Accuracy of Biomarkers for the Diagnosis of Adult Community-acquired Pneumonia: A Meta-analysis.
Ebell MH, Bentivegna M, Cai X, Hulme C, Kearney M. | Acad Emerg Med. 2020 Mar;27(3):195-206
DOI: https://doi.org/10.1111/acem.13889  | Télécharger l'article au format  
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META‐ANALYSES)

Introduction : Biomarkers such as C-reactive protein (CRP) and procalcitonin may help distinguish community-acquired pneumonia (CAP) from other causes of lower respiratory tract infection.

Méthode : We performed a systematic review of the literature to identify prospective studies evaluating the accuracy of a biomarker in patients with acute cough or suspected CAP. We performed parallel abstraction of data regarding study inclusion, characteristics, quality, and test accuracy. Study quality was evaluated using QUADAS-2. Bivariate meta-analysis was performed using the mada package in R, and summary receiver operating characteristic (ROC) curves were created.

Résultats : Fourteen studies met our inclusion and exclusion criteria; three were at low risk of bias and four at moderate risk of bias, largely due to failure to prespecify diagnostic thresholds. Considering all studies regardless of the cutoff used, CRP was most accurate (area under the ROC curve = 0.802), followed by leukocytosis (0.777) and procalcitonin (0.771). Lipopolysaccharide-binding protein and fibrinogen are promising, but were only studied in a single report. For CRP and procalcitonin, the positive and negative likelihood ratios (LR+ and LR-, respectively) varied inversely based on the cutoff. For CRP, LR+ and LR- were 2.08 and 0.32 for a cutoff of 20 mg/L, 3.64 and 0.36 for a cutoff of 50 mg/L, and 5.89 and 0.47 for a cutoff of 100 mg/L. For procalcitonin, LR+ and LR- were 2.50 and 0.39 for a cutoff of 0.10 µg/L, 5.43 and 0.62 for a cutoff of 0.25 µg/L, and 8.25 and 0.76 for a cutoff of 0.50 µg/L. The combination of CRP >49.5 mg/L and procalcitonin >0.1 µg/L had LR+ of 2.24 and LR- of 0.44.

Conclusion : The best evidence supports CRP as the preferred biomarker for diagnosis of outpatient CAP given its accuracy, low cost, and point-of-care availability.

Conclusion (proposition de traduction) : Les meilleures données probantes soutiennent que la CRP est le biomarqueur préféré pour le diagnostic de la pneumopathie communautaire étant donné sa précision, son faible coût et sa disponibilité sur le lieu de soins.

The Association of Trauma Center Transport and Long‐term Functional Outcomes in Head‐injured Older Adults Transported by Emergency Medical Services.
Nishijima DK, Gaona SD, Faul M, Tancredi DJ, Waechter T, Maloney R, Bair T, Blitz A, Elms AR, Farrales RD, Howard C, Montoya J, Garzon H, Holmes JF; Sacramento County Prehospital Research Consortium. | Acad Emerg Med. 2020 Mar;27(3):207-216
DOI: https://doi.org/10.1111/acem.13915
Keywords: Aucun

ORIGINAL CONTRIBUTIONS

Introduction : It is unclear whether trauma center care is associated with improved outcomes in older adults with traumatic brain injury (TBI) compared to management at nontrauma centers. Our primary objectives were to describe the long-term outcomes of older adults with TBI and to evaluate the association of trauma center transport with long-term functional outcome.

Méthode : This was a prospective, observational study at five emergency medical services (EMS) agencies and 11 hospitals representing all 9-1-1 transfers within a county. Older adults (≥55 years) with TBI (defined as closed head injury associated with loss of consciousness and/or amnesia, abnormal Glasgow Coma Scale [GCS] score, or traumatic intracranial hemorrhage) and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and emergency department (ED) and hospital data were abstracted. Functional outcomes were measured using the Extended Glasgow Outcome Scale (GOS-E) at 3- and 6-month intervals by telephone follow-up. Reasons for disabilities were coded as due to head injury, due to illness or injury to other part of body, or due to a mixture of both. To evaluate the association of trauma center transport and functional outcomes, we conducted multivariate ordinal logistic regression analyses on multiple imputed data for 1) all patients with TBI and 2) patients with traumatic intracranial hemorrhage.

Résultats : We enrolled 350 patients with TBI; the median (Q1, Q3) age was 70 (61, 84) years, 187 (53%) were male, and 91 patients (26%) had traumatic intracranial hemorrhage on initial ED cranial computed tomography (CT) imaging. A total of 257 patients (73%) were transported by EMS to a Level I or II trauma center. Sixty-nine patients (20%) did not complete follow-up at 3 or 6 months. Of the patients with follow-up, 119 of 260 patients (46%) had moderate disability or worse at 6 months, including 55 of 260 patients (21%) who were dead at 6-month follow-up. Death or severe disabilities were more commonly attributed to non-TBI causes while moderate disabilities or better were more commonly due to TBI. On adjusted analysis, an abnormal GCS score, higher Charlson Comorbidity Index scores, and the presence of traumatic intracranial hemorrhage on initial ED cranial imaging were associated with worse GOS-E scores at 6 months. Trauma center transport was not associated with GOS-E scores at 6 months for TBI patients and in patients with traumatic intracranial hemorrhage on initial ED CT imaging.

Conclusion : In older adults with TBI, moderate disability or worse is common 6 months after injury. Over one in five of older adults with TBI died by 6 months, usually due to nonhead causes. Patients with TBI or traumatic intracranial hemorrhage did not have improved functional outcomes with initial triage to a trauma center.

Conclusion (proposition de traduction) : Chez les personnes âgées souffrant d'un traumatisme crânien, un handicap modéré ou plus grave est fréquent 6 mois après le traumatisme. Plus d'un adulte âgé sur cinq ayant subi un traumatisme crânien est mort dans les six mois, généralement de causes non liées au traumatisme crânien.
Les patients souffrant d'un traumatisme crânien ou d'une hémorragie intracrânienne traumatique n'ont pas obtenu de meilleurs résultats fonctionnels lors du triage initial vers un centre de traumatologie.

Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study.
Friedman BW, Irizarry E, Chertoff A, Feliciano C, Solorzano C, Zias E, Gallagher EJ. | Acad Emerg Med. 2020 Mar;27(3):229-235
DOI: https://doi.org/10.1111/acem.13898
Keywords: Aucune

ORIGINAL CONTRIBUTIONS

Introduction : Patients with low back pain (LBP) are often treated with nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are modestly effective for LBP, but many patients with LBP continue to suffer despite treatment with these medications. We compared pain and functional outcomes 1 week after emergency department (ED) discharge among patients randomized to a 1-week course of ibuprofen plus acetaminophen versus ibuprofen plus placebo.

Méthode : This was a randomized, double-blind study conducted in two urban EDs. Patients presenting with acute, nontraumatic, nonradicular LBP of no more than 2 weeks' duration were eligible for enrollment immediately prior to discharge from an ED if they had a score > 5 on the Roland Morris Disability Questionnaire (RMDQ), a 24-item validated instrument, indicating more than minimal functional impairment. All patients were given a standardized 10-minute LBP educational session prior to discharge. The primary outcome was improvement on the RMDQ between ED discharge and 1 week later. One secondary outcome was pain intensity, as measured on a 4-point descriptive scale (severe, moderate, mild, none) at 1 week.

Résultats : Enrollment began in October 2018. A total of 120 patients met selection criteria and were randomized. Baseline demographic characteristics were comparable between the two groups. By 1 week after the ED visit, patients randomized to ibuprofen plus placebo reported a mean (±SD) improvement in the RMDQ of 11.9 (±9.7), while those randomized to ibuprofen plus acetaminophen reported a mean (±SD) improvement of 11.1 (±10.7). The 95% CI for the between-group difference of 0.8 was -3.0 to 4.7. At 1 week, moderate or severe pain was reported by 15 of 53 (28%) patients in the ibuprofen plus placebo group and 16 of 57 (28%) patients in the ibuprofen plus acetaminophen group (95% CI for between-group difference of 0% = -17% to 17%).

Conclusion : Among ED patients with acute, nontraumatic, nonradicular LBP, adding acetaminophen to ibuprofen does not improve outcomes within 1 week.

Conclusion (proposition de traduction) : Chez les patients des services d'urgence souffrant de lombalgies aiguës, non traumatiques et non radiculaires, l'ajout d'acétaminophène à l'ibuprofène n'améliore pas les résultats en une semaine.

Covid-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome.
Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. | Am J Respir Crit Care Med. 2020 Mar 30
DOI: https://doi.org/10.1164/rccm.202003-0817le  | Télécharger l'article au format  
Keywords: Aucun

Letter

Editorial : In northern Italy an overwhelming number of patients with Covid-19 pneumonia and acute respiratory failure have been admitted to our Intensive Care Units. Attention is primarily focused on increasing the number of beds, ventilators and intensivists brought to bear on the problem, while the clinical approach to these patients is the one typically applied to severe ARDS, namely high Positive End Expiratory Pressure (PEEP) and prone positioning. However, the patients with Covid-19 pneumonia, fulfilling the Berlin criteria of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristics we are observing (confirmed by colleagues in other hospitals), is the dissociation between their relatively well preserved lung mechanics and the severity of hypoxemia. As shown in our first 16 patients (Figure 1), the respiratory system compliance of 50.2 ± 14.3 ml/cmH2O is associated with shunt fraction of 0.50 ± 0.11. Such a wide discrepancy is virtually never seen in most forms of ARDS. Relatively high compliance indicates well preserved lung gas volume in this patient cohort, in sharp contrast to expectations for severe ARDS.

Conclusion : A possible explanation for such severe hypoxemia occurring in compliant lungs is the loss of lung perfusion regulation and hypoxic vasoconstriction. Actually, in ARDS, the ratio between the shunt fraction to the fraction of gasless tissue is highly variable, with mean 1.25 ± 0.80(1). In eight of our patients with CT scan, however, we measured a ratio of 3.0 ± 2.1, suggesting remarkable hyperperfusion of gasless tissue. If so, the oxygenation increases with high PEEP and/or prone position are not primarily due to recruitment, the usual mechanism in ARDS(2), but instead, in these patients with a poorly recruitable pneumonia(3), to the redistribution of perfusion in response to pressure and/or gravitational forces. We should consider that:
1. Patients treated with Continuous Positive Airway Pressure or Non Invasive Ventilation, presenting with clinical signs of excessive inspiratory efforts, intubation should be prioritized to avoid excessive intrathoracic negative pressures and self-inflicted lung injury(4).
2. High PEEP in a poorly recruitable lung tends to result in severe hemodynamic impairment and fluid retention;
3. Prone positioning of patients with relatively high compliance results in a modest benefit at the price of a high demand for stressed human resources.
After considering that, all we can do ventilating these patients is “buying time” with minimum additional damage: the lowest possible PEEP and gentle ventilation. We need to be patient.

Conclusion (proposition de traduction) : Une explication possible de cette hypoxémie sévère survenant dans les poumons indemnes est la perte de la régulation de la perfusion pulmonaire et la vasoconstriction hypoxique. En fait, dans le SDRA, le rapport entre la fraction non vascularisé et la fraction de tissu non ventilé est très variable, avec une moyenne de 1,25 ± 0,80. Cependant, chez huit de nos patients avec tomodensitométrie, nous avons mesuré un rapport de 3,0 ± 2,1, suggérant une hyperperfusion remarquable de tissu non ventilé. Si c'est le cas, l'oxygénation augmente avec la PEP élevée et/ou la position couchée ne sont pas principalement dues au recrutement, le mécanisme habituel dans le SDRA, mais plutôt, chez ces patients avec une pneumonie mal recrutable, à la redistribution de la perfusion en réponse à la pression et/ou aux forces gravitationnelles. Nous devons considérer que :
1. Les patients traités par pression positive continue ou ventilation non invasive, présentant des signes cliniques d'efforts inspiratoires excessifs, l'intubation doit être priorisée pour éviter des pressions négatives intrathoraciques excessives et des lésions pulmonaires auto-infligées :
2. Une PEP élevée dans un poumon peu recrutable a tendance à entraîner une altération hémodynamique sévère et une rétention hydrique ;
3. Le positionnement enclin des patients avec une observance relativement élevée se traduit par un avantage modeste au prix d'une forte demande de ressources humaines stressées.
Après avoir considéré cela, tout ce que nous pouvons faire pour ventiler ces patients, c'est « gagner du temps » avec un minimum de dommages supplémentaires : la PEP la plus faible possible et une ventilation douce. Nous devons être patients.

