better management of these patients. We can utilize these results to prognosticate and streamline clinical management of these patients.
Conclusion (proposition de traduction) : Les traumatismes rachidiens sont en augmentation et il est utile de connaître les facteurs qui peuvent nous guider pour une meilleure prise en charge de ces patients. Nous pouvons utiliser ces résultats pour établir un pronostic et rationaliser la prise en charge clinique de ces patients.
Early Whole-Body CT for Treatment Guidance in Patients With Return of Spontaneous Circulation After Cardiac Arrest.
Viniol S, Thomas RP, König AM, Betz S, Mahnken AH. | Emerg Radiol. 2020 Feb;27(1):23-29
Keywords: Cardiac arrest; Early whole-body CT; Emergency radiology; ROSC
Introduction : Non-traumatic cardiac arrest (CA) and return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) are often associated with multiple pathologies. Expecting a high prevalence of important findings, a whole-body CT (WBCT) could be of relevance for therapy. The aim of this study is to investigate the feasibility and diagnostic yield of an early WBCT in this setting.
Méthode : This single-center retrospective study included 100 consecutive patients (27 female; 73 male; mean age 68.5± 12.57 years) with non-traumatic, in- and out-of-hospital CA and ROSC following CPR, who underwent a contrast-enhanced WBCT within 6 h after ROSC over 12 months. CT findings were determined corresponding to anatomical region.
Résultats : Early WBCT was successfully carried out in 100% of the patients with CA and ROSC after CPR. Acute pathologies were found not only in the chest but also in the head (15%) and the abdomen (6%). Early global brain edema (n = 12), acute stroke (n = 3), pulmonary embolism (n = 10), pneumothorax (26%), acute abdominal pathologies (n = 6), iatrogenic bleeding (4%), and CPR-related injuries (93%) were detected by CT right from the beginning of the post-cardiac arrest care.
Conclusion : n early WBCT is feasible and provides added diagnostic value for patients with ROSC after non-traumatic CA.
Conclusion (proposition de traduction) : Un scanner précoce corps entier est possible et apporte une valeur ajoutée au diagnostic des patients avec une récupération d'activité cardiaque spontanée (RACS) après un arrêt cardiaque non traumatique.
Predicting Orbital Fractures in Head Injury: A Preliminary Study of Clinical Findings.
Allison JR, Kearns A, Banks RJ. | Emerg Radiol. 2020 Feb;27(1):31-36
DOI: https://doi.org/10.1007/s10140-019-01720-0 | Télécharger l'article au format
Keywords: Fracture, orbital; Head trauma; Maxillofacial injuries; Signs and symptoms; X-ray computed tomography.
Introduction : Patients presenting to emergency departments (EDs) following head injury often undergo computed tomography (CT) of the head to exclude traumatic brain injury. In many cases, this does not show the maxillofacial skeleton. A proportion of these patients also sustain facial fractures, and when fractures involve the orbits, CT imaging is useful in diagnosis and management; obtaining a second scan may cause delay, incur greater cost, and increase radiation dose. The aim of this preliminary study was to examine the value of signs and symptoms of orbital fractures in predicting a fracture on CT.
Méthode : The clinical records of 47 patients who underwent CT of the face following facial trauma were retrospectively examined for the presence of signs and symptoms of orbital fractures. Sensitivity, specificity, negative predictive value (NPV) and positive predictive values (PPV) were then calculated for each sign and symptom for the presence of an orbital fracture on CT. We also described a clinical decision instrument and examined the predictive values of this.
Résultats : Change in the position of the globe, reduced visual acuity, subconjunctival haemorrhage and change in sensation in the maxillary division of the trigeminal nerve were the most specific signs and symptoms for orbital fracture. Our clinical decision instrument had 80.0% sensitivity, 75.0% specificity, 90.3% PPV and 56.3% NPV for predicting the presence of an orbital fracture on CT in this population.
Conclusion : Our results demonstrate that signs and symptoms of orbital fractures may be useful for predicting these injuries, and a decision instrument could be used in the ED to identify patients likely to benefit from extending the radiation field to include the orbits where CT of the head is already planned. This work is however exploratory; and further prospective validation is required before a robust instrument can be recommended for clinical use.
Conclusion (proposition de traduction) : Nos résultats montrent que les signes et les symptômes de fractures orbitales peuvent être utiles pour prédire ces lésions, et un instrument de décision pourrait être utilisé aux urgences pour identifier les patients susceptibles de bénéficier de l'extension du champ de rayonnement pour inclure les orbites quand le scanner crânien est déjà prévu. Ce travail est toutefois exploratoire ; et une validation prospective supplémentaire est nécessaire avant qu'un instrument robuste puisse être recommandé pour un usage clinique.
Commentaire : Les signes faisant suspecter une fracture orbitaire :
• Au moins un des signes suivants : hémorragie sous-conjonctivale illimitée, hypoesthésie dans le territoire du nerf maxillaire (abrégé V2, anciennement nerf maxillaire supérieur, un nerf sensitif, et une des trois branches du nerf trijumeau), changement de position du globe ou acuité visuelle réduite.
• Deux signes associés : ecchymose périorbitaire, diplopie, mouvement oculaire limité.
Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study.
Gartner BA, Fehlmann C, Suppan L, Niquille M, Rutschmann OT, Sarasin F. | Eur J Emerg Med. 2020 Feb;27(1):54-58
DOI: https://doi.org/10.1097/MEJ.0000000000000616 | Télécharger l'article au format
Introduction : The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate.
Méthode : We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality.
Résultats : A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901).
Conclusion : In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
Conclusion (proposition de traduction) : Dans notre système préhospitalier doté d'un personnel médical, l'utilisation de la ventilation non invasive dans l'œdème pulmonaire cardiogénique aigu a diminué à la fois l'intubation endotrachéale et les taux d'admission en soins intensifs.
Effect of chest compression on skeletal chest injuries: a retrospective study.
Kim HI, Cha KC, Chung WJ, Noh YI, Kim OH, Cha YS, Kim H, Lee KH, Kim HS, Hwang SO. | Eur J Emerg Med. 2020 Feb;27(1):59-63
Introduction : Reports indicate that chest compression may induce skeletal chest injuries. We aimed to assess the factors associated with skeletal chest injuries and the probability of skeletal chest injuries following cardiopulmonary resuscitation (CPR) in patients who were successfully resuscitated after cardiac arrest.
Méthode : This retrospective analysis used data from adult patients who were successfully resuscitated after cardiac arrest. Skeletal chest injuries were assessed by chest computed tomography images. Multiple logistic regression analysis was used to identify factors associated with skeletal chest injuries and a cubic spline was fitted to visualize the predicted probability of skeletal chest injuries.
Résultats : Among 274 patients (mean age: 62.6 years, 180 males), 185 (68%) had skeletal chest injuries. Patients with skeletal chest injuries were older in age (66.4 ± 12 vs 54.7 ± 17 years, P < 0.001), had a higher frequency of prehospital CPR (78.9 vs 66.3%, P = 0.024), and had a longer CPR duration (26.3 ± 19.4 vs 21.5 ± 14.8 minutes, P = 0.022). Multiple logistic regression analysis showed that age and CPR duration were associated with skeletal chest injuries [odds ratio (OR): 1.06, 95% confidence interval (CI): 1.04-1.08, P < 0.001 for age; OR: 1.03, 95% CI: 1.01-1.04, P = 0.006 for CPR duration). The probability of skeletal chest injuries was higher in patients over 60 years of age than those in patients under 60 years.
Conclusion : In our study, advanced age and CPR duration were factors associated with a greater risk of skeletal chest injuries in adult patients who were resuscitated after cardiac arrest.
Conclusion (proposition de traduction) : Dans notre étude, l'âge avancé et la durée de la RCP étaient des facteurs associés à un plus grand risque de lésions thoraciques costales chez les patients adultes qui ont été réanimés après un arrêt cardiaque.
Commentaire : Des résultats intuitifs… encore fallait-il le démontrer.
Non-invasive oscillometric versus invasive arterial blood pressure measurements in critically ill patients: A post hoc analysis of a prospective observational study.
