Bibliographie de Médecine d'Urgence

Mois d'avril 2020


Academic Emergency Medicine

Chemical VersusElectrical Cardioversion for AtrialFibrillation.
Bond C, Morgenstern J, Heitz C, Milne WK. | Acad Emerg Med.  2020 Apr;27(4):333-335
DOI: https://doi.org/10.1111/acem.13874  | Télécharger l'article au format  
Keywords: Aucun

HOT OFF THE PRESS

Editorial : Atrial fibrillation (AF) is a significant dysrhythmia that often requires treatment in the emergency department (ED). This can be performed with rhythm control using electrical or chemical cardioversion or with rate control. There is widespread variation in management of AF within Canada and worldwide. This study focuses on rhythm control techniques, comparing ED length of stay when using an electrical-first strategy versus a chemical-first strategy of cardioversion.

Conclusion : In patients in whom a rhythm control strategy is deemed appropriate, this study supports an electrical-first cardioversion strategy for low-risk patients with acute uncomplicated atrial fibrillation. Both chemical-first and electrical-first strategies appear to be successful and well tolerated; however, an electrical-first strategy results in a significantly shorter ED length of stay.

Conclusion (proposition de traduction) : Chez les patients pour lesquels une stratégie de contrôle du rythme est jugée appropriée, cette étude soutient une stratégie de cardioversion en priorité par choc électrique pour les patients à faible risque souffrant de fibrillation atriale paroxystique non compliquée. Les deux stratégies, chimique et électrique, semblent être efficaces et bien tolérées ; cependant, la stratégie électrique se traduit par une durée de séjour beaucoup plus courte.

Anaesthesia and Intensive Care Medicine

Critical care management of adult traumatic brain injury.
Raith EP, Fiorini F, Reddy U. | Anaesth Intensive Care.  2018 Apr;37(2):171-186
DOI: https://doi.org/10.1016/j.mpaic.2020.03.012
Keywords: Aucun

Article in press

Editorial : Severe traumatic brain injury (TBI) is associated with significant morbidity and mortality. The critical care management of TBI requires a coordinated and comprehensive approach to treatment, including strategies to prevent secondary brain injury and maintenance of adequate cerebral perfusion and oxygenation. Management protocols have evolved with international consensus, providing guidelines that assist clinicians in delivering optimal care. Those from the Brain Trauma Foundation are continuously updated to incorporate new trial data ( https://braintrauma.org/coma/guidelines).

Conclusion : The management of traumatic brain injury involves both the management of intracranial pathology and systemic sequelae. Severe traumatic brain injury (TBI) is associated with significant morbidity and mortality. The critical care management of TBI requires a coordinated and comprehensive approach to treatment, including strategies to prevent secondary brain injury and maintenance of adequate cerebral perfusion and oxygenation.

Conclusion (proposition de traduction) : La gestion des traumatismes crâniens implique à la fois la gestion de la pathologie intracrânienne et des séquelles systémiques. Les lésions cérébrales traumatiques graves sont associées à une morbidité et une mortalité importantes. La gestion des soins intensifs des lésions cérébrales traumatiques nécessite une approche coordonnée et globale du traitement, y compris des stratégies visant à prévenir les lésions cérébrales secondaires et à maintenir une perfusion et une oxygénation cérébrales adéquates.

Anaesthesia, Critical Care & Pain Medicine

New Guidelines for the Management of Severe Thermal Burns in the Acute Phase in Adults and Children: Is It Time for a Global Surviving Burn Injury Campaign (SBIC)?.
Holley A, Cohen J, Reade M, Laupland KB, Lipman J. | Anaesth Crit Care Pain Med.  2020 Apr;39(2):195-196
DOI: https://doi.org/10.1016/j.accpm.2020.03.009
Keywords: Aucun

Editorial

Editorial : The World Health Organisation reports that worldwide, 11 million thermally injured patients present annually requiring dedicated specialist services. This cohort of patients constitutes the fourth leading cause of trauma. Significant burns represent a unique form of severe trauma and caring for these patients presents a real challenge for the multidisciplinary team tasked with delivering quality care. Burn severity continues to be reliably determined by depth of the lesion and the total body surface area (TBSA) involved. The prognosis is further affected by extremes of age and presence of a concomitant inhalational injury. Optimal care requires precise initial assessment and, in the appropriate clinical context, transfer to a dedicated burn centre. The subsequent prolonged intensive care admission, surgical intervention, hospitalisation and rehabilitation of thermal injuries, make them among the most time intensive and health care resource demanding presentations.

Conclusion : Finally, we salute the authors for their valuable contribution to the care of this unfortunate population of patients. Perhaps it is now time for the many societies and institutions including, but not exclusively, the French Society of Anaesthesia and Intensive Care Medicine, The Australian and New Zealand Burn Association, the Australian and New Zealand Intensive Care Society, the Interna- tional Society for Burn Injury, the Society for Critical Care Medicine, the European Burns Association and the British Burn Association to collaborate in a Surviving Burn Injury Campaign (SBIC) with the lofty goal of achieving a significant reduction in burn injury morbidity and mortality by 2030?

Conclusion (proposition de traduction) : Enfin, nous saluons les auteurs pour leur précieuse contribution aux soins de cette malheureuse population de patients. Il est peut-être temps maintenant pour les nombreuses sociétés et institutions, notamment la Société française d'anesthésie et de médecine intensive, l'Australian and New Zealand Burn Association, l'Australian and New Zealand Intensive Care Society, l'International Society for Burn Injury, la Society for Critical Care Medicine, l'European Burns Association et la British Burn Association pour collaborer à une campagne Surviving Burn Injury Campaign (SBIC) avec l'objectif ambitieux de parvenir à une réduction significative de la morbidité et de la mortalité par brûlure d'ici 2030 ?

Commentaire : Document de référence :
Société Francophone de Brûlologie, Société Française de Médecine d'Urgence & Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française. Prise en charge du brûlé grave à la phase aiguë chez l’adulte et l’enfant  . Recommandations de Pratiques Professionnelles. Société Française d’Anesthésie et Réanimation (SFAR) mai 2019.

Efficacy and Safety of Remifentanil in a Rapid Sequence Induction in Elderly Patients: A Three-Arm Parallel, Double Blind, Randomised Controlled Trial.
Chaumeron A, Castanie J, Fortier LP, Basset P, Bastide S, Alonso S, Lefrant JY, Cuvillon P. | Anaesth Crit Care Pain Med.  2020 Apr;39(2):215-220
DOI: https://doi.org/10.1016/j.accpm.2019.09.010
Keywords: Adverse event; Heart rate; Induction; Rapid sequence; Remifentanil.

Original article

Introduction : Rapid sequence induction (RSI) is recommended in patients at risk of aspiration, but induced haemodynamic adverse events, including tachycardia. In elderly patients, this trial aimed to assess the impact of the addition of remifentanil during RSI on the occurrence of: tachycardia (primary outcome), hypertension (due to intubation) nor hypotension (remifentanil).

Méthode : In this three-arm parallel, double blind, multicentre controlled study, elderly patients (65 to 90 years old) hospitalised in three centres and requiring RSI were randomly allocated to three groups, where anaesthesia was induced with etomidate (0.3 mg/kg) followed within 15 seconds by either placebo, or low (0.5 μg/kg), or high (1.0 μg/kg) doses of remifentanil, followed by succinylcholine 1.0 mg/kg. Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction and after intubation.