An international multidisciplinary consensus statement onfasting before procedural sedation in adults and children.
Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP; International Committee for the Advancement of Procedural Sedation. | Anaesthesia. 2020 Mar;75(3):374-385
DOI: https://doi.org/10.1111/anae.14892  | Télécharger l'article au format  
Keywords: fasting, NPO guidelines, procedural sedation, pulmonary aspiration

Guidelines Open Access

Conclusion : The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Conclusion (proposition de traduction) : Le Comité international multidisciplinaire pour l'avancement de la sédation procédurale présente les premières recommandations de prévention du jeûne et de l'inhalation spécifiques à la sédation procédurale, basées sur une revue approfondie de la littérature. Ceux-ci ont été développés en utilisant la méthodologie Delphi et l'évaluation de la robustesse des preuves disponibles.
Les preuves de la littérature montrent clairement que le jeûne, tel qu'il est pratiqué actuellement, dépasse souvent considérablement les seuils de temps recommandés et a des conséquences néfastes connues, par exemple, l'irritabilité, la déshydratation et l'hypoglycémie. Le jeûne ne garantit pas un estomac vide, et il n'y a pas d'association observée entre l'inhalation et le respect des directives de jeûne courantes. La probabilité d'une inhalation cliniquement importante pendant la sédation procédurale est négligeable. Dans la littérature post-1984, il n'y a aucun rapport publié de mortalité par inhalation chez les enfants, aucun rapport de décès chez les adultes en bonne santé (état physique ASA 1 ou 2) et seulement neuf décès signalés chez les adultes de statut physique ASA 3 ou plus. Les préoccupations actuelles concernant l'inhalation sont disproportionnées par rapport au risque réel. Étant donné la fréquence d'inhalation et de mortalité observée plus faible que pendant l'anesthésie générale, et la base théorique pour assumer un risque moindre, les stratégies de jeûne dans la sédation procédurale peuvent raisonnablement être moins restrictives. Nous présentons un algorithme consensuel dans lequel chaque patient est d'abord stratifié en fonction du risque lors de son évaluation avant la sédation, en utilisant des facteurs factuels relatifs aux caractéristiques du patient, aux comorbidités, à la nature de la procédure et à la nature de la technique de sédation prévue. Des précautions à jeûne graduées pour les liquides et les solides sont ensuite recommandées pour les procédures électives basées sur cette catégorisation de risque d'inhalation négligeable, léger ou modéré. Cette déclaration de consensus peut servir de ressource aux praticiens et aux décideurs qui effectuent et supervisent la sédation procédurale chez les patients de tous âges, dans le monde entier.

Commentaire :  Algorithme reliant la stratification des risques et les conseils de jeûne.
Notes :
(1) Les définitions suggérées pour l'obésité modérée sont un indice de masse corporelle (IMC) de 30 à 39 kg.m⁻² chez les adultes ou du 85e au 95e percentile d'IMC en fonction de l'âge/sexe chez un enfant, et pour obésité sévère un IMC de 40 kg.m⁻² ou plus chez un adulte ou au 95e centile ou plus chez un enfant.
(2) Comprend : la micrognathie, la macroglossie et la laryngomalacie.
(3) Comprend : la gastroparésie, l'achalasie, l'atrésie, la sténose et la fistule trachéo-œsophagienne.
(4) Comprend : l'iléus, la pseudo-obstruction, la sténose du pylore et l'invagination.
(5) Les liquides clairs sont généralement considérés comme comprenant l'eau, les jus de fruits sans pulpe, le thé clair, le café noir et les liquides contenant des glucides spécialement préparés.
(6) Les intervalles de jeûne ne sont pas absolus, avec des exceptions autorisées lorsque les volumes de prise orale sont mineurs, ou le temps de jeûne raisonnablement proche.

Warnant A, Moumneh T, Roy PM, Penaloza A. | Ann Fr Med Urgence. 2020 Mars;10(2):89-93
DOI: https://doi.org/10.3166/afmu-2019-0154
Keywords: Chest pain; Emergency room; Diagnostic score; Acute coronary syndrome

Mise au point / Update

Editorial : La douleur thoracique est un motif très fréquent de consultation aux urgences. Le diagnostic différentiel est large et regroupe diverses étiologies parmi lesquelles les syndromes coronariens aigus (SCA) qui sont à l’avantplan. L’exclusion d’un SCA demeure une priorité absolue pour l’urgentiste au vu de la morbidité et de la mortalité qui lui sont associées. Afin d’aider le praticien dans sa démarche diagnostique, plusieurs algorithmes ont été élaborés pour exclure et diagnostiquer efficacement un SCA. Ceux-ci intègrent des données cliniques, électrocardiographiques et le dosage de la troponine. Leur utilisation est relativement simple et a été validée dans plusieurs essais cliniques. Ils permettent d’écarter le diagnostic de SCA chez une proportion significative de patients, avec une marge d’erreur très faible. Le score HEART se montre supérieur aux autres scores existants, et son application en salle d’urgences permet d’orienter de manière adéquate la démarche diagnostique, afin de réduire les investigations complémentaires et d’accélérer la prise en charge. Afin d’exclure un SCA sans recourir au dosage de la troponine, la règle CARE a été proposée récemment avec des résultats prometteurs. Issue directement du score HEART, elle permet d’écarter très rapidement le diagnostic de SCA puisqu’elle se passe de dosage biologique tout en gardant un profil de sécurité semblable.

Conclusion (proposition de traduction) : La prise en charge des douleurs thoraciques non traumatiques aux urgences n’est jamais chose aisée. Alors que certaines affections potentiellement graves doivent être évoquées par le contexte clinique (embolie pulmonaire, dissection aortique) ou par l’ECG réalisé à l’admission (STEMI), le diagnostic de SCA sans élévation du segment ST pose souvent problème. Il se doit néanmoins d’être reconnu au vu des conséquences d’un tel événement. Bien entendu, une démarche diagnostique centrée sur l’exclusion du SCA ne doit pas faire oublier les autres étiologies pouvant mettre en jeu le pronostic vital du patient, et l’évaluation initiale du patient reposera avant tout sur un interrogatoire et un examen clinique rigoureux.
Les trois piliers actuels du diagnostic de SCA demeurent la clinique, l’ECG et le dosage de la troponine. Toutefois, bon nombre de patients qui vont bénéficier d’une investigation supplémentaire sur le plan cardiologique sont en réalité à très faible risque de développer un SCA. Plusieurs scores et algorithmes peuvent aider le clinicien dans son processus décisionnel. Le score HEART permet d’exclure un SCA chez une proportion significative de patients après un seul dosage de la troponine, et sa simplicité permet de l’utiliser en pratique courante aux urgences. Récemment introduite, la règle CARE semble prometteuse pour exclure précocement un SCA sur la base de la clinique et de l’ECG uniquement. Applicable dès l’admission du patient, voire lors de la prise en charge préhospitalière, elle nécessite d’être validée à plus large échelle.

Inhaled Methoxyflurane Provides Greater Analgesia and Faster Onset of Action Versus Standard Analgesia in Patients With Trauma Pain: InMEDIATE: A Randomized Controlled Trial in Emergency Departments.
Borobia AM, Collado SG, Cardona CC, Pueyo RC, Alonso CF, Torres IP, González MC, Casal Codesido JR, Betegón MA, Barcela LA, Andicoechea AO, Testa AF, Colina JT, Dorribo AC, Del Arco Galán C, Martínez Ávila JC, Lugilde ST, Carcas Sansuán AJ; InMEDIATE Investigators Group. | Ann Emerg Med. 2020 Mar;75(3):315-328
DOI: https://doi.org/10.1016/j.annemergmed.2019.07.028  | Télécharger l'article au format  
Keywords: Aucun

Trauma

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

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

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

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

Conclusion (proposition de traduction) : Ces résultats sont en faveur de la prise en compte du méthoxyflurane comme alternative non opioïde, facile à administrer, à action rapide et de première intention aux traitements analgésiques actuellement disponibles pour les douleurs traumatiques.

Evaluation of Nonfatal Strangulation in Alert Adults.
Matusz EC, Schaffer JT, Bachmeier BA, Kirschner JM, Musey PI Jr, Roumpf SK, Strachan CC, Hunter BR. | Ann Emerg Med. 2020 Mar;75(3):329-338
DOI: https://doi.org/10.1016/j.annemergmed.2019.07.018
Keywords: Aucun

Trauma

Introduction : There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries.

Méthode : Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours' observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries.

Résultats : Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations.

Conclusion : Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain.

Conclusion (proposition de traduction) : S'ils sont conscient, les patients étranglés ont un faible taux de lésions. Tous les patients souffrant de lésions à la nuque ont eu des résultats inquiétants en plus de la douleur cervicale ; plus précisément, un score de Glasgow inférieur à 15 ou une dysphagie.
Nos conclusions suggèrent, mais ne prouvent pas, qu'une stratégie d'imagerie sélective est sûre chez les patients conscient après des constatations de strangulation en plus de la douleur cervicale.

Prevalence of Intracranial Injury in Adult Patients With Blunt Head Trauma With and Without Anticoagulant or Antiplatelet Use.
Probst MA, Gupta M, Hendey GW, Rodriguez RM, Winkel G, Loo GT, Mower WR. | Ann Emerg Med. 2020 Mar;75(3):354-364
DOI: https://doi.org/10.1016/j.annemergmed.2019.10.004  | Télécharger l'article au format  
Keywords: Aucun

Trauma

Introduction : We determine the prevalence of significant intracranial injury among adults with blunt head trauma who are receiving preinjury anticoagulant or antiplatelet medications.

Méthode : This was a multicenter, prospective, observational study conducted from December 2007 to December 2015. Patients were enrolled in 3 emergency departments (EDs) in the United States. Adults with blunt head trauma who underwent neuroimaging in the ED were included. Use of preinjury aspirin, clopidogrel, and warfarin was recorded. Data on direct oral anticoagulants were not specifically recorded. The primary outcome was prevalence of significant intracranial injury on neuroimaging. The secondary outcome was receipt of neurosurgical intervention.

Résultats : Among 9,070 patients enrolled in this study, the median age was 53.8 years (interquartile range 34.7 to 74.3 years) and 60.7% were men. A total of 1,323 patients (14.6%) were receiving antiplatelet medications or warfarin, including 635 receiving aspirin alone, 109 clopidogrel alone, and 406 warfarin alone. Compared with that of patients without any coagulopathy, the relative risk of significant intracranial injury was 1.29 (95% confidence interval [CI] 0.88 to 1.87) for patients receiving aspirin alone, 0.75 (95% CI 0.24 to 2.30) for those receiving clopidogrel alone, and 1.88 (95% CI 1.28 to 2.75) for those receiving warfarin alone. The relative risk of significant intracranial injury was 2.88 (95% CI 1.53 to 5.42) for patients receiving aspirin and clopidogrel in combination.

Conclusion : Patients receiving preinjury warfarin or a combination of aspirin and clopidogrel were at increased risk for significant intracranial injury, but not those receiving aspirin alone. Clinicians should have a low threshold for neuroimaging when evaluating patients receiving warfarin or a combination of aspirin and clopidogrel.

Conclusion (proposition de traduction) : Les patients recevant de la warfarine ou une combinaison d'aspirine et de clopidogrel avant une lésion présentaient un risque accru de lésion intracrânienne importante, mais pas ceux recevant de l'aspirine seule. Les cliniciens devraient avoir un seuil bas pour la neuroimagerie lorsqu'ils évaluent des patients recevant de la warfarine ou une combinaison d'aspirine et de clopidogrel.

Google Versus PubMed: Comparison of Google and PubMed's Search Tools for Answering Clinical Questions in the Emergency Department.
Morshed T, Hayden S. | Ann Emerg Med. 2020 Mar;75(3):408-415
DOI: https://doi.org/10.1016/j.annemergmed.2019.07.003
Keywords: Aucun

How Scientific Journals Work

Introduction : We assess which search tool returns the highest-quality, most relevant citations for standardized clinical questions arising at the point of care in the emergency department (ED).

Méthode : Search terms related to 3 clinical questions commonly encountered in the ED were entered into 5 search tools. The following search engines and tools were assessed: Google Web, Google Scholar, PubMed, PubMed Clinical Queries set to narrow search, and PubMed Clinical Queries set to broad search. The first 60 hits, in the order of most recent first, were reviewed and assessed for quality of evidence, relevance versus irrelevance, and number of high-quality hits, and each search instrument was graded for overall readability with a visual analog scale. Quality relevance ratio, defined as the ratio of high-quality relevant hits to low-quality irrelevant hits, was calculated for each tool according to these searches.

Résultats : Overall, PubMed Clinical Queries narrow search had the highest quality relevance ratio, averaging 0.85. PubMed Clinical Queries narrow search also returned high-quality relevant hits without the need to filter out as many low-quality irrelevant hits. Google Scholar retrieved the highest number of systematic reviews and randomized controlled trials, and returned the most complete search results, finding relevant citations other search engines did not. Google Web consistently had the lowest quality relevance ratio and contained many duplicate hits.

Conclusion : For the common clinical questions assessed in this study, PubMed Clinical Queries narrow search had the highest-quality, most relevant, and most readable hits. Google Scholar performed well, in some cases retrieving citations that other search engines did not. PubMed and Google Web were not as efficient.

Conclusion (proposition de traduction) : Pour les questions cliniques courantes évaluées dans cette étude, la recherche étroite de PubMed Clinical Queries a donné les résultats de la meilleure qualité, les plus pertinents et les plus lisibles. Google Scholar a obtenu de bons résultats, en récupérant dans certains cas des citations que d'autres moteurs de recherche n'avaient pas. PubMed et Google Web n'étaient pas aussi efficaces.

Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis.
Hoek AE, Anker SCP, van Beeck EF, Burdorf A, Rood PPM, Haagsma JA. | Ann Emerg Med. 2020 Mar;75(3):435-444
DOI: https://doi.org/10.1016/j.annemergmed.2019.06.008
Keywords: Aucun

Education

Introduction : We conduct a systematic review with meta-analysis to provide an overview of the different manners of providing discharge instructions in the emergency department (ED) and to assess their effects on comprehension and recall of the 4 domains of discharge instructions: diagnosis, treatment, follow-up, and return instructions.

Méthode : We performed a systematic search in the PubMed, EMBASE, Web of Science Google Scholar, and Cochrane databases for studies published before March 15, 2018. A quality assessment of included articles was performed. Pooled proportions of correct recall by manner of providing discharge instructions were calculated.

Résultats : A total of 1,842 articles were screened, and after selection, 51 articles were included. Of the 51 included studies, 12 used verbal discharge instructions only, 30 used written discharge instructions, and 7 used video. Correct recall of verbal, written, and video discharge instructions ranged from 8% to 94%, 23% to 92%, and 54% to 89%, respectively. Meta-analysis was performed on data of 1,460 patients who received verbal information only, 3,395 patients who received written information, and 459 patients who received video information. Pooled data showed differences in correct recall, with, on average, 47% for patients who received verbal information (95% confidence interval 32.2% to 61.7%), 58% for patients who received written information (95% confidence interval 44.2% to 71.2%), and 67% for patients who received video information (95% confidence interval 57.9% to 75.7%).