Kaufmann T | J crit care. In Press, Journal Pre-proof
Keywords: Arterial pressureVascular access devicesOscillometryIntensive careNorepinephrineVasoactive medication
Articles in press
Introduction : The aim was to compare non-invasive blood pressure measurements with invasive blood pressure measurements in critically ill patients.
Méthode : Non-invasive blood pressure was measured via automated brachial cuff oscillometry, and simultaneously the radial arterial catheter-derived measurement was recorded as part of a prospective observational study. Measurements of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were compared using Bland-Altman and error grid analyses.
Résultats : Paired measurements of blood pressure were available for 736 patients. Observed mean difference (±SD, 95% limits of agreement) between oscillometrically and invasively measured blood pressure was 0.8 mmHg (±15.7 mmHg, −30.2 to 31.7 mmHg) for SAP, −2.9 mmHg (±11.0 mmHg, −24.5 to 18.6 mmHg) for DAP, and −1.0 mmHg (±10.2 mmHg, −21.0 to 18.9 mmHg) for MAP. Error grid analysis showed that the proportions of measurements in risk zones A to E were 78.3%, 20.7%, 1.0%, 0%, and 0.1% for MAP.
Conclusion : Non-invasive blood pressure measurements using brachial cuff oscillometry showed large limits of agreement compared to invasive measurements in critically ill patients. Error grid analysis showed that measurement differences between oscillometry and the arterial catheter would potentially have triggered at least low-risk treatment decisions in one in five patients.
Conclusion (proposition de traduction) : Les mesures de la pression artérielle par la méthode oscillométrique au brassard huméral ont montré de larges intervalles de confiance (ndlr : donc marge d'incertitude importante) par rapport aux mesures invasives chez les patients de réanimation. L'analyse de la grille d'erreur a montré que les différences de mesure entre l'oscillométrie et le cathéter artériel auraient pu entraîner au moins des décisions de traitement à faible risque chez un patient sur cinq.
Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.
Linde JJ, Kelbæk H, Hansen TF, Sigvardsen PE, Torp-Pedersen C, Bech J, Heitmann M, Nielsen OW, Høfsten D, Kühl JT, Raymond IE, Kristiansen OP, Svendsen IH, Vall-Lamora MHD, Kragelund C, de Knegt M, Hove JD, Jørgensen T, Fornitz GG, Steffensen R, Jurlander B, Abdulla J, Lyngbæk S, Elming H, Therkelsen SK, Jørgensen E, Kløvgaard L, Bang LE, Hansen PR, Helqvist S, Galatius S, Pedersen F, Abildgaard U, Clemmensen P, Saunamäki K, Holmvang L, Engstrøm T, Gislas. | J Am Coll Cardiol. 2020 Feb 11;75(5):453-463
Keywords: acute coronary syndrome; cardiac CT; diagnostic accuracy; timing.
Introduction : In patients with non–ST-segment elevation acute coronary syndrome (NSTEACS), coronary pathology may range from structurally normal vessels to severe coronary artery disease.
OBJECTIVES : The purpose of this study was to test if coronary computed tomography angiography (CTA) may be used to exclude coronary artery stenosis $50% in patients with NSTEACS.
Méthode : The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial (NCT02061891) evaluated the outcome of patients with confirmed NSTEACS randomized 1:1 to very early (within 12 h) or standard (48 to 72 h) invasive coronary angiography (ICA). As an observa- tional component of the trial, a clinically blinded coronary CTA was conducted prior to ICA in both groups. The primary endpoint was the ability of coronary CTA to rule out coronary artery stenosis ($50% stenosis) in the entire population, expressed as the negative predictive value (NPV), using ICA as the reference standard.
Résultats : Coronary CTA was conducted in 1,023 patients—very early, 2.5 h (interquartile range [IQR]: 1.8 to 4.2 h), n 1⁄4 583; and standard, 59.9 h (IQR: 38.9 to 86.7 h); n 1⁄4 440 after the diagnosis of NSTEACS was made. A coronary stenosis $50% was found by coronary CTA in 68.9% and by ICA in 67.4% of the patients. Per-patient NPV of coronary CTA was 90.9% (95% confidence interval [CI]: 86.8% to 94.1%) and the positive predictive value, sensitivity, and specificity were 87.9% (95% CI: 85.3% to 90.1%), 96.5% (95% CI: 94.9% to 97.8%) and 72.4% (95% CI: 67.2% to 77.1%), respectively. NPV was not influenced by patient characteristics or clinical risk profile and was similar in the very early and the standard strategy group.
Conclusion : Coronary CTA has a high diagnostic accuracy to rule out clinically significant coronary artery disease in patients with NSTEACS.
Conclusion (proposition de traduction) : L'angiographie coronaire par tomodensitométrie a une grande précision diagnostique pour exclure une maladie coronarienne cliniquement significative chez les patients présentant un syndrome coronarien aigu sans élévation du segment ST.
Ticagrelor With or Without Aspirin After PCI: The TWILIGHT Platelet Substudy.
Baber U, Zafar MU, Dangas G, Escolar G, Angiolillo DJ, Sharma SK, Kini AS, Sartori S, Joyce L, Vogel B, Farhan S, Gurbel P, Gibson CM, Fuster V, Mehran R, Badimon JJ. . | J Am Coll Cardiol. 2020 Feb 18;75(6):578-586
Introduction : An evolving strategy in the setting of percutaneous coronary intervention (PCI) involves withdrawal of acetylsalicylic acid (ASA), or aspirin, while maintaining P2Y12 inhibition. However, the pharmacodynamic effects of this approach on blood thrombogenicity and platelet reactivity remain unknown.
OBJECTIVES : This study sought to compare the antithrombotic potency of ticagrelor alone versus ticagrelor plus ASA among high-risk patients undergoing PCI with drug-eluting stents.
Méthode : This was a mechanistic substudy within the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial, which randomized patients undergoing PCI to ticagrelor plus placebo versus ticagrelor plus ASA following 3 months of dual antiplatelet therapy. Substudy participants were enrolled after randomization, at which time ex vivo assays to quantify thrombus size under dynamic flow conditions and platelet reactivity were per- formed. Pharmacodynamic assessments were repeated 1 to 6 months thereafter. The primary endpoint was thrombus size at the post-randomization visit with platelet reactivity following stimuli to arachidonic acid, collagen, adenosine diphosphate, and thrombin as secondary endpoints. Results were analyzed using analysis of covariance.
Résultats : A total of 51 patients were enrolled, among whom 42 underwent perfusion assays at baseline and follow-up with a median time between studies of 1.5 months. The adjusted mean difference in post-randomization thrombus area was similar between groups: 218.2 mm2 (95% confidence interval [CI]: 575.9 to 139.9 mm2; p 1⁄4 0.22). Markers sensitive to cyclo-oxygenase-1 blockade, including platelet reactivity in response to arachidonic acid (mean difference: 10.9 U; 95% CI: 1.9 to 19.9 U) and collagen (mean difference: 9.8 U; 95% CI: 0.8 to 18.8 U) stimuli were higher among patients receiving placebo, whereas levels of platelet reactivity were similar with adenosine diphosphate and thrombin.
Conclusion : Among high-risk patients receiving drug-eluting stents, the antithrombotic potency of ticagrelor monotherapy is similar to that of ticagrelor plus ASA with respect to ex vivo blood thrombogenicity, whereas markers sensitive to cyclo-oxygenase-1 blockade are increased in the absence of ASA.
Conclusion (proposition de traduction) : Parmi les patients à haut risque qui ont subi une intervention coronarienne percutanée et qui ont suivi un double traitement antiplaquettaire pendant trois mois, le ticagrelor en monothérapie a été associé à une incidence plus faible d'hémorragies cliniquement pertinentes que le ticagrelor associé à l'aspirine, sans risque accru de décès, d'infarctus du myocarde ou d'accident vasculaire cérébral.
Beaussier M | Prat Anesth Reanim. 2020 February;24(1):5-9
Keywords: Lidocaine; Postoperative pain; Enhanced recoveryafter surgery
Mise au point
Editorial : La lidocaïne peut être administrée en intraveineux en per- et postopératoire immédiat. Son utilisation s’intègre dans le cadre de protocoles d’analgésie multimodale dont l’objectif est non la réduction de l’intensité de la douleur, de la consommation en opiacés, de la durée de l’iléus postopératoire et de la durée de séjour hospitalier. L’usage de la lidocaïne intraveineuse doit respecter des nomes de sécurité.