Résultats : In total, eighty patients were randomised and analysed. Baseline HR and MAP were similar between groups. For primary endpoint, the absolute change in HR between induction and intubation was greater in the control group (15 bpm; 95% CI [8-21]) than that in the remifentanil 0.5 μg/kg group (4 bpm; 95% CI [-1-+8]; P=0.005) and the remifentanil 1.0 μg/kg group (-3 bpm; 95% CI [-9-+3]; P<0.0001). The increase in MAP was greater in the placebo group than in both remifentanil groups (P<0.0001). Twice as many hypertension episodes were recorded in the placebo group compared to the remifentanil 0.5 μg/kg and 1.0 μg/kg groups (60%, 30%, and 28% patients respectively; P=0.032), but no placebo patients experienced hypotension episodes versus 11% and 24% in the remifentanil 0.5 μg/kg and 1.0 μg/kg groups respectively (P=0.016).

Conclusion : Remifentanil (0.5-1.0μg/kg) prevents the occurrence of tachycardia and hypertension in elderly patients requiring RSI.

Conclusion (proposition de traduction) : Le rémifentanil (0,5-1,0 μg/kg) prévient la survenue d'une tachycardie et d'une hypertension chez les patients âgés nécessitant une induction en séquence rapide.

Annals of Emergency Medicine

Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial.
Kerber KA, Damschroder L, McLaughlin T, Brown DL, Burke JF, Telian SA, Tsodikov A, Fagerlin A, An LC, Morgenstern LB, Forman J, Vijan S, Rowell B, Meurer WJ. | Ann Emerg Med.  2020 Apr;75(4):459-470
DOI: https://doi.org/10.1016/j.annemergmed.2019.09.017  | Télécharger l'article au format  
Keywords: Aucun

Neurology

Introduction : We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits.

Méthode : We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews.

Résultats : We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program.

Conclusion : These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.

Conclusion (proposition de traduction) : Ces résultats prouvent qu'une stratégie de mise en œuvre de prise en charge des vertiges positionnels paroxystiques bénins, pour les consultations aux urgences en cas de vertiges, peut être efficace et sûre pour promouvoir les soins fondés sur les preuves. Les taux absolus d'utilisation du test de Dix-Hallpike (DHT) et de la manœuvre de repositionnement des cristaux (CRM) sont cependant restés faibles, ce qui s'explique en partie par nos critères d'inclusion généraux pour les consultation pour vertige.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion.
Bazarian JJ, Raukar N, Devera G, Ellis J, Feden J, Gemme SR, Hafner J, Mannix R, Papa L, Wright DW, Auerbach P; American College of Emergency Physicians Sport-Related Head Injury Prevention Task Force. . | Ann Emerg Med.  2020 Apr;75(4):471-482
DOI: https://doi.org/10.1016/j.annemergmed.2019.05.032  | Télécharger l'article au format  
Keywords: Aucun

Neurology

Editorial : Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion.

Conclusion : This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Conclusion (proposition de traduction) : Cet article fournit des recommandations visant à réduire les handicaps liés aux commotions cérébrales occasionnés par le sport grâce à des stratégies préventives primaires, secondaires et tertiaires mises en place lors des visites aux urgences. Bien que de nombreuses recommandations reposent sur une base factuelle solide, plusieurs lacunes en matière de recherche subsistent. Il faudrait étudier explicitement l'objectif principal d'amélioration des suites des commotions cérébrales liées au sport en adoptant des stratégies de prévention axées sur les services d’urgence.

Do Antiepileptics Reduce the Risk of Poor Neurologic Outcomes and Prevent Seizures in Patients With Spontaneous Intracerebral Hemorrhage?.
Long B, April MD. | Ann Emerg Med.  2020 Apr;75(4):491-493
DOI: https://doi.org/10.1016/j.annemergmed.2019.06.013  | Télécharger l'article au format  
Keywords: Aucun

Neurology

Méthode : Meta-analysis authors identified randomized controlled trials and observational studies by searching MEDLINE and EMBASE from inception through March 1, 2018. They also evaluated the reference lists of all retrieved articles to identify other relevant studies.
Two authors reviewed the abstracts of all identified articles and retrieved studies comparing any prophylactic antiepileptic drugs versus no preventive therapy for adults (>18 years) with spontaneous intracerebral hemorrhage. The authors excluded studies including patients with other causes of intracranial bleeding (ie, subarachnoid hemorrhage, traumatic brain injury, vascular malformation, or tumor). A third author resolved any disagreement in regard to study inclusion. Any antiepileptic drug was eligible for inclusion.

Résultats : The primary outcome was poor clinical outcome at the longest recorded follow-up, defined as either modified Rankin Scale score greater than 3 or all-cause mortality when there was no documentation of the score. Secondary outcomes included seizure incidence at follow-up. Authors abstracted data and obtained effect estimates from included studies by using odds ratios derived from multivariable models adjusting for measured confounders, with 95% confidence intervals. The meta-analysis pooled data with random-effects models and assessed heterogeneity with λ2. Authors assessed bias with the Cochrane Risk of Bias Tool and performed sensitivity analyses based on time of outcome and use of phenytoin.

Conclusion : Antiepileptics do not improve neurologic outcomes or reduce seizures in patients with spontaneous intracerebral hemorrhage.

Conclusion (proposition de traduction) : Les antiépileptiques n'améliorent pas les résultats neurologiques ou ne réduisent pas les crises chez les patients souffrant d'une hémorragie intracérébrale spontanée.

Which Elements of the History and Examination Suggest a Cardiac Cause of Syncope?.
Bridwell RE, April MD, Long B. | Ann Emerg Med.  2020 Apr;75(4):499-501
DOI: https://doi.org/10.1016/j.annemergmed.2019.08.460
Keywords: Aucun

Cardiology

Méthode : Authors searched the MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health, and Cochrane databases for articles in English until April 9, 2019, using Medical Subject Headings terms and a search strategy evaluating physical examination and historical elements associated with “syncope or consciousness or unconsciousness or seizures,” with appropriate Emtree terms when searching EMBASE.
Investigators included prospective or retrospective studies of patients with syncope who were aged 12 years or older and included at least 10 patients. Studies had to include a validated reference standard (ie, noninvasive cardiac evaluation, invasive cardiac evaluation, or cardiology consultation). Studies restricted to patients with unexplained recurrent syncope, a single defined cause of syncope, or completed invasive cardiac interrogation were excluded.

Résultats : Pairs of investigators independently extracted data from the included studies. Primary outcomes included sensitivity, specificity, and likelihood ratios with confidence intervals. Authors used univariate or bivariate random-effect models and determined heterogeneity. Pairs of investigators independently completed qualitative methodological review using the Quality Assessment of Diagnostic Accuracy Studies tool. A third investigator resolved any irreconcilable differences. Authors evaluated level of evidence with the grading system developed for the Rational Clinical Examination series.

Conclusion : Age older than 35 years, dyspnea, angina, witnessed cyanosis during the event, and a medical history of atrial fibrillation or flutter or structural heart disease are associated with an increased likelihood of a cardiac cause of syncope.

Conclusion (proposition de traduction) : Un âge supérieur à 35 ans, une dyspnée, une angine de poitrine, une cyanose constatée au cours de l'événement et des antécédents médicaux de fibrillation auriculaire ou de flutter ou de maladie cardiaque structurelle sont associés à une probabilité accrue de cause cardiaque de syncope.

Does Tranexamic Acid Affect Risk of Venous and Arterial Thrombosis or Mortality in Nonsurgical Patients?.
Long B, April MD. | Ann Emerg Med.  2020 Apr;75(4):535-537
DOI: https://doi.org/10.1016/j.annemergmed.2019.06.014  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Méthode : Meta-analysis authors identified studies from MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 1985 to August 2018 published in English.
Authors included randomized controlled trials that evaluated adults receiving oral or intravenous tranexamic acid for nonsurgical indications, compared tranexamic acid with either placebo or no tranexamic acid, and reported thrombotic events (deep venous thrombosis, pulmonary embolism, stroke, or myocardial infarction) or mortality. Two authors independently evaluated and selected articles, with disagreements resolved by discussion.