Conclusion : Communicating discharge instructions verbally to patients in the ED may not be sufficient. Although overall correct recall was not significantly higher, adding video or written information to discharge instructions showed promising results for ED patients.

Conclusion (proposition de traduction) : La communication verbale des instructions de sortie aux patients du service d'urgence peut ne pas être suffisante. Bien que le taux de rappel global correct n'ait pas été significativement plus élevé, l'ajout d'une vidéo ou d'informations écrites aux instructions de sortie a donné des résultats prometteurs pour les patients des urgences.

Comparison of videolaryngoscopy and direct laryngoscopy by German paramedics during out-of-hospital cardiopulmonary resuscitation; an observational prospective study.
Risse J, Volberg C, Kratz T, Plöger B, Jerrentrup A, Kill C. | BMC Emerg Med. 2020 Mar 23;20(1):22
DOI: https://doi.org/10.1186/s12873-020-00316-z  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Endotracheal intubation; Paramedics; Out-of-hospital cardiac arrest; Videolaryngoscopy

RESEARCH ARTICLE

Introduction : Videolaryngoscopy (VL) has become a popular method of intubation (ETI). Although VL may facilitate ETI in less-experienced rescuers there are limited data available concerning ETI performed by paramedics during CPR. The goal was to evaluate the impact VL compared with DL on intubation success and glottic view during CPR performed by German paramedics. We investigated in an observational prospective study the superiority of VL by paramedics during CPR compared with direct laryngoscopy (DL).

Méthode : In a single Emergency Medical Service (EMS) in Germany with in total 32 ambulances paramedics underwent an initial instruction from in endotracheal intubation (ETI) with GlideScope® (GVL) during resuscitation. The primary endpoint was good visibility of the glottis (Cormack-Lehane grading 1/2), and the secondary endpoint was successful intubation comparing GVL and DL.

Résultats : In total n = 97 patients were included, n = 69 with DL (n = 85 intubation attempts) and n = 28 VL (n = 37 intubation attempts). Videolaryngoscopy resulted in a significantly improved visualization of the larynx compared with DL. In the group using GVL, 82% rated visualization of the glottis as CL 1&2 versus 55% in the DL group (p = 0.02). Despite better visualization of the larynx, there was no statistically significant difference in successful ETI between GVL and DL (GVL 75% vs. DL 68.1%, p = 0.63).

Conclusion : We found no difference in Overall and First Pass Success (FPS) between GVL and DL during CPR by German paramedics despite better glottic visualization with GVL. Therefore, we conclude that education in VL should also focus on insertion of the endotracheal tube, considering the different procedures of GVL.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune différence dans le succès global et le succès à la première tentative entre l'utilisation du GlideScop et de la laryngoscopie directe pendant la réanimation cardio-pulmonaire par les ambulanciers paramédicaux allemands malgré une meilleure visualisation glottique avec le GlideScop. Par conséquent, nous concluons que l'éducation en vidéolaryngoscopie devrait également se concentrer sur l'insertion de la sonde endotrachéale, compte tenu des différentes procédures de l'utilisation du GlideScop.

Commentaire : Le GlideScope fait partie des glottiscopes du groupe 1 avec le McGrath. Il est distribué en France par la Société VERATHON (Schiltigheim).
Par rapport au laryngoscope de Macintosh, l’extrémité de la lame réalise un angle beaucoup plus obtus proche de 65°, il permet donc de visualiser des glottes a priori hautes invisibles avec le laryngoscope de Macintosh. Il est a noter que l’intubation trachéale avec le GlideScope a nécessité un mandrin malléable dans près de 40 % des cas. Si les glottiscopes améliorent la qualité de la vision glottique par rapport à celle du laryngoscope de Macintosh, l’intubation trachéale n’est pas toujours plus rapide.
Amathieu R, Abdi W, Adhoum A, Kamoun W, Sebbah JL, Combes X, Dhonneur G. Les Glottiscopes. MAPAR, 2009  .

Determinants of Prehospital Lactate in Trauma Patients: A Retrospective Cohort Study.
Ter Avest E, Griggs J, Wijesuriya J, Russell MQ, Lyon RM. | BMC Emerg Med. 2020 Mar 11;20(1):18
DOI: https://doi.org/10.1186/s12873-020-00314-1  | Télécharger l'article au format  
Keywords: Helicopter emergency medical service (HEMS); Lactate; Prehospital

Research article

Introduction : Point of care serum lactate measurement is emerging as an adjunct to prehospital clinical assessment and has the potential to guide triage and advanced treatment decision-making. In this study we aimed to assess which factors potentially affect prehospital lactate levels.

Méthode : We performed a retrospective cohort study of all trauma patients attended by the Air Ambulance, Kent, Surrey & Sussex (AAKSS) between July 2017 and April 2018 in whom a pre-hospital lactate was measured. Lactate was measured before AAKSS treatments were commenced, but generally after prehospital treatment by ground ambulance crews was initiated. Primary endpoint of interest was the association of various patient- and treatment characteristics with prehospital lactate levels.

Résultats : During the study period, lactate was measured in 156 trauma patients. Median lactate was 3.0 [2.0-4.1] mmol/l. Patients with an elevated lactate more often had deranged indices of end organ perfusion- and oxygenation (shock index 0.80 [0.58-1.03] vs 0.61 [0.40-0.82], p < 0.001, SpO2 96 [89-100%] vs 98 [96-100%], p = 0.025). They more often suffered from head injuries (62% vs 41%, p = 0.008), and received less analgesia prior to arrival of the AAKSS team (51.6% vs 67.2%, p = 0.03). In multivariate analysis, indices of end organ perfusion- and oxygenation only explained 15% of the variation in lactate levels.

Conclusion : Prehospital lactate levels are not solely associated with indices of end organ perfusion- and oxygenation. Injury type, treatments given on scene and many other (unmeasured) factors likely play an important role as well. This should be taken into account when lactate is used in clinical algorithms to guide prehospital triage or treatment.

Conclusion (proposition de traduction) : Les taux de lactate préhospitaliers ne sont pas uniquement associés aux indices de perfusion et d'oxygénation des organes cibles. Le type de blessure, les traitements administrés sur place et de nombreux autres facteurs (non mesurés) jouent probablement aussi un rôle important. Il faut en tenir compte lorsque le lactate est utilisé dans des algorithmes cliniques pour guider le triage ou le traitement préhospitalier.

Commentaire : (…) Le dosage veineux du lactate a également été évalué dans des études pronostiques de cohorte incluant des patients traumatisés sévères, suspects de sepsis ou admis dans une structure d’urgence. Les populations n’étaient pas toutes comparables et les résultats n’étaient pas univoques en particulier pour les valeurs de lactate veineux inférieures à 4 mmol/L. En revanche, il semble qu’une valeur de lactate veineux supérieure à 4 mmol/L était fortement associée à une augmentation du risque de décès.
Diagnostic et Prise en Charge de l’Acidose Métabolique   - Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) & Société française de médecine d’urgence (SFMU). Janvier 2019.

Hypnosis and communication reduce pain and anxiety in peripheral intravenous cannulation: Effect of Language and Confusion on Pain During Peripheral Intravenous Catheterization (KTHYPE), a multicentre randomised trial.
Fusco N, Bernard F, Roelants F, Watremez C, Musellec H, Laviolle B, Beloeil H; Effect of Language and Confusion on Pain During Peripheral Intravenous Catheterization (KTHYPE) group. | Br J Anaesth. 2020 Mar;124(3):292-298
DOI: https://doi.org/10.1016/j.bja.2019.11.020  | Télécharger l'article au format  
Keywords: Aucun

REGIONAL ANAESTHESIA

Introduction : Clinicians traditionally warn patients of pain before peripheral i.v. cannulation (PIVC). However, using words related to pain or undesirable experiences can result in greater pain and anxiety. The use of positive words can improve pain perception and subjective patient experience. We aimed to compare the effects of three types of communication, including hypnotic communication, on pain, comfort, and anxiety in patients during PIVC.

Méthode : The Effect of Language and Confusion on Pain During Peripheral Intravenous Catheterization (KTHYPE) trial is a randomised, parallel, single-blind, multicentre study of patients undergoing PIVC on the dorsal face of the hand before surgery. Patients from three hospitals were randomly allocated to one of three groups: PIVC performed with a hypnosis technique (hypnosis group), negative connotation (nocebo group), and neutral connotation (neutral group). The primary outcome measure was the occurrence of pain measured with a 0–10 numerical rating scale just after PIVC.

Résultats : Of the 272 subjects analysed (hypnosis, n=89; nocebo, n=92; neutral, n=91), pain after PIVC was lower in the hypnosis group (mean [standard deviation]; range) (1.5 [1.9]; 0–5) compared with the neutral (3.5 [2.3]; 0–9; P<0.0001) and nocebo groups (3.8 [2.5]; 0–10; P<0.0001). Whilst anxiety was higher and comfort lower before PIVC in the hypnosis group, anxiety decreased and comfort perception increased after PIVC when hypnosis was used.

Conclusion : This is one of the first well-designed RCTs showing a significant benefit of a hypnosis technique during a routine procedure, such as PIVC. The results could facilitate implementation of hypnosis in daily clinical care.

Conclusion (proposition de traduction) : Il s'agit de l'un des premiers essais cliniques randomisés bien conçus montrant un bénéfice significatif d'une technique d'hypnose pendant une procédure de routine, telle que la la pose d'une voie veineuse périphérique. Les résultats pourraient faciliter la mise en œuvre de l'hypnose dans les soins cliniques quotidiens.

Just the Facts: Hypertonic Saline Is Just as Good as (And Probably Better Than) Mannitol.
Murphy L | CJEM. 2020 Mar;22(2):152-154
DOI: https://doi.org/10.1017/cem.2019.455  | Télécharger l'article au format  
Keywords: Aucun

Just the Facts

Editorial : A 27-year-old female is brought to the emergency department (ED) by ambulance following a motor vehicle collision at highway speed. She was the belted driver. She has no significant past medical history and is on no medications. Following a prolonged extrication, she is intubated due to decreased level of consciousness before transport.

Conclusion : Despite the lack of guideline endorsement in the adult population, hypertonic saline has become the mainstay of treatment in the neurosurgical literature because, in addition to a more favourable side effect profile, many studies have shown it to more effectively lower intracranial pressure, with lower incidence of treatment failure when compared with mannitol. In the emergency department patient with suspected raised intracranial pressure, hypertonic saline is a reasonable, if not better, choice than mannitol.

Conclusion (proposition de traduction) : Malgré le manque d'approbation des recommandations dans la population adulte, le sérum physiologique hypertonique est devenu le pilier du traitement dans la littérature neurochirurgicale car, en plus d'un profil d'effets secondaires plus favorable, de nombreuses études ont montré qu'il abaissait plus efficacement la pression intracrânienne, avec une incidence plus faible de l'échec du traitement par rapport au mannitol. Chez le patient du service des urgences dont la pression intracrânienne est suspectée, la solution saline hypertonique est un choix raisonnable, sinon meilleur, que le mannitol.

Improved Survival With Extracorporeal Cardiopulmonary Resuscitation Despite Progressive Metabolic Derangement Associated With Prolonged Resuscitation.
Bartos JA, Grunau B, Carlson C, Duval S, Ripeckyj A, Kalra R, Raveendran G, John R, Conterato M, Frascone RJ, Trembley A, Aufderheide TP, Yannopoulos D. | Circulation. 2020 Mar 17;141(11):877-886
DOI: https://doi.org/10.1161/circulationaha.119.042173  | Télécharger l'article au format  
Keywords: cardiopulmonary resuscitation; death, sudden, cardiac; extracorporeal membrane oxygenation; heart arrest; ventricular fibrillation.

RESEARCH ARTICLE

Introduction : The likelihood of neurologically favorable survival declines with prolonged resuscitation. However, the ability of extracorporeal cardiopulmonary resuscitation (ECPR) to modulate this decline is unknown. Our aim was to examine the effects of resuscitation duration on survival and metabolic profile in patients who undergo ECPR for refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest.

Méthode : We retrospectively evaluated survival in 160 consecutive adults with refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest treated with the University of Minnesota (UMN) ECPR protocol (transport with ongoing cardiopulmonary resuscitation [CPR] to the cardiac catheterization laboratory for ECPR) compared with 654 adults who had received standard CPR in the amiodarone arm of the ALPS trial (Amiodarone, Lidocaine, or Placebo Study). We evaluated the metabolic changes and rate of survival in relation to duration of CPR in UMN-ECPR patients.

Résultats : Neurologically favorable survival was significantly higher in UMN-ECPR patients versus ALPS patients (33% versus 23%; P=0.01) overall. The mean duration of CPR was also significantly longer for UMN-ECPR patients versus ALPS patients (60 minutes versus 35 minutes; P<0.001). Analysis of the effect of CPR duration on neurologically favorable survival demonstrated significantly higher neurologically favorable survival for UMN-ECPR patients compared with ALPS patients at each CPR duration interval <60 minutes; however, longer CPR duration was associated with a progressive decline in neurologically favorable survival in both groups. All UMN-ECPR patients with 20 to 29 minutes of CPR (8 of 8) survived with neurologically favorable status compared with 24% (24 of 102) of ALPS patients with the same duration of CPR. There were no neurologically favorable survivors in the ALPS cohort with CPR ≥40 minutes, whereas neurologically favorable survival was 25% (9 of 36) for UMN-ECPR patients with 50 to 59 minutes of CPR and 19% with ≥60 minutes of CPR. Relative risk of mortality or poor neurological function was significantly reduced in UMN-ECPR patients with CPR duration ≥60 minutes. Significant metabolic changes included decline in pH, increased lactic acid and arterial partial pressure of carbon dioxide, and thickened left ventricular wall with prolonged professional CPR.