Conclusion (proposition de traduction) : La LIV possède des propriétés analgésiques et anti-hyperalgésiques qui contribuent au contrôle de la douleur postopératoire et à la réduction de la demande en opioïdes. Elle accélère la reprise du transit intestinal ce qui rend sonadministration intéressante dans le contexte de la chirurgieabdominale, et de l’application des protocoles de récupération améliorée après chirurgie
De Lima L | Méd. droit. 2020 feb;2020(160):6-9
Keywords: Announcing a death; Information (death); Organ donation; Death (information)
Protection de la personne
Editorial : L’annonce d’un décès étant toujours un moment délicat pour les proches et le personnel, la loi apporte de légères précisions sur les modalités d’une telle information. Récemment, le Conseil d’État a également reconnu un préjudice du fait du manque d’empathie du personnel et de l’annonce tardive du décès. Cet arrêt apporte donc des précisions supplémentaires sur les conditions d’annonce d’un décès en milieu hospitalier. Ce sujet fait écho à celui de l’information des proches dans le cadre du don d’organes. Cette procédure étant plus exceptionnelle et très encadrée, les modalités d’information sont beaucoup plus précises.
Conclusion (proposition de traduction) : L’annonce d’un décès et l’évocation du don d’organe sont par nature des sujets sensibles. Face à ce choc émotionnel, les médecins se doivent donc d’adopter un certain comportement afin de rendre cette annonce moins douloureuse qu’elle ne pourrait l’être. Chaque patient est différent, chaque annonce l’est donc aussi. Ainsi, divers éléments doivent être pris en considération lors de ces annonces : la qualité et l’âge des proches, le contexte, la religion…
En effet, même si les représentants des grandes religions (mono-théistes, christianisme, judaïsme et islam) se sont prononcés en faveur du don, l’appréhension de la mort et du don d’organes reste personnelle. Ainsi, l’exigence d’inhumation du corps entier exigé par certaine religion peut primer. La religion du patient et/ou des proches doit alors être prise en compte par le personnel médical.
High-Dose Intravenous Ascorbic Acid: Ready for Prime Time in Traumatic Brain Injury?.
Leichtle SW, Sarma AK, Strein M, Yajnik V, Rivet D, Sima A, Brophy GM. | Neurocrit Care. 2020 Feb;32(1):333-339
Keywords: Antioxidant; Ascorbic acid; Free radical scavenger; Oxidative stress; Secondary brain injury; Traumatic brain injury; Vitamin C.
Editorial : Traumatic brain injury (TBI) is one of the leading public health problems in the USA and worldwide. It is the number one cause of death and disability in children and adults between ages 1-44. Despite efforts to prevent TBIs, the incidence continues to rise. Secondary brain injury occurs in the first hours and days after the initial impact and is the most effective target for intervention. Inflammatory processes and oxidative stress play an important role in the pathomechanism of TBI and are exacerbated by impaired endogenous defense mechanisms, including depletion of antioxidants. As a reducing agent, free radical scavenger, and co-factor in numerous biosynthetic reactions, ascorbic acid (AA, vitamin C) is an essential nutrient that rapidly becomes depleted in states of critical illness. The administration of high-dose intravenous (IV) AA has demonstrated benefits in numerous preclinical models in the areas of trauma, critical care, wound healing, and hematology. A safe and inexpensive treatment, high-dose IV AA administration gained recent attention in studies demonstrating an associated mortality reduction in septic shock patients. High-quality data on the effects of high-dose IV AA on TBI are lacking. Historic data in a small number of patients demonstrate acute and profound AA deficiency in patients with central nervous system pathology, particularly TBI, and a strong correlation between low AA concentrations and poor outcomes. While replenishing deficient AA stores in TBI patients should improve the brain's ability to tolerate oxidative stress, high-dose IV AA may prove an effective strategy to prevent or mitigate secondary brain injury due to its ability to impede lipid peroxidation, scavenge reactive oxygen species, suppress inflammatory mediators, stabilize the endothelium, and reduce brain edema. The existing preclinical data and limited clinical data suggest that high-dose IV AA may be effective in lowering oxidative stress and decreasing cerebral edema. Whether this translates into improved clinical outcomes will depend on identifying the ideal target patient population and possible treatment combinations, factors that need to be evaluated in future clinical studies. With its excellent safety profile and low cost, high-dose IV AA is ready to be evaluated in the early treatment of TBI patients to mitigate secondary brain injury and improve outcomes.
Conclusion : In summary, the existing ample animal and limited clinical data suggest that for the right patient population and at the appropri- ate dose, high-dose IV ascorbic acid can benefit patients with traumatic brain injury.
Conclusion (proposition de traduction) : En résumé, les nombreuses données animales existantes et les données cliniques limitées suggèrent que pour la bonne population de patients et à la dose appropriée, l'acide ascorbique IV à forte dose peut être bénéfique aux patients souffrant de traumatisme crânien.
Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury.
Mangat HS, Wu X, Gerber LM, Schwarz JT, Fakhar M, Murthy SB, Stieg PE, Ghajar J, Härtl R. | Neurosurgery. 2020 Feb 1;86(2):221-230
Keywords: Cerebral perfusion pressure, Hypertonic saline, Intracranial pressure, Mannitol, Traumatic brain injury
Introduction : Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously. Objective: To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI.
Méthode : We performed a case-control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg).
Résultats : There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons.
Conclusion : HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.
Conclusion (proposition de traduction) : Le traitement par bolus de sérum salé hypertonique semble être supérieur au mannitol pour réduire le poids combiné imputable à l'hypertension intracrânienne et l'hypoperfusion [ndlr : cérébrale] associée chez les patients atteints de lésions cérébrales traumatiques graves.
The Effect of External Thermomechanical Stimulation and Distraction on Reducing Pain Experienced by Children During Blood Drawing.
Inal S, Kelleci M. | Pediatr Emerg Care. 2020 Feb;36(2):66-69
Introduction : This study aimed to investigate the sole and combined effects of external thermomechanical stimulation and distraction in pain relief of children during blood drawing.This is a randomized clinical trial.
Méthode : The sample consisted of 218 children aged 6 to 12 years who were randomly assigned to 4 groups: group 1 received no intervention, group 2 received external thermomechanical stimulation using Buzzy, group 3 received distraction via DistrACTION Cards, and group 4 received a combination of both external thermomechanical stimulation and distraction. Preprocedural anxiety was assessed through observers' observations using the Children's Anxiety and Pain Scale. Children's pain levels were assessed by themselves, observers, and parents, as reported using the Faces Pain Scale-Revised.
Résultats : Preprocedural anxiety did not differ significantly (P > 0.05). When the 3 study groups were compared with the control group, all 3 groups had significantly lower pain levels than the control group (P < 0.001).
Conclusion : The lowest pain level was measured in the combined condition (Buzzy and DistrACTION Cards). The mean score of the device group was lower than the distraction group.
Conclusion (proposition de traduction) : Le niveau de douleur le plus faible a été mesuré dans la condition combinée (cartes Buzzy et DistrACTION). Le score moyen du groupe des appareils était inférieur à celui du groupe des distractions.
Management of Pain After Pediatric Trauma.
Day LM, Huang R, Okada PJ. | Pediatr Emerg Care. 2020 Feb;36(2):e33-e37
Introduction : The primary objective of this study was to evaluate the management of pain after traumatic injury in the pediatric emergency department (ED) as measured by time to analgesic administration and pain resolution, stratified by triage acuity level.
Méthode : This is a retrospective descriptive study evaluating the management of children who presented with pain after injury to an urban level 1 trauma center. Consecutive enrollment of 1000 patients identified by ICD-9 codes that included all injuries or external causes for injury (700-999 and all E codes) and who had pain identified by triage pain assessment was performed. For analysis, patients were grouped according to triage level.
Résultats : Fifty-one percent (511/1000) of patients achieved pain resolution, and an additional 20% (200/1000) of patients had documented improvement in pain score during their ED visit. Triage acuity level 1 group received medications the fastest with a median time of 12 minutes (interquartile range, 10-53 minutes); 65.3% of patients (653/1000) received a pain medication during their ED visit; 54.3% of these patients received oral medications only. Average time to intravenous line placement was 2 hours 35 minutes (SD, 2 hours 55 minutes). Only 1.9% of patients received any medications prior to arrival.