Résultats : Primary outcomes included risk of thrombotic events and mortality with systemic tranexamic acid. After study selection and inclusion, authors conducted separate meta- analyses evaluating the risk of thrombotic events and mortality with systemic tranexamic acid compared with placebo or no treatment. Authors calculated risk ratios with 95% confidence intervals, using a random-effects model. Meta-analysis authors assessed heterogeneity with the λ2 statistic and bias with the Cochrane Risk of Bias Tool. The authors further conducted subgroup analyses based on route of tranexamic acid administration and reason for administration.

Conclusion : Tranexamic acid does not increase the risk of venous or arterial thrombosis among nonsurgical patients and may be associated with reduced mortality

Conclusion (proposition de traduction) : L'acide tranexamique n'augmente pas le risque de thrombose veineuse ou artérielle chez les patients non opérés et peut être associé à une réduction de la mortalité

BMC Emergency Medicine

The impact of early administration of vasopressor agents for the resuscitation of severe hemorrhagic shock following blunt trauma.
Uchida K, Nishimura T, Hagawa N, Kaga S, Noda T, Shinyama N, Yamamoto H, Mizobata Y. | BMC Emerg Med.  2020 Apr 16;20(1):26
DOI: https://doi.org/10.1186/s12873-020-00322-1  | Télécharger l'article au format  
Keywords: Blunt trauma; Hemorrhagic shock; Multiple trauma; Resuscitation; Vasopressor.

Research article

Introduction : When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock.

Méthode : In this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25-75% interquartile range) or number.

Résultats : Forty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36-48) vs 45 (34-51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12-0.48] vs 0.21 [0.08-0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680-9320] vs 6540 [4550-7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0-4] vs 14 [10-18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4-26] vs 34 [10-74] hours; p = 0.026) in survivors. Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71-121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90-58.5; p = 0.005) indicated significant higher risk of death in this study.

Conclusion : Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.

Conclusion (proposition de traduction) : L'administration de vasopresseur et leur utilisation à forte dose pour la réanimation d'un choc hémorragique après un traumatisme contondant sévère sont potentiellement associées à une mortalité accrue. Bien que le volume transfusé de produits sanguins ait tendance à être augmenté lors de la réanimation de ces patients, il vaut mieux envisager l'interruption précoce du vasopresseur.

Seasonal and climatic variation in the incidence of adult acute appendicitis: a seven year longitudinal analysis.
York TJ | BMC Emerg Med.  2020 Apr 7;20(1):24
DOI: https://doi.org/10.1186/s12873-020-00321-2  | Télécharger l'article au format  
Keywords: Aucun

Research article

Introduction : Acute appendicitis represents an extremely common surgical emergency, yet its aetiology remains uncertain. A multifactorial understanding of its causation has emerged along with increasing evidence of seasonal variation. This study seeks to find evidence for such a circannual trend within the United Kingdom (UK), and further assess key meteorological indicators which may be causative of any such variation.

Méthode : The patient records of a region health body in the North East of England were retrospectively assessed over a 7-year period. The incident cases of acute appendicitis were recorded and averaged by month before undergoing statistical analysis for variation and correlation with average temperature, sunlight hours, and rainfall.

Résultats : The incidence of acute appendicitis revealed significant seasonal variation with only 38 incident cases in the months of January compared to 73 in July, a 92.1% increase. Only a weak correlation was seen between incidence and average sunlight hours/rainfall, however a significant, positive correlation was found between incidence and average temperature (r = 0.58, p = 0.048).

Conclusion : Compelling evidence is found to support the existence of a circannual trend for acute appendicitis. Data suggests a seasonal peak in the month of July, accompanied by a low in January, a finding that develops the understanding of this trend from previously equivocal research in the UK. A clear correlation is also established between the incidence of acute appendicitis and average temperature. The 92.1% increase between the coolest and warmest months suggests a greater magnitude for this as a risk factor than has previously been shown.

Conclusion (proposition de traduction) : Des preuves irréfutables confirment l'existence d'une tendance circadienne de survenue de l'appendicite aiguë. Les données suggèrent un pic saisonnier au mois de juillet, accompagné d'un creux en janvier, un résultat qui permet de mieux comprendre cette tendance à partir de recherches précédemment équivoques au Royaume-Uni. Une corrélation claire est également établie entre l'incidence de l'appendicite aiguë et la température moyenne. L'augmentation de 92,1 % entre les mois les plus froids et les plus chauds suggère une plus grande ampleur de ce facteur de risque que ce qui a été démontré précédemment.

Critical Care Medicine

Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events.
Conway JA, Kharayat P, Sanders RCJ, Nett S, Weiss SL, Edwards LR, et al MSCE2,41 for the National Emergency Airway Registry for Children (NEAR4KIDS) and for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). | Crit Care Med.  2020 April;
DOI: https://doi.org/10.1097/CCM.0000000000004314
Keywords: Aucun

ONLINE CLINICAL INVESTIGATION: PDF ONLY

Introduction : Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events.

Méthode : We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017.
Setting: Forty international PICUs participating in the National Emergency Airway Registry for Children.
Patients: Critically ill children 0–17 years old who underwent tracheal intubation in a PICU.

Résultats : The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58–0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock.

Conclusion : Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation–associated adverse events.

Conclusion (proposition de traduction) : L'utilisation de kétamine pour l'intubation trachéale est associée à moins d'événements indésirables associés à l'intubation trachéale hémodynamique.

Emergency Radiology

Updated Guidelines for Intravenous Contrast Use for CT and MRI.
Huynh K, Baghdanian AH, Baghdanian AA, Sun DS, Kolli KP, Zagoria RJ. | Emerg Radiol.  2020 Apr;27(2):115-126
DOI: https://doi.org/10.1007/s10140-020-01751-y
Keywords: CT; Contrast material; Emergency radiology; Gadolinium; MRI

Hot Topic Review

Editorial : Intravenous (IV) contrast material is used extensively for CT and MRI scans done in emergency departments (ED). Its use is essential to make many critical diagnoses in ED patients. While adverse reactions can occur, newer research has added to our knowledge of IV contrast media tolerance and safety leading to improved and more liberal guidelines for intravenous contrast use. The updated information described in this review article indicates how intravenous contrast can be used safely in more patients, more expeditiously and with fewer precautions than with prior guidelines. This review article explains the basis for the new recommendations for intravenous contrast material use and describes indicated precautions and preparations to avoid adverse reactions for iodinated agents used for CT and gadolinium agents for MRI.

Conclusion : In the emergency department setting, the use of IV contrast should be based on patient needs and should not be denied without assessment of the patient’s risk factors and consideration of new guidelines for use of IV contrast agents. The greatest risk factors for adverse side effects to contrast use are poor renal function and previous moderate or severe allergic-type reaction to IV contrast injection. The use of effective screening tools can help emergency room providers quickly determine the need for further laboratory evaluation prior to imaging. Premedication can significantly help to reduce adverse reactions especially in patients with a known history of prior moderate or severe contrast reaction. Acute contrast reactions are relatively rare. But familiarity with the types of contrast-associated adverse reactions can lead to faster recognition and timely appropriate management.

Conclusion (proposition de traduction) : Dans le cadre des services d'urgence, l'utilisation d'un produit de contraste par voie intraveineuse doit être basée sur les besoins du patient et ne doit pas être refusée sans évaluation des facteurs de risque du patient et prise en compte de nouvelles recommandations pour l'utilisation des produits de contraste par voie intraveineuse. Les plus grands facteurs de risque d'effets secondaires indésirables liés à l'utilisation de produits de contraste sont une mauvaise fonction rénale et une réaction allergique antérieure de type modéré ou grave à l'injection de produits de contraste par voie intraveineuse. L'utilisation d'outils de dépistage efficaces peut aider les prestataires de services d'urgence à déterminer rapidement la nécessité d'une évaluation supplémentaire en laboratoire avant l'imagerie. La prémédication peut contribuer de manière significative à réduire les effets indésirables, en particulier chez les patients ayant des antécédents connus de réaction de contraste modérée ou sévère. Les réactions de contraste aiguës sont relativement rares. Mais la connaissance des types d'effets indésirables associés aux produits de contraste peut conduire à une reconnaissance plus rapide et à une gestion appropriée en temps utile.