Conclusion : ECPR was associated with improved neurologically favorable survival at all CPR durations <60 minutes despite severe progressive metabolic derangement. However, CPR duration remains a critical determinate of survival.

Conclusion (proposition de traduction) : La réanimation cardio-pulmonaire extra-corporelle a été associée à une amélioration de la survie neurologique favorable pour toutes les durées de RCP < 60 minutes, malgré un dérangement métabolique progressif sévère. Cependant, la durée de la RCP reste un facteur déterminant de la survie.

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19).
Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. | Intensive Care Med. 2020 Mar 28:1–34
DOI: https://doi.org/10.1007/s00134-020-06022-5  | Télécharger l'article au format  
Keywords: COVID-19; Clinical practice guidelines; Coronavirus; Critical illness; SARS CoV-2.

Guideline

Introduction : The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.

Méthode : We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.

Résultats : The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.

Conclusion : The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.

Conclusion (proposition de traduction) : Le panel COVID-19 de la campagne "Surviving Sepsis" a émis plusieurs recommandations pour aider les professionnels de santé à prendre en charge les patients en soins intensifs atteints de COVID-19. Lorsque ces recommandation seront disponibles, nous fournirons de nouvelles recommandations dans les prochaines publications.

WhatsApp and Other Messaging Apps in Medicine: Opportunities and Risks.
Masoni M, Guelfi MR. | Intern Emerg Med. 2020 Mar;15(2):171-173
DOI: https://doi.org/10.1007/s11739-020-02292-5
Keywords: Data confidentiality; GDPR; HIPAA; Regulation; Secure messaging apps; WhatsApp

IM-Point of view

Editorial : WhatsApp is a popular messaging application frequently used by physicians and healthcare organizations that can improve the continuity of care and facilitate effective health services provision, especially in acute settings. However WhatsApp does not comply with the rules of the European GDPR and the US HIPA Act. So it is inappropriate to share clinical information via WhatsApp.For this reason alternatives to Whatsapp are considered. In particular, the features that must have secure messaging apps to be in compliance with GDPR and HIPAA and to protect patient data will be discussed. The aim is to encourage healthcare organizations and physicians to abandon WhatsApp and to adopt one of the many secure messaging apps now available, some of them at no cost.

Conclusion : Compliance with the legislative provision related to the exchange of sensitive data must be considered equally important compared with the sharing of information that can improve the delivery of effective care. So WhatsApp is not an adequate tool to share clinical information due to its non compliance with the GDPR and HIPAA rules. Consequently healthcare organizations and physicians should abandon WhatsApp moving towards SMA able to keep confidential- ity and security of patient data.

Conclusion (proposition de traduction) : Le respect de la disposition législative relative à l'échange de données sensibles doit être considéré comme tout aussi important que le partage d'informations susceptibles d'améliorer la prestation de soins efficaces. WhatsApp n'est donc pas un outil adéquat pour partager des informations cliniques en raison de sa non-conformité avec les règles du RGPD et de la HIPAA. Par conséquent, les organisations de soins de santé et les médecins devraient abandonner WhatsApp pour passer à des applications de messagerie sécurisée capables de préserver la confidentialité et la sécurité des données des patients.

Commentaire : L'utilisation d'une messagerie sécurisée de santé protégeant les données médicales de vos patients est une obligation légale. Ne pas protéger ces données pourrait engager votre responsabilité en tant que professionnel de santé.
Les messageries sécurisées de santé ayant rejoint l’Espace de confiance MSSanté permettent d’envoyer et de recevoir des mails de façon sécurisée conformément aux recommandations CNIL (Autorisation CNIL N°37), indépendamment de votre choix technique ou organisationnel.
Informatiser mon exercice. Conseil national de l‘Ordre des médecins  . 23 avril 2019

Two Different Techniques of Ultrasound-Guided Peripheral Venous Catheter Placement Versus the Traditional Approach in the Pre-Hospital Emergency Setting: A Randomized Study.
Skulec R, Callerova J, Vojtisek P, Cerny V. | Intern Emerg Med. 2020 Mar;15(2):303-310
DOI: https://doi.org/10.1007/s11739-019-02226-w
Keywords: Peripheral venous catheter; Pre-hospital care; Ultrasound

EM - ORIGINAL

Introduction : We performed a randomized pre-hospital clinical study to compare two different techniques of ultrasound-guided peripheral venous catheter (PVC) insertion and the conventional cannulation technique in the pre-hospital emergency setting, with a specific focus on the procedural success rate and the time required to introduce PVC.

Méthode : This pre-hospital prospective controlled randomized clinical trial allocated patients treated by emergency medical service to undergo PVC insertion fully controlled by ultrasound (ultrasound guidance of the PVC tip until it penetrates the lumen, group A), PVC insertion partially controlled by ultrasound (target vein identification only, group B) or to receive PVC without any ultrasound guidance (group C). The study outcomes were monitored until the patient was admitted to the hospital.

Résultats : A total of 300 adult patients were enrolled. The success of the first attempt (group A: 88%, group B: 94%, group C: 76%, p < 0.001) and overall success rate (A: 99%, B: 99%, C: 90%, p < 0.001) were significantly higher in the group A, followed by group B when compared to group C. The number of attempts was significantly lower (A: 1.18 ± 0.54, B: 1.05 ± 0.22, C: 1.22 ± 0.57, p < 0.001) and the time required for the procedure shorter (A: 75.3 ± 60.6, B: 43.5 ± 26.0, C: 82.3 ± 100.9 s, p < 0.001) in group B compared to groups A and C.

Conclusion : Both techniques of ultrasound-guided PVC placement were associated with higher success rates than the conventional method. However, PVC insertion partially controlled by ultrasound was superior to full ultrasound guidance in terms of time and number of cannulation attempts required.

Conclusion (proposition de traduction) : Les deux techniques de placement de cathéter veineux périphérique guidées par ultrasons ont été associées à des taux de réussite plus élevés que la méthode conventionnelle. Cependant, l'insertion du cathéter veineux périphérique partiellement contrôlée par échographie était supérieure au guidage échographique complet en termes de temps et de nombre de tentatives de canulation nécessaires.

Thirty-day Mortality in Atrial Fibrillation Patients With Gastrointestinal Bleeding in the Emergency Department: Differences Between Direct Oral Anticoagulant and Warfarin Users.
Turcato G, Bonora A, Zorzi E, Zaboli A, Zannoni M, Ricci G, Pfeifer N, Maccagnani A, Tenci A. | Intern Emerg Med. 2020 Mar;15(2):311-318
DOI: https://doi.org/10.1007/s11739-019-02229-7
Keywords: Atrial fibrillation; Direct oral anticoagulant; Emergency department; Gastrointestinal bleeding; Warfarin

EM - ORIGINAL

Introduction : More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified. The objective of this study was to assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB.

Méthode : his was a multicentre retrospective study conducted over 2 years. The study included patients evaluated at three different EDs for GIB. The baseline characteristics were included. Subsequently, we assessed the differences in past medical history and clinical data between the two study groups (DOAC and warfarin users). Differences between the two groups were evaluated using Kaplan-Meier curves.

Résultats : Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs and 60.6% (172/284) were treated with warfarin. Overall, 8.1% (23/284) of patients died within 30 days. Among the 172 warfarin-treated patients, 8.7% (15/172) died within 30 days from ED evaluation. In the 112 DOAC-treated patients, the mortality rate was 7.1% (8/112).

Conclusion : The Cox regression analysis, adjusted for possible clinical confounders, and the Kaplan-Meier curves did not outline differences between the two treatment groups. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.

Conclusion (proposition de traduction) : L'analyse de régression de Cox, ajustée pour les facteurs de confusion cliniques possibles, et les courbes de Kaplan-Meier n'ont pas mis en évidence les différences entre les deux groupes de traitement. La présente étude ne montre aucune différence entre les AOD et la warfarine dans la mortalité à court terme après saignement gastro-intestinal.

Cardiovascular Mortality After Type 1 and Type 2 Myocardial Infarction in Young Adults.
Singh A, Gupta A, DeFilippis EM, Qamar A, Biery DW, Almarzooq Z, Collins B, Fatima A, Jackson C, Galazka P, Ramsis M, Pipilas DC, Divakaran S, Cawley M, Hainer J, Klein J, Jarolim P, Nasir K, Januzzi JL, Di Carli MF, Bhatt DL, Blankstein R. | J Am Coll Cardiol. 2020 Mar 10;75(9):1003-1013
DOI: https://doi.org/10.1016/j.jacc.2019.12.052
Keywords: Aucun

ORIGINAL INVESTIGATIONS

Introduction : Type 2 myocardial infarction (MI) and myocardial injury are associated with increased short-term mortality. However, data regarding long-term mortality are lacking.
OBJECTIVES: This study compared long-term mortality among young adults with type 1 MI, type 2 MI, or myocardial injury.

Méthode : Adults age 50 years or younger who presented with troponin >99th percentile or the International Classification of Diseases code for MI over a 17-year period were identified. All cases were adjudicated as type 1 MI, type 2 MI, or myocardial injury based on the Fourth Universal Definition of MI. Cox proportional hazards models were constructed for survival free from all-cause and cardiovascular death.

Résultats : The cohort consisted of 3,829 patients (median age 44 years; 30% women); 55% had type 1 MI, 32% had type 2 MI, and 13% had myocardial injury. Over a median follow-up of 10.2 years, mortality was highest for myocardial injury (45.6%), followed by type 2 MI (34.2%) and type 1 MI (12%) (p < 0.001). In an adjusted model, type 2 MI was associated with higher all-cause (hazard ratio: 1.8; 95% confidence interval: 1.2 to 2.7; p 1⁄4 0.004) and cardiovascular mortality (hazard ratio: 2.7; 95% confidence interval: 1.4 to 5.1; p 1⁄4 0.003) compared with type 1 MI. Those with type 2 MI or myocardial injury were younger and had fewer cardiovascular risk factors but had more noncardiovascular comorbidities. They were significantly less likely to be prescribed cardiovascular medications at discharge.

Conclusion : Young patients who experience a type 2 MI have higher long-term all-cause and cardiovascular mortality than those who experience type 1 MI, with nearly one-half of patients with myocardial injury and more than one-third of patients with type 2 MI dying within 10 years. These findings emphasize the need to provide more aggressive secondary prevention for patients who experience type 2 MI and myocardial injury.

Conclusion (proposition de traduction) : Les jeunes patients qui subissent un infarctus de type 2 ont une mortalité à long terme, toutes causes confondues et cardiovasculaire, plus élevée que ceux qui subissent un infarctus de type 1, près de la moitié des patients ayant subi une lésion myocardique et plus d'un tiers des patients ayant subi un infarctus de type 2 mourant dans les dix ans. Ces résultats soulignent la nécessité de fournir une prévention secondaire plus agressive pour les patients qui subissent un infarctus de type 2 et des lésions myocardiques.

Ventricular Arrhythmias in Myocarditis: Characterization and Relationships With Myocardial Inflammation.
Peretto G, Sala S, Rizzo S, Palmisano A, Esposito A, De Cobelli F, Campochiaro C, De Luca G, Foppoli L, Dagna L, Thiene G, Basso C, Della Bella P. | J Am Coll Cardiol. 2020 Mar 10;75(9):1046-1057
DOI: https://doi.org/10.1016/j.jacc.2020.01.036
Keywords: Aucun

ORIGINAL INVESTIGATIONS

Introduction : Ventricular arrhythmias (VAs) have never been systematically investigated in patients with myocarditis at different stages.
OBJECTIVES : The purpose of this study was to compare baseline and follow-up characteristics of VAs in patients with active myocarditis (AM) versus previous myocarditis (PM).

Méthode : A total of 185 consecutive patients (69% males, age 44
15 years, left ventricular ejection fraction 49
14%) with myocarditis and VA at index hospitalization, including ventricular fibrillation, ventricular tachycardia (VT), nonsustained ventricular tachycardia (NSVT), and Lown’s grade $2 premature ventricular complexes, were enrolled. AM and PM groups were defined based on endomyocardial biopsy and cardiac magnetic resonance findings. A subset of patients (n 1⁄4 46, 25%) also underwent electroanatomic mapping and VA transcatheter ablation.

Résultats : At presentation, AM patients (n 1⁄4 123, 66%) more commonly had ventricular fibrillation (8 cases vs. 0 cases; p 1⁄4 0.053), and both irregular (61% vs. 11%; p < 0.001) and polymorphic VA (NSVT and VT: 19% vs. 2%; p 1⁄4 0.002; premature ventricular complexes: 63% vs. 16%; p < 0.001). Only in PM patients with NSVT or VT, the dominant morphology (right-bundle branch block with superior axis) was 100% predictive of abnormal LV inferoposterior substrate at both cardiac magnetic resonance and electroanatomic mapping. At 27
7 months prospective follow-up, 55 patients (30%) experienced malignant VA (AM vs. PM, p 1⁄4 0.385). Although a prevalence of polymorphic and irregular VA was confirmed in AM patients with persistent inflammation in follow-up (58%), a predominance of monomorphic and regular VA was found in AM patients after myocarditis healing (42%), as well as in PM patients (all p < 0.001).

Conclusion : In myocarditis patients, polymorphic and irregular VA are more common during the active inflammatory phase, whereas monomorphic and regular VA are associated with healed myocarditis.

Conclusion (proposition de traduction) : Chez les patients présentaznt une myocardite, les arythmies ventriculaires polymorphes et irrégulières sont plus fréquentes pendant la phase inflammatoire active, tandis que les arythmies ventriculaires monomorphes et régulières sont associées à une myocardite guérie.