Conclusion : Higher-acuity patients received initial pain medications and had initial pain score decrease before lower-acuity patients. Given the retrospective nature of the study, we were unable to clearly identify barriers that contributed to delay in or lack of pain treatment in our patient population.
Conclusion (proposition de traduction) : Les patients les plus douloureux ont reçu des analgésiques à l'entrée et ont vu leur score initial de douleur diminuer avant les patients moins douloureux. Compte tenu de la nature rétrospective de l'étude, nous n'avons pas pu identifier clairement les obstacles qui ont contribué au retard ou au manque de traitement de la douleur dans notre population de patients.
Success Rates for Reduction of Pediatric Distal Radius and Ulna Fractures by Emergency Physicians.
Putnam K, Kaye B, Timmons Z, Wade Shrader M, Bulloch B. | Pediatr Emerg Care. 2020 Feb;36(2):e56-e60
Introduction : Emergency physicians are trained in urgent fracture reduction. Many hospitals lack readily available in-house orthopedic coverage.
Objectives : The aim of this study was to determine success rates for reduction of pediatric distal radius or ulna fractures by emergency department (ED) physicians.
Méthode : We conducted a retrospective study of children younger than 18 years presenting to a large, urban, freestanding children's hospital from January 1, 2009, to December 31, 2010, with forearm fracture. Exclusions included open fracture, those requiring immediate surgical intervention, or additional fractures. The primary end point was the proportion of successful closed forearm fracture reductions in the ED, as defined by orthopedic follow-up.
Résultats : All reductions were performed by a board-certified/eligible pediatric emergency medicine (PEM) physician or PEM fellow. Two hundred ninety-five fractures were reduced in the ED during the study period. Mean age was 8.27 years (median, 8 years; range, 1-16 years), and males comprised 69.2% (n = 204). A total of 222 fractures (76%) were of the distal forearm, and 70 involved the midshaft (24%). Orthopedic follow-up was completed in 77.3%. A total of 33 patients (11%) required remanipulation; 24 in the distal forearm fracture group (22 closed reductions, 2 open reductions with internal fixation) versus 9 in the midshaft group (7 closed reductions, 2 open reductions with internal fixation) (P = 0.948).
Conclusion : The literature reveals 7% to 39% of children with fracture reductions performed in the ED by orthopedic surgeons/residents require remanipulation. Our rate of 11% is consistent within that range. With training, PEM physicians have similar success rates as orthopedists in forearm fracture reductions.
Conclusion (proposition de traduction) : La littérature révèle que 7 à 39 % des enfants ayant bénéficié d'une réduction de fracture effectuée aux urgences par des chirurgiens/résidents orthopédiques nécessitent une remaniement. Notre taux de 11 % se situe dans cette fourchette. Grâce à leur formation, les médecins d'urgence pédiatrique ont un taux de réussite similaire à celui des orthopédistes dans la réduction des fractures de l'avant-bras.
Parents' Perspective on Trainees Performing Invasive Procedures: A Qualitative Evaluation.
O'Brien EGJ, Bhargava S, Cohen SY, Auerbach M, Tiyyagura G. | Pediatr Emerg Care. 2020 Feb;36(2):e66-e71
Introduction : When obtaining informed permission from parents for invasive procedures, trainees and supervisors often do not disclose information about the trainee's level of experience. The objectives of this study were 3-fold: (1) to assess parents' understanding of both academic medical training and the role of the trainee and the supervisor, (2) to explore parents' preferences about transparency related to a trainee's experience, and (3) to examine parents' willingness to allow trainees to perform invasive procedures.
Méthode : This qualitative study involved 23 one-on-one interviews with parents of infants younger than 30 days who had undergone a lumbar puncture. In line with grounded theory, researchers independently coded transcripts and then collectively refined codes and created themes. Data collection and analysis continued until thematic saturation was achieved. In addition, to triangulate the findings, a focus group was conducted with Yale School of Medicine's Community Bioethics Forum.
Résultats : Our analysis revealed 4 primary themes: (1) the invasive nature of a lumbar puncture and the vulnerability of the newborn creates fear in parents, which may be mitigated by improved communication; (2) parents have varying degrees of awareness of the medical training system; (3) most parents expect transparency about provider experience level and trust that a qualified provider will be performing the procedure; and (4) parents prefer an experienced provider to perform a procedure, but supervisor presence may be a qualifying factor for inexperienced providers.
Conclusion : Physicians must find a way to improve transparency when caring for pediatric patients while still developing critical procedural skills.
Conclusion (proposition de traduction) : Les médecins doivent trouver un moyen d'améliorer la transparence lorsqu'ils soignent des patients pédiatriques tout en développant des compétences procédurales essentielles.
A Randomized Control Trial of Cardiopulmonary Feedback Devices and Their Impact on Infant Chest Compression Quality: A Simulation Study.
Austin AL, Spalding CN, Landa KN, Myer BR, Cure D, Smith JE, Platt G, King HC. | Pediatr Emerg Care. 2020;36(2):e79–e84
Introduction : In effort to improve chest compression quality among health care providers, numerous feedback devices have been developed. Few studies, however, have focused on the use of cardiopulmonary resuscitation feedback devices for infants and children. This study evaluated the quality of chest compressions with standard team-leader coaching, a metronome (MetroTimer by ONYX Apps), and visual feedback (SkillGuide Cardiopulmonary Feedback Device) during simulated infant cardiopulmonary resuscitation.
Méthode : Seventy voluntary health care providers who had recently completed Pediatric Advanced Life Support or Basic Life Support courses were randomized to perform simulated infant cardiopulmonary resuscitation into 1 of 3 groups: team-leader coaching alone (control), coaching plus metronome, or coaching plus SkillGuide for 2 minutes continuously. Rate, depth, and frequency of complete recoil during cardiopulmonary resuscitation were recorded by the Laerdal SimPad device for each participant. American Heart Association-approved compression techniques were randomized to either 2-finger or encircling thumbs.
Résultats : The metronome was associated with more ideal compression rate than visual feedback or coaching alone (104/min vs 112/min and 113/min; P = 0.003, 0.019). Visual feedback was associated with more ideal depth than auditory (41 mm vs 38.9; P = 0.03). There were no significant differences in complete recoil between groups. Secondary outcomes of compression technique revealed a difference of 1 mm. Subgroup analysis of male versus female showed no difference in mean number of compressions (221.76 vs 219.79; P = 0.72), mean compression depth (40.47 vs 39.25; P = 0.09), or rate of complete release (70.27% vs 64.96%; P = 0.54).
Conclusion : In the adult literature, feedback devices often show an increase in quality of chest compressions. Although more studies are needed, this study did not demonstrate a clinically significant improvement in chest compressions with the addition of a metronome or visual feedback device, no clinically significant difference in Pediatric Advanced Life Support-approved compression technique, and no difference between compression quality between genders.
Conclusion (proposition de traduction) : Dans la littérature pour adultes, les appareils de rétroaction montrent souvent une amélioration de la qualité des compressions thoraciques. Bien que d'autres études soient nécessaires, cette étude n'a pas démontré une amélioration cliniquement significative des compressions thoraciques avec l'ajout d'un métronome ou d'un dispositif de rétroaction visuelle, aucune différence cliniquement significative dans la technique de compression approuvée par le Pediatric Advanced Life Support, et aucune différence de qualité de compression entre les sexes.
A Predictive Model for Identification of Children at Risk of Subsequent High-Frequency Utilization of the Emergency Department for Asthma.
Samuels-Kalow ME, Bryan MW, Sommers MS, Zorc JJ, Camargo CA Jr, Mollen C. | Pediatr Emerg Care. 2020 Feb;36(2):e85-e89
Introduction : Asthma is the most common chronic condition among children with high-frequency emergency department (ED) utilization. Previous research has shown in outpatients seen for asthma that acute care visits predict subsequent health care utilization. Among ED patients, however, the optimal method of predicting subsequent ED utilization remains to be described. The goal of this study was to create a predictive model to identify children in the ED who are at risk of subsequent high-frequency utilization of the ED for asthma.