Variability in Practice Patterns Among Emergency Physicians in the Evaluation of Patients With a Suspected Diagnosis of Pulmonary Embolism.
Salehi L, Phalpher P, Ossip M, Meaney C, Valani R, Mercuri M. | Emerg Radiol.  2020 Apr;27(2):127-134
DOI: https://doi.org/10.1007/s10140-019-01740-w
Keywords: Biomarkers; Computed tomography; Diagnostic imaging; Physicians practice patterns; Pulmonary embolism

Original Article

Introduction : To describe the inter-physician variability in the utilisation rate and diagnostic yield of computed tomography pulmonary angiography (CTPA) among a group of emergency department (ED) physicians working in a similar clinical environment.

Méthode : We collected data on all CTPA studies ordered by ED physicians at three affiliated sites during a 2-year period between January 1, 2016, and December 31, 2017. For each physician, we calculated individual CTPA utilisation rate (total number of CTPAs ordered per 1000 ED visits) and diagnostic yield (percentage of CTPAs that were positive for PE). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield.

Résultats : Seventy-seven ED physicians who collectively ordered a total of 2788 CTPAs were included in the study. Utilisation rates ranged from 1.1 to 22.2 CTPA per 1000 ED visits (median: 5.2 CTPA/1000 ED visits; 25%ile: 3.6 CTPA/1000 ED visits; 75%ile: 7.9 CTPA/1000 ED visits) and the CTPA diagnostic yields ranged from 0% to 33% (median: 9.1%; 25%ile: 5.2%; 75%ile: 16.1%). Those physicians in the lower quartile for ordering rate had a higher mean diagnostic yield when compared to the higher quartiles.

Conclusion : The findings of this study demonstrate variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields.

Conclusion (proposition de traduction) : Les résultats de cette étude démontrent la variabilité des schémas de prescription et des rendements diagnostiques de l'angiographie pulmonaire en tomodensitométrie parmi les médecins travaillant dans le même environnement clinique. Certains suggèrent que les médecins qui prescrivent des nombres disproportionnellement plus élevés d'angiographies pulmonaires par tomodensitométrie ont des rendements diagnostiques inférieurs.

The Influence of Arm Positions on Abdominal Image Quality of Whole-Body Computed Tomography in Trauma: Systematic Review.
Speelman ES, Brocx B, Wilbers JE, de Bie MJ, Ivashchenko O, Tank Y, van der Molen AJ. | Emerg Radiol.  2020 Apr;27(2):141-150
DOI: https://doi.org/10.1007/s10140-019-01732-w  | Télécharger l'article au format  
Keywords: Artifacts; Patient positioning; Systematic review; Tomography; Traumatology; X-ray computed

Original Article

Introduction : Whole-body computed tomography (WBCT) is the standard diagnostic method for evaluating polytrauma patients. When patients are unable to elevate their arms, the arms are placed along the body, which affects the image quality negatively. Aim of this systematic review is to evaluate the influence of below the shoulder arm positions on image quality of WBCT.

Méthode : Literature in PubMed and Scopus databases was systematically searched. Results of the papers were stratified into 4 categories: arms elevated, 1 arm up 1 arm down, arms ventrally supported, arms along the body. A qualitative analysis was performed on subjective image quality and a quantitative analysis on objective quality (image noise).

Résultats : Eight studies were included with 1421 participants. Various studies reported significantly higher quality scores with arms elevated, compared to arms along the body. Significant differences in objective image quality were found between the arms elevated and the arms ventrally on support group. The arms ventrally supported group had a significantly higher image quality than the arms along the body group. A statistically significant difference was found in objective image quality between the 1 arm up 1 arm down and arms along the body group. No preferential below the shoulders position could be identified.

Conclusion : Positioning the arms alongside the body results in a poor image quality. Placing the arms on a pillow ventrally to the chest improves image quality. Interestingly, asymmetrical arm positioning has potential to improve the image quality for patients that are unable to elevate the arms.

Conclusion (proposition de traduction) : La position des bras le long du corps donne une image de mauvaise qualité. Le fait de placer les bras sur un oreiller en position ventrale par rapport au thorax améliore la qualité de l'image. Il est intéressant de noter que le positionnement asymétrique des bras peut améliorer la qualité de l'image pour les patients qui ne sont pas capables d'élever les bras.

A Simple CT Score to Quantify Pelvic and Retroperitoneal Hematoma Associated With Pelvic Fractures Predicts Transfusion Needs, Pelvic Hemostatic Procedures, and Outcome.
Charbit J, Ramin S, Hermida M, Cavaille P, Murez T, Taourel P, Capdevila X, Millet I. | Emerg Radiol.  2020 Apr;27(2):173-184
DOI: https://doi.org/10.1007/s10140-019-01745-5
Keywords: External fixator; MTC score; Massive transfusion; Organ failure; Pelvic trauma

Original Article

Introduction : Pelvic and retroperitoneal hematoma (PRH) in case of pelvic fracture may lead to early hemorrhagic shock. Quantifying PRH remains challenging in clinical practice. The goal of this study was to determine the statistical association between a semi-quantitative scoring system for PRH assessed with computed tomography (CT) and transfusion needs, pelvic hemostatic procedures, and outcome.

Méthode : All consecutive severe trauma patients with pelvic ring fracture between 2010 and 2015 were included in this retrospective study. PRH was quantified using semi-quantitative analysis on admission CT scan. The pelvis and retroperitoneal cavity was assessed as 10 compartments. Hematoma was counted as 0 (absent), 1 (minimal or moderate), and 2 (large or bilateral) for each compartment (maximum score of 20). The patients were divided into the following 3 groups: no or minimal PRH (score 0-5), moderate PRH (6-9), and large PRH (10-20). These groups were compared in terms of initial transfusion needs, massive transfusion, hemostatic procedures, and outcome. Logistic regression and receiver operating characteristic (ROC) curves were analyzed.

Résultats : The study included 311 patients with pelvic fracture (mean age 41.9, [SD] 19.9 years; mean ISS 27.4, [SD] 19.4; unstable fractures, 32%; ≥5 units of packed red blood cells, 37%; massive transfusion, 19%; multiple organ failure, 29%; mortality, 13%), divided into no or minimal PRH group (128 (22%)), moderate PRH group (115 (37%)), and large PRH group (68 (22%)). Increasing PRH was found to increase transfusion needs and massive transfusions, with a higher number of pelvic hemostatic procedures, multiple organ failures, increasing need for mechanical ventilation, and prolonged hospitalization; mortality was also increased. These significant statistical associations were confirmed by logistic regression models (odds ratio, 1.2-12.1 for moderate PRH, 3.1-30.2 for large PRH) and ROC curve analysis (area under the ROC curve, 0.59-0.76).

Conclusion : Semi-quantitative assessment of PRH on admission CT scan allows to predict transfusion needs, hemostatic procedures, and worse outcome of severe trauma patients with pelvic fracture.

Conclusion (proposition de traduction) : L'évaluation semi-quantitative des hématomes pelviens et rétropéritonéaux lors de la TDM à l'admission permet de prédire les besoins transfusionnels, les procédures hémostatiques et les mauvais résultats pour les patients traumatisés graves atteints de fracture pelvienne.