Early Diagnosis of Myocardial Infarction With Point-of-Care High-Sensitivity Cardiac Troponin I.
Wussler D, Lopez-Ayala P, Walter JE, Troester V, Ratmann PD, Seidel F, Zimmermann T, Badertscher P, Wildi K, Rubini Giménez M, Potlukova E, Strebel I, Freese M, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Christ M, Twerenbold R, Mueller C; APACE Investigators. | J Am Coll Cardiol. 2020 Mar 17;75(10):1111-1124
DOI: https://doi.org/10.1016/j.jacc.2019.12.065
Keywords: Aucun

ORIGINAL INVESTIGATIONS

Introduction : Until now, high-sensitivity cardiac troponin (hs-cTn) assays were mainly developed for large central laboratory platforms. OBJECTIVES This study aimed to assess the clinical performance of a point-of-care (POC)-hs-cTnI assay in patients with suspected myocardial infarction (MI).

Méthode : This study enrolled patients presenting to the emergency department with symptoms suggestive of MI. Two cardiologists centrally adjudicated the final diagnosis using all clinical data including cardiac imaging. The primary objective was to directly compare diagnostic accuracy of POC-hs-cTnI-TriageTrue versus best-validated central laboratory assays. Secondary objectives included the derivation and validation of a POC-hs-cTnI-TriageTrue–specific 0/1-h algorithm.

Résultats : MI was the adjudicated final diagnosis in 178 of 1,261 patients (14%). The area under the curve (AUC) for POC- hs-cTnI-TriageTrue at presentation was 0.95 (95% confidence interval [CI]: 0.93 to 0.96) and was at least comparable to hs-cTnT-Elecsys (AUC: 0.94; 95% CI: 0.93 to 0.96; p 1⁄4 0.213) and hs-cTnI-Architect (AUC: 0.92; 95% CI: 0.90 to 0.93; p < 0.001). A single cutoff concentration <3 ng/l at presentation identified 45% of patients at low risk with a negative predictive value (NPV) of 100% (95% CI: 99.4% to 100%). A single cutoff concentration >60 ng/l identified patients at high risk with a positive predictive value (PPV) of 76.8% (95% CI: 68.9% to 83.6%). The 0/1-h algorithm ruled out 55% of patients (NPV: 100%; 95% CI: 98.8% to 100%), and ruled in 18% of patients (PPV: 76.8%; 95% CI: 67.2% to 84.7%). Ruled-out patients had cumulative event rates of 0% at 30 days and 1.6% at 2 years. This study confirmed these findings in a secondary analysis including hs-cTnI-Architect for central adjudication.

Conclusion : The POC-hs-cTnI-TriageTrue assay provides high diagnostic accuracy in patients with suspected MI with a clinical performance that is at least comparable to that of best-validated central laboratory assays

Conclusion (proposition de traduction) : Le dosage de la troponine cardiaque à haute sensibilité au point de service - TriageTrue - offre une grande précision diagnostique chez les patients chez qui l'on suspecte un infarctus du myocarde avec une performance clinique au moins comparable à celle des meilleurs dosages de laboratoire central validés

Diuretic Therapy for Patients With Heart Failure: JACC State-of-the-Art Review.
Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. | J Am Coll Cardiol. 2020 Mar 17;75(10):1178-1195
DOI: https://doi.org/10.1016/j.jacc.2019.12.059
Keywords: congestion; diuretics; heart failure; pharmacology.

THE PRESENT AND FUTURE

Editorial : Expansion of extracellular fluid volume is central to the pathophysiology of heart failure. Increased extracellular fluid leads to elevated intracardiac filling pressures, resulting in a constellation of signs and symptoms of heart failure referred to as congestion. Loop diuretics are one of the cornerstones of treatments for heart failure, but in contrast to other therapies, robust clinical trial evidence to guide the use of diuretics is sparse. A nuanced understanding of renal physiology and diuretic pharmacokinetics is essential for skillful use of diuretics in the management of heart failure in both the inpatient and outpatient settings. Diuretic resistance, defined as an inadequate quantity of natriuresis despite an adequate diuretic regimen, is a major clinical challenge that generally portends a poor prognosis. In this review, the authors discuss the fundamental mechanisms and physiological principles that underlie the use of diuretic therapy and the available data on the optimal use of diuretics.

Conclusion : The skillful use of diuretic therapy remains funda- mental to HF management. An understanding of the physiological effects, as well as the pharmacokinetic and pharmacodynamic properties, of these drugs is key for safe and effective use. Despite the long- standing clinical experience with loop diuretic agents, ongoing research (both fundamental and clinical trials) is providing insights into more effec- tive diuretic use and how these agents can best be used to improve outcomes for patients with HF.

Conclusion (proposition de traduction) : La bonne utilisation des diurétiques reste la base de la gestion de l'insuffisance cardiaque. La compréhension des effets physiologiques, ainsi que des propriétés pharmacocinétiques et pharmacodynamiques de ces médicaments est essentielle pour une utilisation sûre et efficace. Malgré la longue expérience clinique des diurétiques de l'anse, les recherches en cours (essais fondamentaux et cliniques) permettent de mieux comprendre l'efficacité des diurétiques et la manière dont ces agents peuvent être utilisés au mieux pour améliorer les résultats chez les patients souffrant d'insuffisance cardiaque.

Oral Anticoagulation and Cardiovascular Outcomes in Patients With Atrial Fibrillation and End-Stage Renal Disease.
Pokorney SD, Black-Maier E, Hellkamp AS, Friedman DJ, Vemulapalli S, Granger CB, Thomas L, Peterson ED, Piccini JP Sr. | J Am Coll Cardiol. 2020 Mar 24;75(11):1299-1308
DOI: https://doi.org/10.1016/j.jacc.2020.01.019
Keywords: anticoagulation; atrial fibrillation; bleeding; end-stage renal disease; stroke.

Research article

Introduction : Atrial fibrillation (AF) is common in patients with end-stage renal disease (ESRD). The impact of oral anticoagulation (OAC) in ESRD patients is uncertain. Objectives: The purpose of this study was to describe patterns of OAC use in ESRD patients with AF and their associations with cardiovascular outcomes.

Méthode : Using Medicare fee-for-service 5% claims data from 2007 to 2013, we analyzed treatment and outcomes in a cohort of patients with ESRD and AF. Prescription drug benefit information was used to determine the timing of OAC therapy. Cox proportional hazards modeling was used to compare outcomes including death, all-cause stroke, ischemic stroke, hemorrhagic stroke, and bleeding hospitalizations in ESRD patients treated with or without OAC.

Résultats : The cohort included 8,410 patients with AF and ESRD. A total of 3,043 (36.2%) patients were treated with OAC at some time during the study period. Propensity scores used to match 1,519 patients with AF and ESRD on OAC with 3,018 ESRD patients without OAC. Treatment with OAC was not associated with hospitalization for stroke (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.23 to 1.35; p = 0.97) or death (HR: 1.02; 95% CI: 0.94 to 1.10; p = 0.62). OAC was associated with an increased risk of hospitalization for bleeding (HR: 1.26; 95% CI: 1.09 to 1.46; p = 0.0017) and intracranial hemorrhage (HR: 1.30; 95% CI: 1.07 to 1.59; p = 0.0094).

Conclusion : OAC utilization was low in patients with AF and ESRD. We found no association between OAC use and reduced risk of stroke or death. OAC use was associated with increased risks of hospitalization for bleeding or intracranial hemorrhage. Alternative stroke prevention strategies are needed in patients with ESRD and AF.

Conclusion (proposition de traduction) : L'utilisation de l'anticoagulation orale était faible chez les patients souffrant de fibrillation auriculaire et d'insuffisance rénale terminale. Nous n'avons trouvé aucune association entre l'utilisation d'anticoagulants oraux et la réduction du risque d'accident vasculaire cérébral ou de décès. L'utilisation de l'anticoagulation orale a été associée à un risque accru d'hospitalisation pour saignement ou hémorragie intracrânienne. Des stratégies alternatives de prévention des accidents vasculaires cérébraux sont nécessaires chez les patients atteints d'insuffisance rénale terminale et de fibrillation auriculaire.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. | Lancet. 2020 Mar 28;395(10229):1038
DOI: https://doi.org/10.1016/s0140-6736(20)30566-3  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described.

Méthode : In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death.

Résultats : 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days.

Conclusion : The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future.

Conclusion (proposition de traduction) : Les facteurs de risque potentiels que sont l'âge avancé, un score SOFA élevé et des d-dimères supérieurs à 1 μg/mL pourraient aider les cliniciens à identifier les patients avec un mauvais pronostic à un stade précoce. L'excrétion virale prolongée justifie une stratégie d'isolement des patients infectés et des interventions antivirales optimales à l'avenir.

Commentaire : Erratum in:
• Lancet. 2020 Mar 28;395(10229):1038. doi: 10.1016/S0140-6736(20)30606-1  . Epub 2020 Mar 12.
• Lancet. 2020 Mar 28;395(10229):1038. doi: 10.1016/S0140-6736(20)30638-3  . Epub 2020 Mar 17.

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium.
Sulton C, Kamat P, Mallory M, Reynolds J. | Pediatr Emerg Care. 2020 Mar;36(3):138-142
DOI: https://doi.org/10.1097/pec.0000000000001199
Keywords: Aucun

Original contribution

Introduction : The objective of this study was to describe the use of intranasal dexmedetomidine (IN DEX) for sedated magnetic resonance imaging (MRI) examinations in children. The use of IN DEX for MRI in children has not been well described in the literature.

Méthode : The Pediatric Sedation Research Consortium (PSRC) is a collaborative and multidisciplinary group of sedation practitioners dedicated to understanding and improving the process of pediatric sedation. We searched the 2007 version of the PSRC database solely for instances in which IN DEX was used for MRI diagnostic studies. Patients receiving intravenous medications were excluded. Patient demographics, IN DEX dose, adjunct medications and dose, as well as procedure completion, complications, interventions, and monitoring providers were analyzed.

Résultats : A total of 224 sedation encounters were included in our primary analysis. There were no major adverse events. Most sedations (88%) required no intervention. Registered nurses were the monitoring provider in over 99% of cases. The median (interquartile range) dose of dexmedetomidine was 3 (2.5-3) mcg/kg. Adjunctive midazolam was used in 219/224 (98%) of the cases. All procedures were completed.

Conclusion : This report from the Pediatric Sedation Research Consortium shows that intranasal dexmedetomidine in combination with midazolam is an effective medication regimen for children who require an magnetic resonance imaging with sedation.

Conclusion (proposition de traduction) : Ce rapport du Pediatric Sedation Research Consortium montre que la dexmédétomidine intranasale en combinaison avec le midazolam est un régime médicamenteux efficace pour les enfants qui ont besoin d'une imagerie par résonance magnétique avec sédation.

Commentaire : La dexmédétomidine est un alpha-2 agoniste très sélectif avec un rapport de sélectivité alpha-2/alpha-1 sept fois plus élevé que celui de la clonidine. Ses principaux effets sont un effet sédatif sans effet dépresseur respiratoire, ainsi qu’un effet antalgique. Ses propriétés en font une molécule particulièrement attractive dans de nombreux domaines d’anesthésie et de réanimation.
Ract C. La dexmédétomidine en réanimation. MAPAR 2013  

Pediatric Drowning: A Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion.
Best RR, Harris BHL, Walsh JL, Manfield T. | Pediatr Emerg Care. 2020 Mar;36(3):143-146
DOI: https://doi.org/10.1097/pec.0000000000001169
Keywords: Aucun

Original contribution

Introduction : Drowning is one of the leading causes of death in children. Resuscitating a child following submersion is a high-pressure situation, and standard operating procedures can reduce error. Currently, the Resuscitation Council UK guidance does not include a standard operating procedure on pediatric drowning. The objective of this project was to design a standard operating procedure to improve outcomes of drowned children.

Méthode : A literature review on the management of pediatric drowning was conducted. Relevant publications were used to develop a standard operating procedure for management of pediatric drowning.

Résultats : A concise standard operating procedure was developed for resuscitation following pediatric submersion. Specific recommendations include the following: the Heimlich maneuver should not be used in this context; however, prolonged resuscitation and therapeutic hypothermia are recommended.

Conclusion : This standard operating procedure is a potentially useful adjunct to the Resuscitation Council UK guidance and should be considered for incorporation into its next iteration.

Conclusion (proposition de traduction) : Cette procédure opératoire standard est un complément potentiellement utile aux directives du laquo; Resuscitation Council UK » et devrait être envisagée pour être incorporée dans sa prochaine itération.

Commentaire : 

Risk Factors for Compartment Syndrome in Pediatric Trauma Patients.
Sees JA, Cutler GJ, Ortega HW. | Pediatr Emerg Care. 2020 Mar;36(3):e115-e119
DOI: https://doi.org/10.1097/pec.0000000000001636
Keywords: Aucun

Original contribution

Introduction : This study aimed to identify risk factors for compartment syndrome (CS) in pediatric trauma populations.

Méthode : We included patients younger than 19 years treated at trauma centers contributing to the National Trauma Data Bank between 2009 and 2012. Multivariable logistic regression was used to examine the association between risk factors and the development of CS. The final model adjusted for age, sex, race, number of comorbidities, Glascow Coma Scale, Injury Severity Score, mechanism of injury, and fracture of the lower limb.