Méthode : We used 3 years of data, 2013-2015, drawn from the electronic health records at a tertiary care, urban, children's hospital that is a high-volume center for asthma care. Data were split into a derivation (50%) and validation/test (50%) set, and 3 models were created for testing: (1) all index patients; (2) removing patients with complex chronic conditions; and (3) subset of patients with in-network care on whom more clinical data were available. Each multivariable model was then tested in the validation set, and its performance evaluated by predicting error rate, calculation of a receiver operating characteristic (ROC) curve, and identification of the optimal cutpoint to maximize sensitivity and specificity.
Résultats : There were 5535 patients with index ED visits, of whom 2767 were in the derivation set and 2768 in the validation set. Of the 5535 patients, 125 patients (2.3%) had 4 or more visits for asthma in the outcome year. Significant predictors in models 1 and 2 were age and number of prior ED visits for asthma. For model 3 (additional clinical information available), the predictors were number of prior ED visits for asthma, number of primary care visits, and not having a controller medication. Areas under the ROC curve were 0.77 for model 1, 0.80 for model 2, and 0.77 for model 3.
Conclusion : Administrative data available at the time of ED triage can predict subsequent high utilization of the ED, with areas under the ROC curve of 0.77 to 0.80. The addition of clinical variables did not improve the model performance. These models provide useful tools for researchers interested in examining intervention efficacy by predicted risk group.
Conclusion (proposition de traduction) : Les données administratives disponibles au moment du triage des urgences peuvent prédire la forte utilisation ultérieure du service des urgences, avec des surfaces sous la courbe ROC de 0,77 à 0,80. L'ajout de variables cliniques n'a pas amélioré la performance du modèle. Ces modèles fournissent des outils utiles aux chercheurs qui souhaitent examiner l'efficacité des interventions par groupe de risque prédit.
Dispatcher Identification of Out-of-Hospital Cardiac Arrest and Neurologically Intact Survival: A Retrospective Cohort Study.
Mapp JG, Darrington AM, Harper SA, Kharod CU, Miramontes DA, Wampler DA; Prehospital Research and Innovation in Military and Expeditionary Environments (PRIME) Research Group. | Prehosp Disaster Med. 2020 Feb;35(1):17-23
Keywords: Emergency Medical Services; emergency medical dispatching; out-of-hospital cardiac arrest; recognition
Introduction : To date, there are no published data on the association of patient-centered outcomes and accurate public-safety answering point (PSAP) dispatch in an American population. The goal of this study is to determine if PSAP dispatcher recognition of out-of-hospital cardiac arrest (OHCA) is associated with neurologically intact survival to hospital discharge.
Méthode : This retrospective cohort study is an analysis of prospectively collected Quality Assurance/Quality Improvement (QA/QI) data from the San Antonio Fire Department (SAFD; San Antonio, Texas USA) OHCA registry from January 2013 through December 2015. Exclusion criteria were: Emergency Medical Services (EMS)-witnessed arrest, traumatic arrest, age <18 years old, no dispatch type recorded, and missing outcome data. The primary exposure was dispatcher recognition of cardiac arrest. The primary outcome was neurologically intact survival (defined as Cerebral Performance Category [CPC] 1 or 2) to hospital discharge. The secondary outcomes were: bystander cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) use, and prehospital return of spontaneous return of circulation (ROSC).
Résultats : Of 3,469 consecutive OHCA cases, 2,569 cases were included in this analysis. The PSAP dispatched 1,964/2,569 (76.4%) of confirmed OHCA cases correctly. The PSAP dispatched 605/2,569 (23.6%) of confirmed OHCA cases as another chief complaint. Neurologically intact survival to hospital discharge occurred in 99/1,964 (5.0%) of the recognized cardiac arrest group and 28/605 (4.6%) of the unrecognized cardiac arrest group (OR = 1.09; 95% CI, 0.71-1.70). Bystander CPR occurred in 975/1,964 (49.6%) of the recognized cardiac arrest group versus 138/605 (22.8%) of the unrecognized cardiac arrest group (OR = 3.34; 95% CI, 2.70-4.11).
Conclusion : This study found no association between PSAP dispatcher identification of OHCA and neurologically intact survival to hospital discharge. Dispatcher identification of OHCA remains an important, but not singularly decisive link in the OHCA chain of survival.
Conclusion (proposition de traduction) : Cette étude n'a trouvé aucune association entre l'identification du répartiteur PSAP de l'OHCA et la survie neurologiquement intacte jusqu'à la sortie de l'hôpital. L'identification des OHCA par les répartiteurs demeure un maillon important, mais pas particulièrement décisif, dans la chaîne de survie des OHCA.
The Effect of Operator Position on the Quality of Chest Compressions Delivered in a Simulated Ambulance.
Mullin S, Lydon S, O'Connor P. | Prehosp Disaster Med. 2020 Feb;35(1):55-60
Keywords: ambulance; cardiopulmonary resuscitation; chest compressions; out-of-hospital cardiac arrest; simulation
Introduction : Ambulances are where patient care is often initiated or maintained, but this setting poses safety risks for paramedics. Paramedics have found that in order to optimize patient care, they must compromise their own safety by standing unsecured in a moving ambulance.
Hypothesis/problem: This study sought to compare the quality of chest compressions in the two positions they can be delivered within an ambulance.
Méthode : A randomized, counterbalanced study was carried out with 24 paramedic students. Simulated chest compressions were performed in a stationary ambulance on a cardiopulmonary resuscitation (CPR) manikin for two minutes from either: (A) an unsecured standing position, or (B) a seated secured position. Participants' attitudes toward the effectiveness of the two positions were evaluated.
Résultats : The mean total number of chest compressions was not significantly different standing unsecured (220; SD = 12) as compared to seated and secured (224; SD = 21). There was no significant difference in mean compression rate standing unsecured (110 compressions per minute; SD = 6) as compared to seated and secured (113 compressions per minute; SD = 10). Chest compressions performed in the unsecured standing position yielded a significantly greater mean depth (52 mm; SD = 6) than did seated secured (26 mm; SD = 7; P < .001). Additionally, the standing unsecured position produced a significantly higher percentage (83%; SD = 21) for the number of correct compressions, as compared to the seated secured position (8%; SD = 17; P < .001). Participants also believed that chest compressions delivered when standing were more effective than those delivered when seated.
Conclusion : The quality of chest compressions delivered from a seated and secured position is inferior to those delivered from an unsecured standing position. There is a need to consider how training, technologies, and ambulance design can impact the quality of chest compressions.
Conclusion (proposition de traduction) : La qualité des compressions thoraciques effectuées en position assise et sécurisée est inférieure à celles effectuées en position debout non sécurisée. Il est nécessaire d'examiner comment la formation, les technologies et la conception des ambulances peuvent influer sur la qualité des compressions thoraciques.
Potion A : Position debout non sécurisé - Position B : Position assise et sécurisée
NDLR : une solution est peut-être la planche à masser…
efining and Operationalizing Disaster Preparedness in Hospitals: A Systematic Literature Review.
Verheul ML, Dückers M. Defining and Operationalizing Disaster Preparedness in Hospitals. | Prehosp Disaster Med. 2020 Feb;35(1):61-68
Keywords: definition; disaster preparedness; hospitals; operationalization; systematic review
Introduction : Societies invest substantial amounts of resources on disaster preparedness of hospitals. However, the concept is not clearly defined nor operationalized in the international literature. Aim: This review aims to systematically assess definitions and operationalizations of disaster preparedness in hospitals, and to develop an all-encompassing model, incorporating different perspectives on the subject.
Méthode : A systematic search was conducted in five databases: Scopus, PubMed, Web of Science, Disaster Information Management Research Centre, and SafetyLit. Peer-reviewed articles containing definitions and operationalizations of disaster preparedness in hospitals were included. Articles published in languages other than English, or without available full-text, were excluded, as were articles on prehospital care. The findings from literature were used to build a model for hospital disaster preparedness.
Résultats : In the included publications, 13 unique definitions of disaster preparedness in hospitals and 22 different operationalizations of the concept were found. Although the definitions differed in emphasis and width, they also reflected similar elements. Based on an analysis of the operationalizations, nine different components could be identified that generally were not studied in relation to each other. Moreover, publications primarily focused on structure and process aspects of disaster preparedness. The aim of preparedness was described in seven articles.