European Journal of Emergency Medicine

Tranexamic Acid in Emergency Care.
Bloom B | Eur J Emerg Med.  2020 Apr;27(2):81-82
DOI: https://doi.org/10.1097/mej.0000000000000673
Keywords: Aucun

Perspective Articles

Editorial : Studies of tranexamic acid (TXA) in emergency care are dominated by three trials run by the London School of Hygiene and Tropical Medicine [1–3]. Although there are more than 70 trials of TXA in surgical situations, and almost all show a positive treatment effect to reduce bleeding, most are also small, recruiting fewer than 200 patients. In contrast the main studies discussed here all recruited several thousand patients.

Conclusion : More than 50 000 patients have now been recruited into randomised trials of TXA in the context of trauma, traumatic brain injury and post-partum haemorrhage. TXA has been shown to be effective, safe and cheap. When so much of emergency care is delivered with little or no evidence base, I welcome the firm scientific basis to treat patients with bleeding.

Conclusion (proposition de traduction) : Plus de 50 000 patients ont été recrutés dans des essais randomisés sur l'acide tranexamique dans le contexte de traumatismes, de lésions cérébrales traumatiques et d'hémorragies du post-partum. L'acide tranexamique s'est avéré efficace, sûr et bon marché. Lorsque tant de soins d'urgence sont dispensés avec peu ou pas de preuves, je me réjouis de la solide base scientifique pour traiter les patients atteints de saignement.

Tranexamic Acid in Traumatic Intracranial Bleeding: Recognizing the Limit of Results (Of the CRASH-3 Trial).
Heymann EP | Eur J Emerg Med.  2020 Apr;27(2):83-84
DOI: https://doi.org/10.1097/mej.0000000000000657
Keywords: Aucun

Perspective Articles

Editorial : The recent publication of the CRASH-3 trial was eagerly awaited for by the Emergency Medicine community. Indeed, tranexamic acid (TXA), with its relatively safe profile, seemed destined to become a standard of treatment for the haemorrhaging (critical care) patient if one is to believe the widespread adoption of the drug in countless trauma guidelines worldwide. This interest for the medication arose following the publication of the CRASH-2 trial results in 2010, an impressive multicentre international randomised controlled study of 20211 patients, which showed an absolute (mortality) difference of 1.5% in favour of TXA. It was soon followed by other studies and trials, and although these later publications failed to demonstrate a statistically significant mortality benefit, the momentum for TXA was set. And while the exsanguinating patient of CRASH-2 seemed to have benefited from the administration of TXA, a pragmatic question remained: will the drug be beneficial to a more common presentation of everyday Emergency Medicine, that is, the intracranial bleed? While a subgroup analysis had shown a trend towards mortality reduction in the intracranial bleeding patient in a CRASH-2 cohort, and a second small trial trended towards a mortality benefit for intracranial bleeding patients treated with TXA, the CRASH-3 study aimed to answer this question (as well as attempting to address its influence on disability and adverse events) with a large international multicentre randomized (placebo) controlled trial. The answer, as with all clinical trials, is a bit more complicated than a simple yes or no.

Conclusion : A final note on safety is tranexamic acid as safe as it is often described? Much evidence seems to paint a favourable portrait of the drug, claiming similar or even reduced side-effects/disability/morbidity following its administration in the bleeding patient (versus placebo). Yet the CRASH-3 study does not seem to paint such an image: from what is reported, if head-injury–related deaths are excluded, it would seem as though tranexamic acid actually increases overall death rate (though nonstatically significant) (relative risk 1.31; 95% CI: 0.93–1.85). I believe we will need to be paying more attention to the safety profile of the drug in the future. Till then, I very much look forward to reading more about tranexamic acid (and its many proposed uses) in future studies (such as the PATCH-Trauma study).

Conclusion (proposition de traduction) : Une dernière remarque sur la sécurité : l'acide tranexamique est-il aussi sûr qu'on le décrit souvent ? De nombreux éléments semblent dresser un portrait favorable du médicament, faisant état d'effets secondaires/d'incapacité/morbidité similaires, voire réduits, après son administration chez le patient qui saigne (par rapport au placebo). Pourtant, l'étude CRASH-3 ne semble pas brosser un tel tableau : d'après ce qui est rapporté, si l'on exclut les décès liés aux traumatismes crâniens, il semblerait que l'acide tranexamique augmente en fait le taux de mortalité global (bien que non significatif sur le plan statique) (risque relatif 1,31 ; IC à 95% : 0,93-1,85). Je pense que nous devrons à l'avenir accorder plus d'attention au profil de sécurité du médicament. D'ici là, j'attends avec impatience d'en savoir plus sur l'acide tranexamique (et ses nombreuses utilisations proposées) dans de futures études (comme l'étude PATCH-Trauma).

Tranexamic Acid for Acute Traumatic Hemorrhage in Emergency Medicine: Why Not, But….
Heidet M | Eur J Emerg Med.  2020;27(2):85–86
DOI: https://doi.org/10.1097/mej.0000000000000671
Keywords: Aucun

Perspective Articles

Editorial : Tranexamic acid (TXA) is an antifibrinolytic drug that has been broadly used since the early 1960s in diverse acute hemorrhagic indications, ranging from epistaxis and menstrual bleeding, to dentistry and surgery. It has recently gained high interest in emergency medicine, after the publication of CRASH-2, an international, randomized clinical trial versus placebo in over 20 000 patients with severe prehospital trauma, which concluded that TXA reduced mortality when given within 3 hours after trauma, without any increase in the risk of thromboembolic events. The CRASH-3 study recently showed a benefit of TXA in traumatic brain injury.

Conclusion : Current guidelines broadly recommend using TXA in severely injured patients, so yes. But clinicians should adopt a cautious approach in order to limit their use of TXA to the most severe patients, and stay aware that many gaps remain unanswered to date. Current strategy of ‘rapid TXA for all’ may improperly lead to overexpose patients who would not benefit from this practice.

Conclusion (proposition de traduction) : Les directives actuelles recommandent largement l'utilisation de l'acide tranexamique chez les patients gravement blessés, donc oui. Mais les cliniciens doivent adopter une approche prudente afin de limiter leur utilisation de l'acide tranexamique aux patients les plus graves, et rester conscients que de nombreuses lacunes restent à ce jour sans réponse. La stratégie actuelle de « l'acide tranexamique rapide pour tous » ; peut conduire à une surexposition de patients qui ne bénéficieraient pas de cette pratique.

Effect of oxygen therapy on the risk of mechanical ventilation in emergency acute pulmonary edema patients.
Chu MYS, Guo W, Lim KK, Lim BL. | Eur J Emerg Med.  2020 Apr;27(2):99-104
DOI: https://doi.org/10.1097/mej.0000000000000634
Keywords: Aucun

Original Articles

Introduction : We investigated the effects of hyperoxemia on morbidity and mortality in acute cardiogenic pulmonary edema (ACPE).

Méthode : We conducted a retrospective cohort study of patients in our emergency department (ED) with ACPE who received arterial blood gases. Patients were classified based on the first PaO2 as hypoxemic (<75 mmHg), normoxemic (75-100 mmHg) and hyperoxemic (>100 mmHg). The primary outcome was the rates of mechanical ventilation (MV). We also reported adjusted odds ratios (AOR) and their 95% confidence intervals (CI) of the primary outcome after adjusting for predictors of MV determined a priori. Secondary outcomes were median hospital length of stay (LOS) and in-hospital mortality.