Résultats : A total of 341,238 patients were eligible for analysis, and 896 patients developed CS (0.3%). In adjusted regression models, older patients had significantly higher odds of CS compared with patients 1 years or younger (odds ratio [OR], 3.29 [95% confidence interval [CI], 1.29-8.37; 2-6 years]; OR, 7.55 [95% CI, 3.08-18.55 [7-12 years]; OR, 10.34 [95% CI, 4.26-25.09 [13-18 years]). Male patients had significantly increased odds of CS compared with female patients, as did patients with lower limb fractures compared with patients without lower limb fractures (OR, 1.93 [95% CI, 1.56-2.40]; OR, 7.61 [95% CI, 6.48-8.94]; respectively). Finally, patients with a firearm injury had higher odds of CS compared with other mechanisms of injury (OR, 3.51 [95% CI, 2.70-4.56]).

Conclusion : Older pediatric trauma patients, male patients, and those with lower limb fractures and firearm injuries have increased odds of compartment syndrome. Information on risk factors can be used to help identify patients most likely to develop compartment syndrome, facilitating timely diagnosis and treatment.

Conclusion (proposition de traduction) : Les patients âgés de traumatisme pédiatrique, les patients masculins et ceux qui ont des fractures des membres inférieurs et des blessures par arme à feu ont plus de risque de présenter un syndrome des loges. Les informations sur les facteurs de risque peuvent être utilisées pour aider à identifier les patients les plus susceptibles de développer un syndrome des loges, facilitant le diagnostic et le traitement en temps opportun.

Lung Ultrasound Findings and Bronchiolitis Ultrasound Score for Predicting Hospital Admission in Children With Acute Bronchiolitis.
Özkaya AK, Yilmaz HL, Kendir ÖT, Gökay SS, Eyüboğlu İ. | Pediatr Emerg Care. 2020 Mar;36(3):e135-e142
DOI: https://doi.org/10.1097/pec.0000000000001705
Keywords: Aucun

Original contribution

Introduction : The purposes of this study were to determine the benefit of the bronchiolitis ultrasound score (BUS) in predicting hospital admission in children with acute bronchiolitis and to characterize lung sonography findings.

Méthode : This prospective observational study was performed in an academic pediatric emergency department. Children younger than 24 months presenting to the emergency department, diagnosed with acute bronchiolitis by 2 independent pediatricians were included in the study. Lung ultrasound was performed by a single sonographer, who was blinded to as much clinical information as possible. In addition, the treating physicians were blinded to the lung ultrasound findings. Logistic regression analysis models were used to identify admission predictors. Receiver operating characteristic analysis was used to evaluate the predictive value for effects of the BUS and the modified Bronchiolitis Severity Score on admission.

Résultats : The median age of the 76 patients diagnosed with acute bronchiolitis was 6 months (interquartile range, 3.6-10 months). Forty-two (55.3%) of the 76 patients enrolled were admitted. Lung ultrasound was compatible with acute bronchiolitis in 74 patients (97%). A significant correlation was determined between modified Bronchiolitis Severity Score and BUS in children with acute bronchiolitis (r = 0.698, P < 0.001). The most effective parameter in determining admission on logistic regression analysis, independently of other variables, was BUS (P = 0.044; adjusted odds ratio, 1.859; 95% confidence interval, 1.016-3.404). Bronchiolitis ultrasound score values of 3 or greater exhibited 73.81% sensitivity and 73.53% specificity, whereas BUS values of 4 or greater exhibited 50% sensitivity and 91.18% specificity.

Conclusion : Point-of-care lung ultrasound can accurately detect pulmonary anomalies in children with acute bronchiolitis, has a close correlation with clinical findings, and is a useful tool in predicting hospital admission.

Conclusion (proposition de traduction) : L'échographie pulmonaire au point de service peut détecter avec précision les anomalies pulmonaires chez les enfants atteints de bronchiolite aiguë, a une corrélation étroite avec les résultats cliniques et est un outil utile pour prédire l'admission à l'hôpital.

The Influence of Chloride for the Interpretation of Plasma Bicarbonate During the Treatment of Diabetic Ketoacidosis.
Ferreira JP, Hamui M, Torrents M, Carrano R, Ferraro M, Toledo I. | Pediatr Emerg Care. 2020 Mar;36(3):e143-e145
DOI: https://doi.org/10.1097/pec.0000000000001245
Keywords: Aucun

Original contribution

Introduction : Hyperchloremic metabolic acidosis can occur in diabetic ketoacidosis (DKA) and may affect the acid-base interpretation during treatment.
Objectives : This study aims to describe the prevalence of hyperchloremia during the treatment of DKA and its effect on the interpretation of bicarbonate value.

Méthode : A cross-sectional study, including all cases of DKA in patients aged 1 to 18 years old admitted from 2010 to 2015, was performed. Laboratory tests were performed on admission (baseline), 2 and 6 hours after admission, and when resolution of DKA was achieved. Adjusted bicarbonate value was calculated using regression equations.

Résultats : Seventy-nine DKA episodes were included. The average age was 13.3 ± 3.8 years. Baseline levels were as follows: plasma glucose, 479 ± 133 mg/dL; pH 7.1 ± 0.083; bicarbonate, 9.65 ± 2.9; and anion gap, 23.9 ± 7.5. The time to achieve resolution of DKA was 12.2 ± 4.4 hours, and the decrease in capillary glucose was 25.5 (19.7-38.2) mg/dL per hour. After 6 hours of treatment, the proportion of patients presenting hyperchloremia increased from 23% to 77%. By using adjusted bicarbonate, the percentage of patients achieving resolution of DKA after 6 hours of treatment would have been 35.4% (confidence interval 95%, 28-49), in comparison with 24.1% (confidence interval 95%, 18-37) using observed bicarbonate (P = 0.004).

Conclusion : The hyperchloremia developed during the treatment of diabetic ketoacidosis could modify the value of measured plasma bicarbonate concentration and unnecessarily prolong the initial phase of treatment.

Conclusion (proposition de traduction) : L'hyperchlorémie développée au cours du traitement de l'acidocétose diabétique pourrait modifier la valeur de la concentration plasmatique de bicarbonate mesurée et prolonger inutilement la phase initiale du traitement.

Barriers to Effective Teamwork Relating to Pediatric Resuscitations: Perceptions of Pediatric Emergency Medicine Staff.
Sherman JM, Chang TP, Ziv N, Nager AL. | Pediatr Emerg Care. 2020 Mar;36(3):e146-e150
DOI: https://doi.org/10.1097/pec.0000000000001275
Keywords: Aucun

Original contribution

Introduction : In the pediatric emergency department (PED), resuscitations require medical teams form ad hoc, rarely communicating beforehand. Literature has shown that the medical community has deficiencies in communication and teamwork. However, we as medical providers do not know or understand the perceived barriers of our colleagues. Physicians may perceive a barrier that is different from nurses, respiratory therapists, pharmacists, or technicians. Perhaps we do not know in which area of teamwork and communication we are deficient. Only when we understand the perceptions of our fellow coworkers can we take steps toward improvement in quality resuscitations and therefore patient safety.
Methods : The primary objectives of this study were to describe and understand the perceived barriers to effective communication and teamwork among different disciplines forming spontaneous resuscitation teams at a tertiary urban PED and to determine if providers of different disciplines perceived these barriers differently.

Méthode : This was a mixed-methods study conducted in a single, tertiary care freestanding children's hospital emergency department. Survey questions were iteratively developed to measure the construct of barriers and best practices within resuscitation teamwork, which was administered to staff among 5 selected roles: physicians, nurses, respiratory technicians, PED technicians, and PED pharmacists. It contained open-ended questions to provide statements on specific barriers or goals in effective teamwork, as well as a priority ranking on 25 different statements on teamwork extracted from the literature. From the participant data, 9 core themes related to resuscitation teamwork were coalesced using affinity diagramming by the authors. All statements from the survey were coded to the 9 core themes by 2 authors, with high reliability (κ = 0.93). Descriptive statistics were used to summarize the prevalence of themes mentioned by survey participants. A χ test was used to determine differences in prevalence of core themes by role. Rank data for the 25 statements were converted to a point system (5 points for most important, 4 points for second most important, etc), and a mixed within-between analysis of variance was used to determine the association of role and relative rank.

Résultats : There were 125 respondents (62% response rate) who provided 893 coded statements. The core theme of communication-in particular, closed-loop communication-was the most prevalent theme, although no differences in the proportion of themes represented were seen by PED staff of different roles (P = 0.18). There was a significant effect from the core theme (P = 0.002, partial η = 0.13), with highest priority on team leader performance (mean points out of 5 = 2.5 ± 1.9), but neither effect nor interaction with role (P = 0.6, P = 0.7).

Conclusion : When answering open-ended questions regarding barriers to effective resuscitations, all disciplines perceived communication, particularly closed-loop communication, as the primary theme lacking during resuscitations. However, when choosing from a list of themes, all groups except physicians perceived deficiencies in team leader qualities to be the greatest barrier. We as physicians must work on improving our communication and leadership attributes if we want to improve the quality of our resuscitations.

Conclusion (proposition de traduction) : Lorsqu'elles répondent à des questions ouvertes sur les obstacles à une réanimation efficace, toutes les spécialités ont perçu la communication, en particulier la communication en boucle fermée, comme le thème principal manquant lors des réanimations. Cependant, lorsqu'ils ont choisi parmi une liste de thèmes, tous les groupes, à l'exception des médecins, ont perçu les lacunes dans les qualités de chef d'équipe comme le plus grand obstacle.
En tant que médecins, nous devons nous efforcer d'améliorer nos qualités de communicatio et de leadership si nous voulons améliorer la qualité de nos réanimations.

How Accurate Are Pediatric Emergency Tapes? A Comparison of 4 Emergency Tapes With Different Length-Based Weight Categorization.
Both CP, Schmitz A, Buehler PK, Weiss M, Schmidt AR. | Pediatr Emerg Care. 2020 Mar;36(3):e151-e155
DOI: https://doi.org/10.1097/pec.0000000000001212
Keywords: Aucun

Original contribution

Introduction : Pediatric emergency tapes have been developed to support paramedics and emergency physicians when dosing drugs and selecting medical equipment in pediatric emergency situations. The aim of this study was to compare the accuracy of 4 pediatric emergency tapes to correctly estimate patient's weight based on a large population of patients.

Méthode : Patients undergoing general anesthesia between January 2012 and March 2015 with documented age, sex, body weight, and length were identified from the electronic anesthesia patient data management system of the Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland. Weight estimation by means of the Broselow-Tape, the Pädiatrisches Notfalllineal, the Paulino System, and the Kinder-Sicher were compared with true patient's weight. Percentages of estimated body weight within a ±10% and ±20% interval were calculated. Data are median (interquartile range) or count (percent); statistical calculations were done with McNemar and Bonferroni correction.

Résultats : A total of 3307 patients were identified with complete data sets, 1930 (58.4%) were male, median age was 4.1 years (1.1-8.2 years), median length 101.0 cm (74.0-126.0 cm) and median patient weight 15.8 kg (9.2-25.0 kg). The proportion weight estimation within the ±10% and the ±20% interval was the highest in the Broselow-Tape with 54.0% and 81.5% (P < 0.001 and P = 0.003), followed by the Pädiatrisches Notfalllineal (50.5% and 79.8%), Paulino System (49.9% and 78.0%) and Kinder-Sicher (48.2% and 77.5%).

Conclusion : The overall accuracy of all 4 emergency tapes tested is poor and including a larger number of weight categories does not necessarily increase accuracy. Other strategies have to be developed to improve weight estimation in pediatric emergency situations.

Conclusion (proposition de traduction) : La précision globale des 4 bandes Broselow d'urgence pédiatrique testées est médiocre et l'inclusion d'un plus grand nombre de catégories de poids n'augmente pas nécessairement la précision. D'autres stratégies doivent être développées pour améliorer l'estimation du poids dans les situations d'urgence pédiatrique.

Point-of-Care Troponin Testing During Ambulance Transport to Detect Acute Myocardial Infarction.
Stopyra JP, Snavely AC, Scheidler JF, Smith LM, Nelson RD, Winslow JE, Pomper GJ, Ashburn NP, Hendley NW, Riley RF, Koehler LE, Miller CD, Mahler SA. | Prehosp Emerg Care. 2020 Mar 3:1-9
DOI: https://doi.org/10.1080/10903127.2020.1721740
Keywords: chest pain; myocardial infarction; point-of-care; prehospital; troponin

Article

Introduction : Use of point-of-care (POC) troponin (cTn) testing in the Emergency Department (ED) is well established. However, data examining POC cTn measurement in the prehospital setting, during ambulance transport, are limited. The objective of this study was to prospectively test the performance of POC cTn measurement by paramedics to detect myocardial infarction (MI) among patients transported to the ED for acute chest pain.

Méthode : A prospective cohort study of adults with non-traumatic chest pain was conducted in three Emergency Medical Services agencies (December 2016 to January 2018). Patients with ST-elevation MI on ECG were excluded. During ambulance transport paramedics initiated intravenous access, collected blood, and used a POC device (i-STAT; Abbott Laboratories) to measure cTn. Following ED arrival, participants received standard evaluations including clinical blood draws for cTn measurement in the hospital central lab (AccuTnI +3 assay; Beckman Coulter, or cTnI-Ultra assay; Siemens). Blood collected during ambulance transport was also analyzed for cTn in the central lab. Index visit MI was adjudicated by 3 experts using central lab cTn measures from the patient’s clinical blood draws. Test characteristics (sensitivity, specificity, and predictive values) for detection of MI were calculated for POC and central lab cTn measurement of prehospital blood and compared with McNemar’s test.

Résultats : During the study period prehospital POC cTn results were obtained on 421 patients, of which 5.0% (21/421) had results >99th percentile upper reference limit. MI was adjudicated in 16.2% (68/421) during the index visit. The specificity and positive predictive value of the POC cTn measurement were 99.2% (95% CI 97.5–99.8%) and 85.7% (95% CI 63.7–97.0%) for MI. However, the sensitivity and NPV of prehospital POC cTn were 26.5% (95% CI 16.5–38.6%) and 87.5% (95% CI 83.9–90.6%). Compared to POC cTn, the central lab cTn measurement of prehospital blood resulted in a higher sensitivity of 67.9% (95% CI 53.7–80.1%, p < 0.0001), but lower specificity of 92.4% (95% CI 88.4–95.4%, p = 0.0001).