Conclusion : This review points at an absence of consensus on the definition and operationalization of disaster preparedness in hospitals. By combining elements of definitions and components operationalized, disaster preparedness could be conceptualized in a more comprehensive and complete way than before. The model presented can guide future disaster preparedness activities and research.
Conclusion (proposition de traduction) : Cette revue de la littérature met en évidence l'absence de consensus sur la définition et l'efficience de la préparation aux catastrophes dans les hôpitaux. En combinant des éléments de définitions et des composantes opérationnalisées, la préparation aux catastrophes pourrait être conceptualisée de manière plus complète et plus exhaustive qu'auparavant. Le modèle présenté peut guider les activités et les recherches futures en matière de préparation aux catastrophes.
Advantage and Limitation of Using a Visual Feedback Device During Cardiopulmonary Resuscitation Training.
Kim CW, Oh JH. | Prehosp Disaster Med. 2020 Feb;35(1):104-108
Keywords: cardiopulmonary resuscitation; feedback; training
Introduction : Recent cardiopulmonary resuscitation (CPR) guidelines recommend the use of CPR prompt/feedback devices during CPR training because it can improve the quality of CPR. Problem: Chest compression depth and full chest recoil show a trade-off relationship. Therefore, achievement of both targets (adequate chest compression depth and full chest recoil) simultaneously is a difficult task for CPR instructors. This study hypothesized that introducing a visual feedback device to the CPR training could improve the chest compression depth and ratio of full chest recoil simultaneously.
Méthode : The study investigated the effects of introducing a visual feedback device during CPR training by comparing the results of skill tests before and after introducing a visual feedback device. The results of skill tests from 2016 through 2018 were retrospectively reviewed. The strategy of emphasizing chest compression depth was implemented during the CPR training in 2017, and a visual feedback device was introduced in 2018. The interval between the CPR training and skill tests was seven days. Feedback was not provided during the skill tests.
Résultats : In total, 159 students completed skill tests. Although the chest compression depth increased significantly from 50 mm (42-54) to 60 mm (59-61) after emphasizing chest compression depth (P < .001), the ratio of full chest recoil decreased simultaneously from 100% (100-100) to 81% (39-98; P < .001). The ratio of full chest recoil increased significantly from 81% (39-98) to 95% (77-100) after introducing a visual feedback device (P = .018). However, the students who did not achieve 80% of the ratio of full chest recoil remained significantly higher than in 2016 (1% in 2016, 49% in 2017, and 27% in 2018; P < .001).
Conclusion : Although introducing a visual feedback device during CPR training resulted in increasing the ratio of full chest recoil while maintaining the adequacy of chest compression depth, 27% of the students still did not achieve 80% of the ratio of full chest recoil. Another educational strategy should be considered to increase the qualities of CPR more completely.
Conclusion (proposition de traduction) : Bien que l'introduction d'un dispositif de rétroaction visuel pendant la formation à la RCP ait permis d'augmenter le taux de relâchement de la paroi thoracique complète tout en maintenant une profondeur de compression thoracique adéquate, 27 % des élèves n'ont toujours pas atteint 80 % du taux de relâchement de la paroi thoracique complète. Une autre stratégie éducative devrait être envisagée pour améliorer les qualités de la RCP de manière plus complète.
Mobile phone-based alerting of CPR-trained volunteers simultaneously with the ambulance can reduce the resuscitation-free interval and improve outcome after out-of-hospital cardiac arrest: A German, population-based cohort study.
Stroop R, Kerner T, Strickmann B, Hensel M. | Resuscitation. 2020 Feb 1;147:57-64
Keywords: Alerting; Cardiac arrest; First aider; Mobile-phone; Prehospital; Resuscitation
Introduction : To test the hypothesis that simultaneous mobile phone-based alerting of CPR-trained volunteers (Mobile-Rescuers) with Emergency Medical Service (EMS) teams leads to better outcomes in out-of-hospital cardiac arrest (OHCA) victims than EMS alerting alone.
Méthode : The outcomes of 730 OHCA patients were retrospectively analysed, depending on who initiated CPR: Mobile-Rescuer-initiated-CPR (n = 94), EMS-initiated-CPR (n = 359), lay bystander-initiated-CPR (n = 277). An adjusted analysis of the intervention and their main outcomes (emergency response time, return of spontaneous circulation, hospital discharge rate, neurological outcomes) was performed (Propensity Score Method with patient matching).
Résultats : Recruited and trained Mobile-Rescuers (n = 740) arrived at the scene in 46% of all triggered alarms. There was a significant difference in response time between Mobile-Rescuers (4 min) and EMS teams (7 min), (p < 0.001). Compared to EMS-initiated-CPR, Mobile-Rescuer-initiated-CPR patients more frequently showed a return of spontaneous circulation, but statistical significance was narrowly missed (p = 0.056). The hospital discharge rate was significantly higher with the Mobile-Rescuer (18%) vs. EMS (7%), (p = 0.049). Good neurological outcomes (Cerebral Performance Categories Score 1 and 2) were seen in 11% of Mobile-Rescuer patients and 4% of EMS patients (p = 0.165). There were no significant differences compared with lay bystander-initiated-CPR.
Conclusion : Simultaneous alerting of nearby CPR-trained volunteers complementary to professional EMS teams can reduce both the response time and resuscitation-free interval and might improve hospital discharge rate and neurological outcomes after OHCA.
Conclusion (proposition de traduction) : L'alerte simultanée de volontaires formés à la RCP à proximité, complémentaires aux équipes professionnelles des services médicaux d'urgence, peut réduire à la fois le temps de réponse et l'intervalle sans réanimation et pourrait améliorer le taux de sortie de l'hôpital et les résultats neurologiques après un arrêt cardiaque extra-hospitalier.
Aspirin for Prevention of Cardiovascular Disease.
Peters AT, Mutharasan RK. | JAMA. 2020 Feb 18;323(7):676
JAMA Patient Page
Introduction : For different reasons, millions of people take low-dose aspirin every day. For people who have had a heart attack, a stroke, placement of a coronary artery stent, or coronary artery bypass graft surgery, there is strong evidence that aspirin helps prevent another such event. This use is called secondary prevention: making an already diagnosed disease less likely to get worse.
Aspirin is also sometimes used for primary prevention: to prevent people from developing cardiovascular disease in the first place. However, recent studies and guidelines indicate that few people benefit from using aspirin in this way.
Conclusion : First, the new guidelines are clear about who should not be taking low-dose aspirin to prevent cardiovascular disease. Patients who are older than 70 years, younger than 40 years, or at high bleeding risk because of another medical condition or medication should not be taking aspirin. Medical conditions that increase bleeding risk include previous gastrointestinal bleeding, peptic ulcer disease, blood clotting problems, and kidney disease. Medications that in- crease bleeding risk include nonsteroidal anti-inflammatory drugs, steroids, and other blood thinners.
Conclusion (proposition de traduction) : Tout d'abord, les nouvelles recommandations sont claires quant aux personnes qui ne doivent pas prendre d'aspirine à faible dose pour prévenir les maladies cardiovasculaires. Les patients âgés de plus de 70 ans, de moins de 40 ans ou présentant un risque élevé d'hémorragie en raison d'une autre maladie ou d'un médicament ne doivent pas prendre d'aspirine. Les maladies qui augmentent le risque d'hémorragie comprennent les hémorragies gastro-intestinales antérieures, les ulcères gastro-duodénaux, les problèmes de coagulation sanguine et les maladies rénales. Les médicaments qui augmentent le risque de saignement comprennent les anti-inflammatoires non stéroïdiens, les stéroïdes et autres anticoagulants.
Commentaire : Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Sep 10;140(11):e596-e646. doi: 10.1161/CIR.0000000000000678 . Epub 2019 Mar 17. Erratum in: Circulation. 2019 Sep 10;140(11):e649-e650. Erratum in: Circulation. 2020 Jan 28;141(4):e60. PMID: 30879355.
Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial.
Lamontagne F, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Rowan KM, Mouncey PR; 65 trial investigators. | JAMA. 2020 Feb 12;323(10):938–49
DOI: https://doi.org/10.1001/jama.2020.0930 | Télécharger l'article au format
Introduction : Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients.