Résultats : We recruited 335 patients; 34.0% had hyperoxemia. The rates of normoxemia and hypoxemia were 27.5% and 38.5%, respectively. The rates of MV were: hypoxemic 60/129 (46.5%) vs. normoxemic 41/92 (44.6%) vs. hyperoxemic 50/114 (43.9%); P = 0.62. The AORs for MV for the hyperoxemic and hypoxemic groups (reference: normoxemic group) were 0.98 (95% CI: 0.53-1.79) and 1.38 (95% CI: 0.77-2.48), respectively. Intubation rates for the groups were: hypoxemic 15/129 (11.6%) vs. normoxemic 6/92 (6.5%) vs. hyperoxemic 12/114 (10.6%); P = 0.43. The secondary outcomes were comparable among the groups. In-hospital mortality rates were: hypoxemic 6/129 (4.7%) vs. 6/92 (6.5%) vs. 10/114 (8.8%); P = 0.42.

Conclusion : Our exploratory study did not report effects on mechanical ventilation, median hospital LOS and in-hospital mortality from hyperoxemia compared to hypoxemic and normoxemic ED patients with ACPE. Further studies are warranted to prove or disprove our findings.

Conclusion (proposition de traduction) : Notre étude exploratoire n'a pas fait état d'effets sur la ventilation mécanique, la durée médiane du séjour à l'hôpital et la mortalité hospitalière due à l'hyperoxémie par rapport aux patients hypoxémiques et normoxémiques des services d'urgence souffrant d'un œdème aigu pulmonaire cardiogénique. D'autres études sont nécessaires pour prouver ou infirmer nos conclusions.

Persistently elevated early warning scores and lactate identifies patients at high risk of mortality in suspected sepsis.v.
Picton G, Venn R, Hodgson LE. | Eur J Emerg Med.  2020 Apr;27(2):125-131
DOI: https://doi.org/10.1097/mej.0000000000000630
Keywords: Aucun

Original Articles

Introduction : In the UK, the National Early Warning Score (NEWS) is recommended as part of screening for suspicion of sepsis. Is a change in NEWS a better predictor of mortality than an isolated score when screening for suspicion of sepsis?

Méthode : A prospectively gathered cohort of 1233 adults brought in by ambulance to two UK nonspecialist hospitals, with suspicion of sepsis at emergency department (ED) triage (2015-2017) was analysed. Associations with 30-day mortality and ICU admission rate were compared between groups with an isolated NEWS ≥5 points prehospital and those with persistently elevated NEWS prehospital, in ED and at ward admission. The effect of adding the ED (venous or arterial) lactate was also assessed.

Résultats : Mortality increased if the NEWS persisted ≥5 at ED arrival 22.1% vs. 10.2% [odds ratio (OR) 2.5 (1.6-4.0); P < 0.001]. Adding an ED lactate ≥2 mmol/L was associated with an increase in mortality greater than for NEWS alone [32.2% vs. 13.3%, OR 3.1 (2.2-4.1); P < 0.001], and increased ICU admission [13.9% vs. 3.7%, OR 3.1 (2.2-4.3); P < 0.001]. If NEWS remained ≥5 at ward admission (predominantly within 4 h of ED arrival), mortality was 32.1% vs. 14.3%, [OR 2.8 (2.1-3.9); P < 0.001] and still higher if accompanied by an elevated ED lactate [42.1% vs. 16.4%, OR 3.7 (2.6-5.3); P < 0.001].

Conclusion : Persistently elevated NEWS, from prehospital through the ED to the time of ward admission, combined with an elevated ED lactate identifies patients with suspicion of sepsis at highest risk of in-hospital mortality.

Conclusion (proposition de traduction) : Un score « National Early Warning Score » (NEWS) constamment élevé, de la période préhospitalière jusqu'à l'admission dans le service des urgences, combiné à un taux de lactate élevé dans le service des urgences, permet d'identifier les patients soupçonnés de septicémie qui présentent le plus grand risque de mortalité hospitalière.

HAL

Estimating the burden of SARS-CoV-2 in France.
Salje H, Tran Kiem C, Lefrancq N, Courtejoie N, Bosetti P, Paireau J, Andronico A, Hoze N, Richet J, Dubost CL, Le Strat Y, Lessler J, Bruhl DL, Fontanet A, Opatowski L, Boelle1 PY, Cauchemez S. | HAL.  pasteur-02548181
DOI: https://hal-pasteur.archives-ouvertes.fr/pasteur-02548181  | Télécharger l'article au format  
Keywords: Aucun

Archive ouverte pluridisciplinaire HAL

Editorial : France has been heavily affected by the SARS-CoV-2 epidemic and went into lockdown on the 17th March 2020. Using models applied to hospital and death data, we estimate the impact of the lockdown and current population immunity. We find 2.6% of infected individuals are hospitalized and 0.53% die, ranging from 0.001% in those <20y to 8.3% in those >80y. Across all ages, men are more likely to be hospitalized, enter intensive care, and die than women. The lockdown reduced the reproductive number from 3.3 to 0.5 (84% reduction). By 11 May, when interventions are scheduled to be eased, we project 3.7 million (range: 2.3-6.7) people, 5.7% of the population, will have been infected. Population immunity appears insufficient to avoid a second wave if all control measures are released at the end of the lockdown

Conclusion : This study shows the massive impact the French lockdown had on SARS-CoV-2 transmission. It estimates underlying probabilities of infection, hospitalization and death, which is essential for the interpretation of COVID-19 surveillance data. The forecasts we provide can inform planning of ICU bed occupancy and lockdown exit strategies. The estimated low level of immunity against SARS-CoV-2 indicates that efficient control measures that limit transmission risk will have to be maintained beyond the 11th May to avoid a rebound of the epidemic.

Conclusion (proposition de traduction) : Cette étude montre l'impact massif que le confinement français a eu sur la transmission du SRAS-CoV-2. Il estime les probabilités sous-jacentes d'infection, d'hospitalisation et de décès, ce qui est essentiel pour l'interprétation des données de surveillance COVID-19. Les prévisions que nous fournissons peuvent éclairer la planification de l'occupation des lits dans les USI et les stratégies de sortie du confinement. Le faible niveau d'immunité estimé contre le SRAS-CoV-2 indique que des mesures de contrôle efficaces qui limitent le risque de transmission devront être maintenues au-delà du 11 mai pour éviter un rebond de l'épidémie.

Internal and Emergency Medicine

Association between long boarding time in the emergency department and hospital mortality: a single-center propensity score-based analysis.
Boulain T, Maitre O. | Intern Emerg Med.  2020 Apr;15(3):479-489
DOI: https://doi.org/10.1007/s11739-019-02231-z
Keywords: Crowding; Data interpretation; Emergency service; Hospital; Hospital mortality; Propensity score; Statistical

EM - ORIGINAL

Introduction : Once diagnostic work-up and first therapy are completed in patients visiting the emergency department (ED), boarding them within the ED until an in-hospital bed became available is a common practice in busy hospitals. Whether this practice may harm the patients remains a debate. We sought to determine whether an ED boarding time longer than 4 h places the patients at increased risk of in-hospital death.

Méthode : This retrospective, propensity score-matched analysis and propensity score-based inverse probability weighting analysis was conducted in an adult ED in a single, academic, 1136-bed hospital in France. All patients hospitalized via the adult ED from January 1, 2013 to March 31, 2018 were included. Hospital mortality (primary outcome) and hospital length of stay (LOS) were assessed in (1) a matched cohort (1:1 matching of ED visits with or without ED boarding time longer than 4 h but similar propensity score to experience an ED boarding time longer than 4 h); and (2) the whole study cohort. Sensitivity analysis to unmeasured confounding and analyses in pre-specified cohorts of patients were conducted.