Conclusion : Prehospital POC i-STAT cTn measurement in patients transported with acute chest pain was highly specific for MI but had low sensitivity. This suggests that prehospital i-STAT POC cTn could be useful to rule-in MI, but should not be used to exclude MI.

Conclusion (proposition de traduction) : L'utilisation préhospitalière au point d'intervention du dispositif de mesure de la troponine par le système i-STAT (Laboratoire Abbott) chez des patients pris en charge pour une douleur thoracique aiguë était très spécifique pour l'infarctus du myocarde, mais avait une faible sensibilité. Cela suggère que l'utilisation préhospitalière du dispositif i-STAT pour la mesure de la troponine au point d'intervention pourrait être utile pour confirmer le diagnostic d'infarctus du myocarde, mais ne devrait pas être utilisée pour exclure un infarctus du myocarde.

Commentaire : Dans l'étude, la mesure préhospitalière de la troponine avec l'i-STAT avait une spécificité de 99,2 % (versus 92,4 % pour la mesure au laboratoire) et une valeur prédictive positive de 85,7 %. La sensibilité étaient de 26,5 % (versus 67,9 % pour la mesure au laboratoire) et la valeur prédictive négative était de 87,5 %.

Rappel :
• La sensibilité (Se) est la probabilité qu'un test réalisé sur une personne malade se révèle positif; autrement dit, que le test soit positif sachant que la personne est malade. La sensibilité correspond donc au nombre de personnes malades et positives au test (vrais positifs) parmi l'ensemble des personnes malades.
• La spécificité (Sp) est la probabilité qu'un test réalisé sur une personne saine se révèle négatif; autrement dit, que le test soit négatif sachant que la personne n'est pas malade. La spécificité correspond donc au nombre de personnes non-malades et négatives au test (vrais négatifs) parmi l'ensemble des personnes non-malades.

Control of Severe, Life-Threatening External Bleeding in the Out-Of-Hospital Setting: A Systematic Review.
Charlton NP, Swain JM, Brozek JL, Ludwikowska, Swain JM, Brozek JL, Ludwikowska M, Singletary E, Zideman D, Epstein J, Darzi A, Bak A, Karam S, Les Z, Carlson JN, Lang E, Nieuwlaat R; International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force. | Prehosp Emerg Care. 2020 Mar 24:1-49
DOI: https://doi.org/10.1080/10903127.2020.1743801
Keywords: bleeding; direct pressure; hemorrhage; hemostatic dressing; tourniquet.

Article

Introduction : Trauma, with resultant bleeding, is a significant cause of morbidity and mortality throughout the world, however the best possible method of bleeding control by immediate responders is unknown. We performed a systematic review of the effectiveness of treatment modalities for severe, life-threatening external bleeding in the out-of-hospital first aid setting.

Méthode : We followed the Cochrane Handbook for Systematic Reviews of Interventions methodology and report results according to PRISMA guidelines. We included randomized controlled trials, non-randomized comparative studies and case series investigating adults and children with severe, life-threatening external bleeding who were treated with therapies potentially suitable for first aid providers. We assessed the certainty of the evidence and risk of bias. Outcomes were prioritized by first aid specialists based on importance for patients and decision-makers and included mortality due to bleeding, all-cause mortality, cessation of bleeding, time to cessation of bleeding, a decrease in bleeding and complications/adverse effects. Results were reported in Evidence Profiles.

Résultats : Of the 1,051 full-text articles screened, 107 were included for analysis including 22,798 patients. The primary methods of bleeding control were tourniquets (n=49), hemostatic dressings (n=34), hemostatic devices (n= 14), pressure dressings/bandages/devices (n=8), pressure points (n=4), including two studies that reported multiple hemorrhage control methods. Overall, certainty of evidence was very low and often relied on indirect evidence and poorly controlled studies. Tourniquets were associated with a decrease in mortality when compared with direct manual pressure. Hemostatic dressings resulted in a shorter time to hemostasis than direct manual pressure using standard dressings. Direct manual compression resulted in a shorter time to hemostasis than pressure dressings/devices.

Conclusion : Overall, data regarding the control of life-threatening bleeding is of very low certainty, making it difficult to draw robust conclusions for treatment by immediate responders. While more robust data is needed on first aid treatments of life-threatening bleeding, this systematic review aggregates the most comprehensive to date to help guide recommendations.

Conclusion (proposition de traduction) : Dans l'ensemble, les données concernant le contrôle des hémorragies mortelles sont très peu sûres, ce qui rend difficile de tirer des conclusions solides pour le traitement par les intervenants immédiats. Bien que des données plus solides soient nécessaires sur les traitements de premiers secours des hémorragies mortelles, cette étude systématique regroupe les données les plus complètes à ce jour pour aider à orienter les recommandations.

Survival and Rearrest in out-of-Hospital Cardiac Arrest Patients With Prehospital Return of Spontaneous Circulation: A Prospective Multi-Regional Observational Study.
Woo JH, Cho JS, Lee CA, Kim GW, Kim YJ, Moon HJ, Park YJ, Lee KM, Jeong WJ, Choi IK, Choi HJ, Choi HJ. | Prehosp Emerg Care. 2020 Mar 20:1-8
DOI: https://doi.org/10.1080/10903127.2020.1733716
Keywords: Cardiopulmonary resuscitation; emergency medical services; risk factors; survival; telemedicine.

Article

Introduction : We aimed to determine the factors associated with rearrest after prehospital return of spontaneous circulation (ROSC) and examine the factors associated with survival despite rearrest.

Méthode : We conducted a prospective multi-regional observational study of out-of-hospital cardiac arrest (OHCA) patients between August 2015 and July 2016. Patients received prehospital advanced cardiovascular life support performed by emergency medical technicians (EMTs). EMTs were directly supervised by medical directors (physicians) via real-time smartphone video calls [Smart Advanced Life Support (SALS)]. The study participants were categorized into rearrest (+) and rearrest (-) groups depending on whether rearrest occurred after prehospital ROSC. After rearrest, patients were further classified as survivors or non-survivors at discharge.

Résultats : SALS was performed in 1,711 OHCA patients. Prehospital ROSC occurred in 345 patients (20.2%); of these patients, 189 (54.8%) experienced rearrest [rearrest (+) group] and 156 did not experience rearrest [rearrest (-) group]. Multivariate analysis showed that a longer interval from collapse to first prehospital ROSC was independently associated with rearrest [odds ratio (OR) 1.081; 95% confidence interval (CI) 1.050-1.114]. The presence of an initial shockable rhythm was independently associated with survival after rearrest (OR 6.920; 95% CI 2.749-17.422). As a predictor of rearrest, the interval from collapse to first prehospital ROSC (cut-off: 24 min) had a sensitivity of 77% and a specificity of 54% (AUC = 0.715 [95% CI 0.661-0.769]).

Conclusion : A longer interval from collapse to first prehospital ROSC was associated with rearrest, and an initial shockable rhythm was associated with survival despite the occurrence of rearrest. Emergency medical service providers and physicians should be prepared to deal with rearrest when pulses are obtained late in the resuscitation.

Conclusion (proposition de traduction) : Un intervalle plus long entre l'arrêt cardiaque et le premier RACS préhospitalier a été associé à un nouvel arrêt cardiaque, et un rythme initial choquable a été associé à la survie malgré l'apparition d'un nouvel arrêt cardiaque. Les prestataires de services médicaux d'urgence et les médecins doivent être prêts à faire face à un nouvel arrêt cardiaque lorsque le pouls est récupéré tardivement lors de la réanimation.

Head-Neck Motion in Prehospital Trauma Patients Under Spinal Motion Restriction: A Pilot Study.
McDonald N, Kriellaars D, Weldon E, Pryce R. | Prehosp Emerg Care. 2020 Mar 18:1-8
DOI: https://doi.org/10.1080/10903127.2020.1727591
Keywords: spinal immobilization; cervical spine; cervical collar; long backboard

Article

Introduction : pinal precautions are intended to limit motion of potentially unstable spinal segments. The efficacy of various treatment approaches for motion restriction in the cervical spine has been rigorously investigated using healthy volunteers and, to a lesser extent, cadaver samples. No previous studies have objectively measured this motion in trauma patients with potential spine injuries during prehospital care. Objective: The purpose of this study was to characterize head-neck (H-N) kinematics in a sample of trauma patients receiving spinal precautions in the field.

Méthode : This was a prospective observational study of trauma patients in the prehospital setting. Trauma patients meeting criteria for spinal precautions were eligible for inclusion. Participants received usual care, consisting of either a long backboard, cervical collar, and head blocks (BC) or a cervical collar only (CO), and behavior was categorized as compliant (C) or non-compliant (N). Three inertial measurement units (IMUs), placed on each participant's forehead, sternum, and stretcher, yielded data on H-N motion. Outcomes were described in terms of H-N displacement and acceleration, including single- and multi-planar values, root mean square (RMS), and bouts of continuous motion above pre-determined thresholds. Data were analyzed to compare H-N motion by phase of prehospital care, as well as treatment type and patient behavior.

Résultats : Substantial single- and multi-plane H-N motion was observed among all participants. Maximum single-plane displacements were between 11.3 ± 3.0 degrees (rotation) and 19.0 ± 16.6 degrees (flexion-extension). Maximum multi-plane displacements averaged 31.2 ± 7.2 degrees (range: 7.2 to 82.1 degrees). Maximum multi-plane acceleration averaged 5.8 ± 1.4 m/s2 (range: 1.2 to 19.9 m/s2). There were no significant differences among participants between prehospital phase and treatment type. Non-compliant participants showed significantly more motion than compliant participants.

Conclusion : Among actual patients, movement appears to be greater than previously recorded in simulation studies, and to be associated with patient behavior. Miniature IMUs are a feasible approach to field-based measurement of H-N kinematics in trauma patients. Future research should evaluate the effects of patient compliance, treatment, and phase of care using larger samples.

Conclusion (proposition de traduction) : Chez les patients dans la vraie vie, les mouvements semblent être plus importants que ceux enregistrés précédemment dans les études de simulation, et être associés au comportement du patient. Les unités de mesure inertielle miniatures constituent une approche réalisable pour la mesure sur le terrain de la cinématique tête-cou chez les patients traumatisés. Les recherches futures devraient évaluer les effets de l'observance du traitement par le patient, du traitement et de la phase de soins en utilisant des échantillons plus importants.

Prehospital Epinephrine as a Potential Factor Associated With Prehospital Rearrest.
Yamashita A, Kurosaki H, Takada K, Tanaka Y, Nishi T, Wato Y, Inaba H. | Prehosp Emerg Care. 2020 Mar 6:1-10
DOI: https://doi.org/10.1080/10903127.2020.1725197
Keywords: Out-of-hospital cardiac arrest; rearrest; outcomes; epinephrine; emergency medical service.

Article

Introduction : To investigate the impact of epinephrine on prehospital rearrest and re-attainment of prehospital return of spontaneous circulation (ROSC).

Méthode : Data for 9,292 (≥ 8 years) out-of-hospital cardiac arrest (OHCA) patients transported to hospitals by emergency medical services were collected in Ishikawa Prefecture, Japan during 2010-2018. Univariate and multivariable analyses were retrospectively performed for 1,163 patients with prehospital ROSC.

Résultats : Of 1,163 patients, rearrest occurred in 272 (23.4%) but not in 891 (76.6%). Both single and multiple doses of epinephrine administered before prehospital ROSC (adjusted odds ratio (OR): 3.62, 95% confidence interval (CI): 2.42-5.46 for 1 mg, and 4.27, 2.58-6.79 for ≥ 2 mg) were main factors associated with rearrest. The association between initial and rearrest rhythms was significantly associated with epinephrine administration (p = 0.02). However, the rearrest rhythm was primarily associated with the initial rhythm (p < 0.01). The majority of patients with the non-shockable initial rhythm had pulseless electrical activity (PEA) as the rearrest rhythm, regardless of epinephrine administration (80.4% for administration, 81.6% for no administration). When the initial rhythm was shockable, the primary rearrest rhythms in patients with and without epinephrine administration before prehospital ROSC were PEA (52.2%) and ventricular fibrillation/pulseless ventricular tachycardia (56.8%), respectively. Only epinephrine administration after rearrest was associated with prehospital re-attainment of ROSC (adjusted OR: 2.49, 95% CI: 1.20-5.19). Stepwise multivariable logistic regression analyses revealed that neurologically favorable outcome was poorer in patients with rearrest than those without rearrest (9.9% vs. 25.0%, adjusted OR: 0.42, 95% CI: 0.23-0.73). The total prehospital doses of epinephrine were associated with poorer neurological outcome in a dose-dependent manner (adjusted OR: 0.22, 95% CI: 0.13-0.36 for 1 mg; 0.09, 0.04-0.19 for 2 mg; 0.03, 0.01-0.09 for ≥ 3 mg, no epinephrine as a reference). Transportation to hospitals with a unit for post-resuscitation care was associated with better neurological outcome (adjusted OR: 1.53, 95% CI: 1.02-2.32).

Conclusion : The requirement for epinephrine administration before prehospital ROSC was associated with subsequent rearrest. Routine epinephrine administrations and rearrest were associated with poorer neurological outcome of OHCA patients with prehospital ROSC.

Conclusion (proposition de traduction) : L'obligation d'administrer de l'adrénaline avant le retour préhospitalier à une circulation cardiaque spontanée (RACS) a été associée à un ré-arrêt cardiaque ultérieur. L'administration systématique d'adrénaline et le ré-arrêt cardiaque ont été associés à de moins bons résultats neurologiques chez les patients ayant subi un arrêt cardiaque extra-hospitalier, avec un retour préhospitalier à une circulation cardiaque spontanée (RACS).