Objective : To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm Hg) reduces mortality at 90 days in ICU patients aged 65 years or older with vasodilatory hypotension.
Méthode : A multicenter, pragmatic, randomized clinical trial was conducted in 65 ICUs in the United Kingdom and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension (assessed by treating clinician). The study was conducted from July 2017 to March 2019, and follow-up was completed in August 2019.
Interventions : Patients were randomized 1:1 to vasopressors guided either by MAP target (60-65 mm Hg, permissive hypotension) (n = 1291) or according to usual care (at the discretion of treating clinicians) (n = 1307).
Main outcome and measures: The primary clinical outcome was all-cause mortality at 90 days.
Résultats : Of 2600 randomized patients, after removal of those who declined or had withdrawn consent, 2463 (95%) were included in the analysis of the primary outcome (mean [SD] age 75 years [7 years]; 1387 [57%] men). Patients randomized to the permissive hypotension group had lower exposure to vasopressors compared with those in the usual care group (median duration 33 hours vs 38 hours; difference in medians, -5.0; 95% CI, -7.8 to -2.2 hours; total dose in norepinephrine equivalents median, 17.7 mg vs 26.4 mg; difference in medians, -8.7 mg; 95% CI, -12.8 to -4.6 mg). At 90 days, 500 of 1221 (41.0%) in the permissive hypotension compared with 544 of 1242 (43.8%) in the usual care group had died (absolute risk difference, -2.85%; 95% CI, -6.75 to 1.05; P = .15) (unadjusted relative risk, 0.93; 95% CI, 0.85-1.03). When adjusted for prespecified baseline variables, the odds ratio for 90-day mortality was 0.82 (95% CI, 0.68 to 0.98). Serious adverse events were reported for 79 patients (6.2%) in the permissive care group and 75 patients (5.8%) in the usual care group. The most common serious adverse events were acute renal failure (41 [3.2%] vs 33 [2.5%]) and supraventricular cardiac arrhythmia (12 [0.9%] vs 13 [1.0%]).
Conclusion : Among patients 65 years or older receiving vasopressors for vasodilatory hypotension, permissive hypotension compared with usual care did not result in a statistically significant reduction in mortality at 90 days. However, the confidence interval around the point estimate for the primary outcome should be considered when interpreting the clinical importance of the study.
Conclusion (proposition de traduction) : Chez les patients de 65 ans ou plus recevant des vasopresseurs pour une hypotension vasodilatatrice, l'hypotension permissive comparée aux soins habituels n'a pas entraîné une réduction statistiquement significative de la mortalité à 90 jours. Toutefois, l'intervalle de confiance autour de l'estimation ponctuelle du résultat primaire doit être pris en compte lors de l'interprétation de l'importance clinique de l'étude.
Commentaire : Voir l'éditorial :
Marshall JC. Choosing the Best Blood Pressure Target for Vasopressor Therapy. JAMA. 2020 Feb 12. doi: 10.1001/jama.2019.22526 . Epub ahead of print. PMID: 32049266.
Management of Acute Asthma in Adults in 2020.
Zaidan MF, Ameredes BT, Calhoun WJ. | JAMA. 2020 Feb 11;323(6):563-564
JAMA Insights Clinical Update
Editorial : Asthma is a chronic airway disease that typically presents with episodes of severe respiratory distress known as exacerbations. Asthma exacerbations result in 1.8 million hospitalizations per year, with an estimated mortality rate of 13.3 deaths per million per year in US adults. This article summarizes evidence regarding management for acute asthma including : (1) inhaled corticosteroids (ICSs), (2) azithromycin and magnesium, (3) nebulized bronchodilators vs metered-dose inhalers, and innovative therapies undergoing investigation for treatment of adults with acute asthma exacerbations. Randomized clinical trials of acute asthma management published in major medical journals in the past 7 years were reviewed.
Conclusion : Appropriate management of asthma exacerbations consists of acutely restoring lung function and preventing disease progression. Essential strategies include prompt aerosol administration of β2-agonists, muscarinic antagonists, systemic corticosteroids, and oxygen as necessary.
Conclusion (proposition de traduction) : Une gestion appropriée des exacerbations de l'asthme consiste à restaurer de manière aiguë la fonction pulmonaire et à prévenir la progression de la maladie. Les stratégies essentielles comprennent l'administration rapide d'aérosols d'agonistes β2, d'antagonistes muscariniques, de corticostéroïdes systémiques et d'oxygène si nécessaire.
Association of Home Noninvasive Positive Pressure Ventilation With Clinical Outcomes in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis.
Wilson ME, Dobler CC, Morrow AS, Beuschel B, Alsawas M, Benkhadra R, Seisa M, Mittal A, Sanchez M, Daraz L, Holets S, Murad MH, Wang Z. | JAMA. 2020 Feb 4;323(5):455-465
DOI: https://doi.org/10.1001/jama.2019.22343 | Télécharger l'article au format
Introduction : The association of home noninvasive positive pressure ventilation (NIPPV) with outcomes in chronic obstructive pulmonary disease (COPD) and hypercapnia is uncertain.
Objective : To evaluate the association of home NIPPV via bilevel positive airway pressure (BPAP) devices and noninvasive home mechanical ventilator (HMV) devices with clinical outcomes and adverse events in patients with COPD and hypercapnia.
Méthode : Search of MEDLINE, EMBASE, SCOPUS, Cochrane Central Registrar of Controlled Trials, Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, and Scopus for English-language articles published from January 1, 1995, to November 6, 2019.
Study selection: Randomized clinical trials (RCTs) and comparative observational studies that enrolled adults with COPD with hypercapnia who used home NIPPV for more than 1 month were included.
Data extraction and synthesis: Data extraction was completed by independent pairs of reviewers. Risk of bias was evaluated using the Cochrane Collaboration risk of bias tool for RCTs and select items from the Newcastle-Ottawa Scale for nonrandomized studies.
Main outcomes and measures: Primary outcomes were mortality, all-cause hospital admissions, need for intubation, and quality of life at the longest follow-up.
Résultats : A total of 21 RCTs and 12 observational studies evaluating 51 085 patients (mean [SD] age, 65.7 [2.1] years; 43% women) were included, among whom there were 434 deaths and 27 patients who underwent intubation. BPAP compared with no device was significantly associated with lower risk of mortality (22.31% vs 28.57%; risk difference [RD], -5.53% [95% CI, -10.29% to -0.76%]; odds ratio [OR], 0.66 [95% CI, 0.51-0.87]; P = .003; 13 studies; 1423 patients; strength of evidence [SOE], moderate), fewer patients with all-cause hospital admissions (39.74% vs 75.00%; RD, -35.26% [95% CI, -49.39% to -21.12%]; OR, 0.22 [95% CI, 0.11-0.43]; P < .001; 1 study; 166 patients; SOE, low), and lower need for intubation (5.34% vs 14.71%; RD, -8.02% [95% CI, -14.77% to -1.28%]; OR, 0.34 [95% CI, 0.14-0.83]; P = .02; 3 studies; 267 patients; SOE, moderate). There was no significant difference in the total number of all-cause hospital admissions (rate ratio, 0.91 [95% CI, 0.71-1.17]; P = .47; 5 studies; 326 patients; SOE, low) or quality of life (standardized mean difference, 0.16 [95% CI, -0.06 to 0.39]; P = .15; 9 studies; 833 patients; SOE, insufficient). Noninvasive HMV use compared with no device was significantly associated with fewer all-cause hospital admissions (rate ratio, 0.50 [95% CI, 0.35-0.71]; P < .001; 1 study; 93 patients; SOE, low), but not mortality (21.84% vs 34.09%; RD, -11.99% [95% CI, -24.77% to 0.79%]; OR, 0.56 [95% CI, 0.29-1.08]; P = .49; 2 studies; 175 patients; SOE, insufficient). There was no statistically significant difference in the total number of adverse events in patients using NIPPV compared with no device (0.18 vs 0.17 per patient; P = .84; 6 studies; 414 patients).
Conclusion : In this meta-analysis of patients with COPD and hypercapnia, home BPAP, compared with no device, was associated with lower risk of mortality, all-cause hospital admission, and intubation, but no significant difference in quality of life. Noninvasive HMV, compared with no device, was significantly associated with lower risk of hospital admission, but there was no significant difference in mortality risk. However, the evidence was low to moderate in quality, the evidence on quality of life was insufficient, and the analyses for some outcomes were based on small numbers of studies.