Résultats : Among 68,632 included ED visits, 17,271 (25.2%) had an ED boarding time longer than 4 h. Conditional logistic regression performed on a 10,581 pair-matched cohort, and generalized estimating equations with adjustment on confounders and stabilized propensity score-based inverse probability weighting applied on the whole cohort showed a significantly increased risk of hospital death in patients experiencing an ED boarding time longer than 4 h: odds ratio (OR) of 1.13 (95% confidence interval [95% CI] 1.05-1.22), P = 0.001; and OR of 1.12 (95% CI 1.03-1.22), P = 0.007, respectively. Sensitivity analyses showed that these findings might be robust to unmeasured confounding. Hospital LOS was significantly longer in patients exposed to ED boarding time longer than 4 h: median difference 2 days (95% CI 1-2) (P < 0.001) in matched analysis and mean difference 1.15 days (95% CI 1.02-1.28) (P < 0.001) in multivariable unmatched analysis.

Conclusion : In this single-center propensity score-based cohort analysis, patients experiencing an ED boarding time longer than 4 h before being transferred to an in-patient bed were at increased risk of hospital death.

Conclusion (proposition de traduction) : Dans cette analyse de cohorte basée sur un score de propension monocentrique, les patients qui subissaient un séjour aux urgences de plus de 4 h avant d'être transférés dans un lit d'hospitalisation présentaient un risque accru de décès à l'hôpital.

Point-of-care ultrasound modalities in terms of diagnosing acute decompensated heart failure in emergency department; a diagnostic accuracy study.
Farahmand S, Abdolhoseini A, Aliniagerdroudbari E, Babaniamansour S, Baratloo A, Bagheri-Hariri S. | Intern Emerg Med.  2020 Apr;15(3):491-499
DOI: https://doi.org/10.1007/s11739-019-02233-x
Keywords: Brain; Dyspnea; Heart failure; Natriuretic peptide; Ultrasonography

EM - ORIGINAL

Introduction : This study aimed to compare the diagnostic accuracy of heart, lung and inferior vena cava (IVC) ultrasonography modalities, alone and combined, for possible added accuracy in diagnosing acute decompensated heart failure (ADHF), in a group of patients with the final diagnosis of ADHF based on plasma level of B-type natriuretic peptide (BNP) as the standard.

Méthode : The present study is a diagnostic accuracy study, which was carried out in the emergency department of Imam Khomeini hospital, affiliated to Tehran University of Medical Sciences, in 2014-2015. All patients over 18 years old, who were referred to emergency department with complaint of acute dyspnea were regarded as eligible and no exclusion criteria were considered. All ultrasounds were performed by a trained emergency medicine resident and then saved and classified for each patient, separately, and reviewed by the attending emergency medicine physician. In this study, patients with BNP levels higher than 500 pg/ml were considered positive for dyspnea caused by heart failure.

Résultats : A total of 120 patients with an average age of 60.83 ± 16.528 years were studied, 64 (53%) of which were male. In total, 47.5% of patients had a BNP level over 500 pg/ml. Among patients with positive ultrasound, 94.7% were true positive and among those with a negative ultrasound, 61.4% were true negative. Based on the findings, B-line ≥ 10 has the highest specificity and left ventricular ejection fraction (LVEF) < 45% has the highest sensitivity. The combination of LVEF and IVC collapsibility index (IVC-CI), LVEF and BLC, IVC-CI and BLC, and IVC-CI and BBPC had a higher specificity rate and combination of LVEF and BBPC and BLC and BBPC had the highest sensitivity. Sensitivity, specificity, positive predictive value and negative predictive value of all three ultrasounds combined were 31.6%, 98.4%, 94.7% and 61.4%, respectively.

Conclusion : In this study, the diagnostic accuracy of double and triple ultrasonography of heart, lung and IVC in the diagnosis of ADHF was very high, among which triple ultrasonography was more preferable.

Conclusion (proposition de traduction) : Dans cette étude, la précision diagnostique de la double et de la triple échographie du cœur, des poumons et de la veine cave inférieure dans le diagnostic de l'insuffisance cardiaque décompensée aiguë était très élevée, entre les deux la triple échographie était meilleure.

International Journal of Emergency Medicine

Manual ventilation quality is improved with a real-time visual feedback system during simulated resuscitation.
Gould JR, Campana L, Rabickow D, Raymond R, Partridge R. | Int J Emerg Med.  2020 Apr 16;13(1):18
DOI: https://doi.org/10.1186/s12245-020-00276-y  | Télécharger l'article au format  
Keywords: Airway; Cardiopulmonary resuscitation (CPR); Tidal volume; Ventilation

Practice innovations in emergency medicine

Introduction : Manual ventilations during cardiac arrest are frequently performed outside of recommended guidelines. Real-time feedback has been shown to improve chest compression quality, but the use of feedback to guide ventilation volume and rate has not been studied. The purpose of this study was to determine whether the use of a real-time visual feedback system for ventilation volume and rate improves manual ventilation quality during simulated cardiac arrest.

Méthode : Teams of 2 emergency medical technicians (EMTs) performed two 8-min rounds of cardiopulmonary resuscitation (CPR) on a manikin during a simulated cardiac arrest scenario with one EMT performing ventilations while the other performed compressions. The EMTs switched roles every 2 min. During the first round of CPR, ventilation and chest compression feedback was disabled on a monitor/defibrillator. Following a 20-min rest period and a brief session to familiarize the EMTs with the feedback technology, the trial was repeated with feedback enabled. The primary outcome variables for the study were ventilations and chest compressions within target. Ventilation rate (target, 8-10 breaths/minute) and tidal volume (target, 425-575 ml) were measured using a novel differential pressure-based flow sensor. Data were analyzed using paired t tests.

Résultats : Ten teams of 2 EMTs completed the study. Mean percentages of ventilations performed in target for rate (41% vs. 71%, p < 0.01), for volume (31% vs. 79%, p < 0.01), and for rate and volume together (10% vs. 63%, p < 0.01) were significantly greater with feedback.

Conclusion : The use of a novel visual feedback system for ventilation quality increased the percentage of ventilations in target for rate and volume during simulated CPR. Real-time feedback to perform ventilations within recommended guidelines during cardiac arrest should be further investigated in human resuscitation.

Conclusion (proposition de traduction) : L'utilisation d'un nouveau système de rétroaction visuelle pour la qualité de la ventilation a augmenté le pourcentage de ventilations dans la cible pour la fréquence et le volume pendant la RCP en simulation. La rétroaction en temps réel pour effectuer des ventilations selon les recommandations pendant un arrêt cardiaque doit être étudiée plus en détail dans la réanimation humaine.

Journal of Critical Care

Safe bronchodilator treatment in mechanically ventilated COVID-19 patients: A single center experience.
Miller A, Epstein D. | J Crit Care.  2020 Apr 21;
DOI: https://doi.org/10.1016/j.jcrc.2020.04.010  | Télécharger l'article au format  
Keywords: Ventilators, Mechanical; COVID-19; Pulmonary Disease, Chronic Obstructive; Asthma; Bronchodilator Agents

Journal Pre-proof

Editorial : Over one million people worldwide have been infected with Coronavirus disease 2019 (COVID-19). Up to 12% of them may require intensive care unit admission and 75% of them may need mechanical ventilation [1,2]. A significant proportion of COVID-19 patients suffer from chronic obstructive lung disease, asthma or other pulmonary disorders, which are associated with an increased risk of severe infection requiring respiratory assistance

Conclusion : In order to mitigate these hazards, we successfully use continuous inhalation by Aeroneb Solo (Aerogen©, Galway, Ireland) in invasively and non-invasively ventilated COVID-19 patients with COPD and asthma. The system is composed of a syringe mounted on a pump that continuously delivers medication to the nebulizing reservoir, isolated from the breathing circuit, where an electric powered ultrasonic mesh vibrating at ultra-high rate transforms the drug into an aerosol that enters the ventilator circuit. This closed system requires minimal staff handling and no circuit opening, thereby reducing workload and increasing safety. To our knowledge, this is the first report of administering bronchodilators safely and efficiently to COVID-19 ventilated patients.