Ability of Layperson Callers to Apply a Tourniquet Following Protocol-Based Instructions From an Emergency Medical Dispatcher.
Scott G, Olola C, Gardett MI, Ashwood D, Broadbent M, Sangaraju S, Stiegler P, Fivaz MC, Clawson JJ. | Prehosp Emerg Care. 2020 Mar 3:1-8
DOI: https://doi.org/10.1080/10903127.2020.1718259
Keywords: emergency medical dispatch; emergency medical services; hemorrhage; layperson tourniquet use; stop the bleed; tourniquet.

Article

Introduction : One of the greatest casualty-care improvements resulting from US military operations in Iraq and Afghanistan has been the reduction of preventable death from massive extremity hemorrhage - largely due to the widespread use of limb tourniquets. More recently, tourniquet use in civilian, prehospital settings has shown promise in reducing deaths in cases of catastrophic arterial limb hemorrhage. Telephone instructions by trained emergency medical dispatchers (EMDs) on applying an available tourniquet may help achieve such a benefit.
Objectives : The objective of the study was to determine whether layperson callers can effectively stop simulated bleeding using an improvised or a commercial tourniquet, when provided with scripted instructions via phone from a trained protocol-aided EMD.

Méthode : This was a prospective, randomized trial involving layperson volunteers, done at four locations in Salt Lake City, Utah, USA. Volunteers were assigned randomly to three groups: one for each of two commonly available commercial tourniquets and one for an improvised tourniquet.

Résultats : A total of 246 subjects participated in the study at the four locations between February 11, 2019 and June 22, 2019. The overall median time for all trials (i.e., elapsed time from the start to the end of the simulation) was 3 minutes and 19 seconds. Median time to stop the bleeding (i.e., elapsed time from the start of the simulation to the time the participant was able to successfully stop the bleeding) was 2 minutes and 57 seconds. Median tourniquet pressure was 256 mmHg and median-end blood loss was 1,365 mL. A total of 198 participants (80.49%) were able to completely stop the bleeding while 16 participants (6.5%) had the tourniquet applied with some bleeding still occurring, and 32 participants (13.01%) exceeded the threshold of 2,500 mL of blood loss, resulting in the "patient" not surviving.

Conclusion : The study findings demonstrated that untrained bystanders provided with instructions via phone from a trained Emergency Medical Dispatcher applied a tourniquet and successfully stopped the bleeding completely in most cases.

Conclusion (proposition de traduction) : Les résultats de l'étude ont démontré que des spectateurs non formés, recevant des instructions par téléphone d'un répartiteur médical d'urgence qualifié, ont appliqué un garrot et ont réussi à arrêter complètement l'hémorragie dans la plupart des cas.

Survival After Out-Of-Hospital Cardiac Arrest in Europe - Results of the EuReCa TWO Study.
Gräsner JT, Wnent J, Herlitz J, Perkins GD, Lefering R, Tjelmeland I, Koster RW, Masterson S, Rossell-Ortiz F, Maurer H, Böttiger BW, Moertl M, Mols P, Alihodžić H, Hadžibegović I, Ioannides M, Truhlář A, Wissenberg M, Salo A, Escutnaire J, Nikolaou N, Nagy E, Jonsson BS, Wright P, Semeraro F, Clarens C, Beesems S, Cebula G, Correia VH, Cimpoesu D, Raffay V, Trenkler S, Markota A, Strömsöe A, Burkart R, Booth S, Bossaert L. | Resuscitation. 2020 Mar 1;148:218-226
DOI: https://doi.org/10.1016/j.resuscitation.2019.12.042
Keywords: Bystander CPR; European registry of cardiac arrest; Out-of-hospital cardiac arrest; Outcome after OHCA; Resuscitation.

Clinical Papers

Introduction : The epidemiology and outcome after out-of-hospital cardiac arrest (OHCA) varies across Europe. Following on from EuReCa ONE, the aim of this study was to further explore the incidence of and outcomes from OHCA in Europe and to improve understanding of the role of the bystander.

Méthode : This prospective, multicentre study involved the collection of registry-based data over a three-month period (1st October 2017 to 31st December 2017). The core study dataset complied with the Utstein-style. Primary outcomes were return of spontaneous circulation (ROSC) and survival to hospital admission. Secondary outcome was survival to hospital discharge.

Résultats : All 28 countries provided data, covering a total population of 178,879,118. A total of 37,054 OHCA were confirmed, with CPR being started in 25,171 cases. The bystander cardiopulmonary resuscitation (CPR) rate ranged from 13% to 82% between countries (average: 58%). In one third of cases (33%) ROSC was achieved and 8% of patients were discharged from hospital alive. Survival to hospital discharge was higher in patients when a bystander performed CPR with ventilations, compared to compression-only CPR (14% vs. 8% respectively).

Conclusion : In addition to increasing our understanding of the role of bystander CPR within Europe, EuReCa TWO has confirmed large variation in OHCA incidence, characteristics and outcome, and highlighted the extent to which OHCA is a public health burden across Europe. Unexplained variation remains and the EuReCa network has a continuing role to play in improving the quality management of resuscitation.

Conclusion (proposition de traduction) : En plus d'accroître notre compréhension du rôle de la RCP par les témoins en Europe, EuReCa TWO a confirmé une grande variation de l'incidence, des caractéristiques et des résultats de l'arrêt cardiaque extra-hospitalier, et a souligné dans quelle mesure l'arrêt cardiaque extra-hospitalier est un coût important pour la santé publique en Europe. Des variations inexpliquées demeurent et le réseau EuReCa a un rôle continu à jouer dans l'amélioration de la gestion de la qualité de la réanimation.

Rational use of face masks in the COVID-19 pandemic.
Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. | Lancet Respir Med. 2020 Mar 20
DOI: https://doi.org/10.1016/s2213-2600(20)30134-x  | Télécharger l'article au format  
Keywords: Aucun

COMMENT

Editorial : Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that caused coronavirus disease 2019 (COVID-19), the use of face masks has become ubiquitous in China and other Asian countries such as South Korea and Japan. Some provinces and municipalities in China have enforced compulsory face mask policies in public areas; however, China's national guideline has adopted a risk-based approach in offering recommendations for using face masks among health-care workers and the general public. We compared face mask use recommendations by different health authorities. Despite the consistency in the recommendation that symptomatic individuals and those in health-care settings should use face masks, discrepancies were observed in the general public and community settings. For example, the US Surgeon General advised against buying masks for use by healthy people. One important reason to discourage widespread use of face masks is to preserve limited supplies for professional use in health-care settings. Universal face mask use in the community has also been discouraged with the argument that face masks provide no effective protection against coronavirus infection.

Conclusion : It is time for governments and public health agencies to make rational recommendations on appropriate face mask use to complement their recommendations on other preventive measures, such as hand hygiene. WHO currently recommends that people should wear face masks if they have respiratory symptoms or if they are caring for somebody with symptoms. Perhaps it would also be rational to recommend that people in quarantine wear face masks if they need to leave home for any reason, to prevent potential asymptomatic or presymptomatic transmission. In addition, vulnerable populations, such as older adults and those with underlying medical conditions, should wear face masks if available. Universal use of face masks could be considered if supplies permit. In parallel, urgent research on the duration of protection of face masks, the measures to prolong life of disposable masks, and the invention on reusable masks should be encouraged. Taiwan had the foresight to create a large stockpile of face masks; other countries or regions might now consider this as part of future pandemic plans.

Conclusion (proposition de traduction) : Il est temps que les gouvernements et les organismes de santé publique fassent des recommandations rationnelles sur l'utilisation appropriée des masques faciaux pour compléter leurs recommandations sur d'autres mesures préventives, telles que l'hygiène des mains. L'OMS recommande actuellement que les gens portent un masque facial s'ils ont des symptômes respiratoires ou s'ils s'occupent d'une personne présentant des symptômes. Il serait peut-être également rationnel de recommander aux personnes en quarantaine de porter un masque facial si elles doivent quitter leur domicile pour une raison quelconque, afin de prévenir une éventuelle transmission asymptomatique ou présymptomatique. En outre, les populations vulnérables, telles que les personnes âgées et celles souffrant de maladies sous-jacentes, doivent porter des masques faciaux si ceux-ci sont disponibles. L'utilisation universelle des masques faciaux pourrait être envisagée si les fournitures le permettent. Parallèlement, il convient d'encourager les recherches urgentes sur la durée de protection des masques faciaux, les mesures visant à prolonger la durée de vie des masques jetables et l'invention de masques réutilisables. Taïwan a eu la prévoyance de créer un grand stock de masques faciaux ; d'autres pays ou régions pourraient maintenant considérer cela comme faisant partie de leurs futurs plans de lutte contre la pandémie.

Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome.
Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. | N Engl J Med. 2020 Mar 12;382(11):999-1008
DOI: https://doi.org/10.1056/nejmoa1916431
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : In patients with acute respiratory distress syndrome (ARDS), the National Heart, Lung, and Blood Institute ARDS Clinical Trials Network recommends a target partial pressure of arterial oxygen (Pao2) between 55 and 80 mm Hg. Prospective validation of this range in patients with ARDS is lacking. We hypothesized that targeting the lower limit of this range would improve outcomes in patients with ARDS.

Méthode : In this multicenter, randomized trial, we assigned patients with ARDS to receive either conservative oxygen therapy (target Pao2, 55 to 70 mm Hg; oxygen saturation as measured by pulse oximetry [Spo2], 88 to 92%) or liberal oxygen therapy (target Pao2, 90 to 105 mm Hg; Spo2, ≥96%) for 7 days. The same mechanical-ventilation strategies were used in both groups. The primary outcome was death from any cause at 28 days.

Résultats : After the enrollment of 205 patients, the trial was prematurely stopped by the data and safety monitoring board because of safety concerns and a low likelihood of a significant difference between the two groups in the primary outcome. Four patients who did not meet the eligibility criteria were excluded. At day 28, a total of 34 of 99 patients (34.3%) in the conservative-oxygen group and 27 of 102 patients (26.5%) in the liberal-oxygen group had died (difference, 7.8 percentage points; 95% confidence interval [CI], -4.8 to 20.6). At day 90, 44.4% of the patients in the conservative-oxygen group and 30.4% of the patients in the liberal-oxygen group had died (difference, 14.0 percentage points; 95% CI, 0.7 to 27.2). Five mesenteric ischemic events occurred in the conservative-oxygen group.

Conclusion : Among patients with ARDS, early exposure to a conservative-oxygenation strategy with a Pao2 between 55 and 70 mm Hg did not increase survival at 28 days.

Conclusion (proposition de traduction) : Chez les patients en SDRA, l’admnistration précoce d’un oxygénathérapie conservatrice avec un PaO₂ entre 55 et 70 mm Hg n’a pas augmenté la survie à 28 jours.

Commentaire : Il a été observé un signe inquiétant mais non établi d’augmentation, de la mortalité à 90 jours et d’ischémie mésentérique. Lors de la dernière réunion du comité de surveillance des données et de la sécurité, l’essai a été interrompu prématurément après l’inclusion de 205 patients en raison de ce risque.
Un signal de sécurité inquiétant a été observé dans le groupe affecté à une exposition plus faible à l’oxygène. La signification de ce signal pour la pratique clinique n’est pas claire.

Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial.
Duiverman ML, Vonk JM, Bladder G, van Melle JP, Nieuwenhuis J, Hazenberg A, Kerstjens HAM, van Boven JFM, Wijkstra PJ. | Thorax. 2020 Mar;75(3):244-252
DOI: https://doi.org/10.1136/thoraxjnl-2019-213303
Keywords: COPD; non-invasive ventilation; telemedicine

Original research

Introduction : Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic COPD patients. While the number of patients increases, home initiation of NIV would greatly alleviate the healthcare burden. We hypothesise that home initiation of NIV with the use of telemedicine in stable hypercapnic COPD is non-inferior to in-hospital NIV initiation.

Méthode : Sixty-seven stable hypercapnic COPD patients were randomised to initiation of NIV in the hospital or at home using telemedicine. Primary outcome was daytime arterial carbon dioxide pressure (PaCO2) reduction after 6 months NIV, with a non-inferiority margin of 0.4 kPa. Secondary outcomes were health-related quality of life (HRQoL) and costs.

Résultats : Home NIV initiation was non-inferior to in-hospital initiation (adjusted mean difference in PaCO2 change home vs in-hospital: 0.04 kPa (95% CI -0.31 to 0.38 kPa), with both groups showing a PaCO2 reduction at 6 months compared with baseline (home: from 7.3±0.9 to 6.4±0.8 kPa (p<0.001) and in-hospital: from 7.4±1.0 to 6.4±0.6 kPa (p<0.001)). In both groups, HRQoL improved without a difference in change between groups (Clinical COPD Questionnaire total score-adjusted mean difference 0.0 (95% CI -0.4 to 0.5)). Furthermore, home NIV initiation was significantly cheaper (home: median €3768 (IQR €3546-€4163) vs in-hospital: median €8537 (IQR €7540-€9175); p<0.001).

Conclusion : This is the first study showing that home initiation of chronic NIV in stable hypercapnic COPD patients, with the use of telemedicine, is non-inferior to in-hospital initiation, safe and reduces costs by over 50%.

Conclusion (proposition de traduction) : Il s'agit de la première étude montrant que l'initiation à domicile d'une ventilation non invasive ambulatoire chez des patients atteints de BPCO hypercapnique stable, sous contrôle de la télémédecine, n'est pas inférieure à l'initiation à l'hôpital, est sûre et réduit les coûts de plus de 50 %.