Conclusion (proposition de traduction) : Dans cette méta-analyse de patients atteints de BPCO et d'hypercapnie, la BiPAP à domicile, comparée à l'absence de dispositif, a été associée à un risque de mortalité plus faible, à une admission à l'hôpital toutes causes confondues et à une intubation, mais sans différence significative dans la qualité de vie. Le respirateur mécanique non invasif à domicile, par rapport à l'absence de dispositif, a été associé de manière significative à un risque d'hospitalisation plus faible, mais il n'y a pas eu de différence significative dans le risque de mortalité. Cependant, les preuves étaient de qualité faible à modérée, les preuves sur la qualité de vie étaient insuffisantes et les analyses de certains résultats étaient basées sur un petit nombre d'études.
Electrical Versus Pharmacological Cardioversion for Emergency Department Patients With Acute Atrial Fibrillation (RAFF2): A Partial Factorial Randomised Trial.
Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Rowe BH, Brison RJ, Thiruganasambandamoorthy V, Macle L, Borgundvaag B, Morris J, Mercier E, Clement CM, Brinkhurst J, Sheehan C, Brown E, Nemnom MJ, Wells GA, Perry JJ. | Lancet. 2020 Feb 1;395(10221):339-349
Introduction : Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion.
Méthode : We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion.
Résultats : Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68).
Conclusion : Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.
Conclusion (proposition de traduction) : Les stratégies de réduction médicamenteuse et électrique ont été très efficaces, rapides et sûres pour rétablir le rythme sinusal des patients des urgences souffrant de fibrillation atriale récente, évitant ainsi le retour à l'hôpital. La perfusion de médicament a fonctionné pour environ la moitié des patients et a permis d'éviter la sédation procédurale, qui exige beaucoup de ressources, nécessaire à la cardioversion électrique. Nous n'avons pas non plus trouvé de différence significative entre les positions des palettes en antérolatéral ou en antéro-postérieur pour la cardioversion électrique. Le contrôle immédiat du rythme pour les patients des urgences souffrant de fibrillation atriale récente donne d'excellents résultats.
Commentaire : Rappel :
P. Taboulet, J. Duchenne, H. Lefort, C. Zanker, P. Jabre, J.-M. Davy, J.-Y. Le Heuzey, O. Ganansia et les membres de la commission des référentiels de la SFMU. Prise en charge de la fibrillation atriale en médecine d’urgence. Recommandations de la Société française de médecine d’urgence en partenariat avec la Société française de cardiologie. Ann Fr Med Urgence. 2015 sept;5(4):260-279 :
(…) En cas de FA de durée inférieure à 48 heures :
➔ Une cardioversion électrique ou pharmacologique doit être envisagée, pour orienter la stratégie ultérieure ambulatoire vers un contrôle du rythme (ESC, classe IIa).
➔ Une cardioversion pharmacologique peut être réalisée si le patient est stable et sans maladie cardiaque sévère (ESC, classe IIa).
➔ L’amiodarone IV est recommandée en présence d’une cardiopathie structurelle (ESC, classe I).
➔ Le flécaïnide IV est recommandé en l’absence de — ou si minime — cardiopathie structurelle (ESC, classe I).
➔ La digoxine ou le sotalol peuvent être dangereux et ne doivent pas être utilisés pour une cardioversion (ESC, classe III).
➔ Après la cardioversion, une surveillance du rythme pendant au moins trois heures est recommandée (SFMU/SFC, classe I).
➔ En cas de FA de durée supérieure à 48 heures ou de début indéterminé (sauf hémodynamique instable), une cardioversion ne doit pas être envisagée chez un patient sans anticoagulation efficace depuis au moins trois semaines (SFMU/SFC, classe III).
Les recommandations actuelles préconisent :
➔ un défibrillateur externe biphasique ;
➔ un positionnement antéropostérieur des électrodes, de préférence au positionnement antérolatéral ;
➔ une énergie initiale (courant biphasique) de 200 J pour une FA (entre 120 et 200 J pour un flutter). En cas d’échec d’un premier choc, une énergie supérieure est recommandée ;
➔ un choc synchrone avec les complexes QRS, afin de prévenir l’apparition d’une arythmie ventriculaire ;
➔ un positionnement des électrodes à distance d’un éventuel dispositif implanté (pacemaker, défibrillateur) et un contrôle du dispositif après cardioversion ;
➔ une sédation brève dans les conditions techniques de sédation avant d’effectuer un CEE chez un patient conscient. Le propofol est le médicament de choix pour cette sédation (administration IV lente et titrée de 0,5 à 0,8 mg/kg) ; (…)
Le risque thromboembolique est minime avant la 48e heure chez la plupart des patients.
Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial.
Villar J, Ferrando C, Martínez D, Ambrós A, Muñoz T, Soler JA, Aguilar G, Alba F, González-Higueras E, Conesa LA, Martín-Rodríguez C, Díaz-Domínguez FJ, Serna-Grande P, Rivas R, Ferreres J, Belda J, Capilla L, Tallet A, Añón JM, Fernández RL, González-Martín JM; dexamethasone in ARDS network. . | Lancet Respir Med. 2020 Mar;8(3):267-276
Introduction : There is no proven specific pharmacological treatment for patients with the acute respiratory distress syndrome (ARDS). The efficacy of corticosteroids in ARDS remains controversial. We aimed to assess the effects of dexamethasone in ARDS, which might change pulmonary and systemic inflammation and result in a decrease in duration of mechanical ventilation and mortality.
Méthode : We did a multicentre, randomised controlled trial in a network of 17 intensive care units (ICUs) in teaching hospitals across Spain in patients with established moderate-to-severe ARDS (defined by a ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen of 200 mm Hg or less assessed with a positive end-expiratory pressure of 10 cm H2O or more and FiO2 of 0·5 or more at 24 h after ARDS onset). Patients with brain death, terminal-stage disease, or receiving corticosteroids or immunosuppressive drugs were excluded. Eligible patients were randomly assigned based on balanced treatment assignments with a computerised randomisation allocation sequence using blocks of 10 opaque, sealed envelopes to receive immediate treatment with dexamethasone or continued routine intensive care (control group). Patients in the dexamethasone group received an intravenous dose of 20 mg once daily from day 1 to day 5, which was reduced to 10 mg once daily from day 6 to day 10. Patients in both groups were ventilated with lung-protective mechanical ventilation. Allocation concealment was maintained at all sites during the trial. Primary outcome was the number of ventilator-free days at 28 days, defined as the number of days alive and free from mechanical ventilation from day of randomisation to day 28. Secondary outcome was all-cause mortality 60 days after randomisation. All analyses were done according to the intention-to-treat principle.
Résultats : Between March 28, 2013, and Dec 31, 2018, we enrolled 277 patients and randomly assigned 139 patients to the dexamethasone group and 138 to the control group. The trial was stopped by the data safety monitoring board due to low enrolment rate after enrolling more than 88% (277/314) of the planned sample size. The mean number of ventilator-free days was higher in the dexamethasone group than in the control group (between-group difference 4·8 days [95% CI 2·57 to 7·03]; p<0·0001). At 60 days, 29 (21%) patients in the dexamethasone group and 50 (36%) patients in the control group had died (between-group difference -15·3% [-25·9 to -4·9]; p=0·0047). The proportion of adverse events did not differ significantly between the dexamethasone group and control group. The most common adverse events were hyperglycaemia in the ICU (105 [76%] patients in the dexamethasone group vs 97 [70%] patients in the control group), new infections in the ICU (eg, pneumonia or sepsis; 33 [24%] vs 35 [25%]), and barotrauma (14 [10%] vs 10 [7%]).
Conclusion : Early administration of dexamethasone could reduce duration of mechanical ventilation and overall mortality in patients with established moderate-to-severe ARDS.
Conclusion (proposition de traduction) : L'administration précoce de dexaméthasone pourrait réduire la durée de la ventilation mécanique et la mortalité globale chez les patients atteints d'un SDRA modéré à sévère.
Commentaire : Voir l'étude :
RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med. 2020 Jul 17:NEJMoa2021436