Conclusion (proposition de traduction) : Afin d'atténuer ces risques, nous utilisons avec succès l'inhalation continue par Aeroneb Solo (Aerogen©, Galway, Irlande) chez les patients COVID-19 ventilés de manière invasive et non invasive avec une BPCO et un asthme. Le système est composé d'une seringue montée sur une pompe qui délivre en continu des médicaments dans le réservoir de nébulisation, isolé du circuit respiratoire, où un maillage ultrasonique électrique vibrant à très haute vitesse transforme le médicament en aérosol qui pénètre dans le circuit du ventilateur. Ce système fermé nécessite une manipulation minimale du personnel et aucune ouverture de circuit, réduisant ainsi la charge de travail et augmentant la sécurité.
À notre connaissance, il s'agit du premier rapport sur l'administration de bronchodilatateurs de manière sûre et efficace à des patients COVID-19 ventilés.

Commentaire : 

Risk of major bleeding associated with aspirin use in non-surgical critically ill patients receiving therapeutic anticoagulation.
Subat Y, Rayes H, Hanson A, Johnson M, Schulte P, Evans K, Weister T, Trivedi V, Gajic O, Warner M. | J Crit Care.  2020 April;
DOI: https://doi.org/10.1016/j.jcrc.2020.04.003
Keywords: Aucun

In Press, Journal Pre-proof

Introduction : We aimed to evaluate the risk of major bleeding in non-surgical critically ill patients who received aspirin in conjunction with therapeutic anticoagulation (concomitant therapy) compared to those who received therapeutic anticoagulation alone.

Méthode : therapeutic anticoagulation at a large academic medical center from 2007 to 2016. The exposure of interest was aspirin therapy during anticoagulation. The primary outcome was the incidence of major bleeding during hospitalization. Secondary outcomes included in-hospital mortality, hospital free days, and new myocardial infarction or stroke.

Résultats : 5507 (73.2%) patients received anticoagulation alone and 2014 (26.8%) received concomitant therapy; major bleeding occurred in 19.0% and 22.2%, respectively. There was no increased risk of major bleeding [OR 1.10 (95% CI: 0.93–1.30); p = .27] or mortality [OR 0.93 (95% CI: 0.77–1.11); p = .43] with concomitant therapy. Patients receiving concomitant therapy had fewer hospital-free days (mean decrease of 0.73 [1.36, 0.09]; p = .03) and were more likely to experience new myocardial infarction or stroke [OR 2.61 (95% CI: 1.72–3.98); p < 

Conclusion : In non-surgical critically ill patients receiving therapeutic anticoagulation, concomitant use of aspirin was not associated with an increased risk of bleeding or in-hospital mortality.

Conclusion (proposition de traduction) : Chez les patients gravement malades non chirurgicaux recevant une anticoagulation thérapeutique, l'utilisation concomitante d'aspirine n'était pas associée à un risque accru de saignement ou de mortalité hospitalière.

Commentaire : Points forts
• Étude de cohorte rétrospective de patients en soins intensifs à la Mayo Clinic Rochester de 2007 à 2016
• Des saignements majeurs se sont produits dans 19% avec l'aspirine seule, 22% avec l'aspirine associé à une anticoagulation
• L'aspirine et l'anticoagulation n'étaient pas associées à un risque accru de saignement
• L'arrêt de l'aspirine n'a pas entraîné d'augmentation d'AVC ni d'infarctus du myocarde

Journal of the American College of Cardiology

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up.
Bikdeli B, Madhavan MV, Jimenez D, Chuich T, Dreyfus I, Driggin E, Nigoghossian C, Ageno W, Madjid M, Guo Y, Tang LV, Hu Y, Giri J, Cushman M, Quéré I, Dimakakos EP, Gibson CM, Lippi G, Favaloro EJ, Fareed J, Caprini JA, Tafur AJ, Burton JR, Francese DP, Wang EY, Falanga A, McLintock C, Hunt BJ, Spyropoulos AC, Barnes GD, Eikelboom JW, Weinberg I, Schulman S, Carrier M, Piazza G, Beckman JA, Steg PG, Stone GW, Rosenkranz S, Goldhaber SZ, Parikh SA, Monreal. | J Am Coll Cardiol.  2020 Apr 15:S0735-1097(20)35008-7
DOI: https://doi.org/10.1016/j.jacc.2020.04.031  | Télécharger l'article au format  
Keywords: Coronavirus disease 2019; SARS-CoV-2; anticoagulant; antiplatelet; antithrombotic therapy; thrombosis.

JACC State-of-the-Art Review

Editorial : Coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, due to excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, we review the current understanding of the pathogenesis, epidemiology, management and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, and of those with preexisting thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.

Conclusion : In conclusion, thrombotic diseasemay be precedent factors or incident complications in patients with COVID-19. Important considerations for the preventive and therapeutic use of antithrombotic agents should be kept in mind to mitigate the thrombotic and hemorrhagic events in these high-risk patients.
Funding agencies, professional societies, patients, clinicians, and investigators should work collaboratively to effectively and efficiently address numerous critical areas of knowledge gap.

Conclusion (proposition de traduction) : En conclusion, les maladies thrombotiques peuvent être des facteurs primitifs ou des complications accidentelles chez les patients atteints de COVID-19. Il convient de garder à l'esprit des considérations importantes pour l'utilisation préventive et thérapeutique des agents antithrombotiques afin d'atténuer les événements thrombotiques et hémorragiques chez ces patients à haut risque.
Les organismes de financement, les sociétés professionnelles, les patients, les cliniciens et les chercheurs doivent travailler en collaboration pour s'attaquer de manière efficace et efficiente à de nombreux domaines critiques du déficit de connaissances.

Commentaire :  Voir l'analyse de l'article sur le site Medscape : COVID-19 : des recommandations pour réduire le risque thromboembolique  . Rédigé par Vincent Richeux le 30 avril 2020.

medRχiv

Smoking is Associated with COVID-19 Progression: A Meta-Analysis.
Patanavanich R, Glantz SA. | medRχiv [Internet].  2020.04.13.20063669
DOI: https://doi.org/10.1101/2020.04.13.20063669  | Télécharger l'article au format  
Keywords: Aucun

Preprint

Introduction : To determine the association between smoking and progression of COVID-19. Design: A meta-analysis of 12 published papers.

Méthode : Data Source: PubMed database was searched on April 6, 2020. Eligibility criteria and data analysis: We included studies reporting smoking behavior of COVID-19 patients and progression of disease. Search terms included smoking, smoker*, characteristics, risk factors, outcomes, and COVID-19, COVID, coronavirus, sar cov-2, sar cov 2. There were no language limitations. One author extracted information for each study, screened the abstract or the full text, with questions resolved through discussion among both authors. A random effects meta-analysis was applied. Main Outcome Measures: The study outcome was progression of COVID-19 among people who already had the disease.

Résultats : We identified 12 papers with a total of 9,025 COVID-19 patients, 878 (9.7%) with severe disease and 495 with a history of smoking (5.5%). The meta-analysis showed a significant association between smoking and progression of COVID-19 (OR 2.25, 95% CI 1.49-3.39, p=0.001). Limitations in the 12 papers suggest that the actual risk of smoking may be higher.

Conclusion : Smoking is a risk factor for progression of COVID-19, with smokers having higher odds of COVID-19 progression than never smokers. Physicians and public health professionals should collect data on smoking as part of clinical management and add smoking cessation to the list of practices to blunt the COVID-19 pandemic.

Conclusion (proposition de traduction) : Le tabagisme est un facteur de risque de progression du COVID-19, les fumeurs ayant plus de chances de voir leur COVID-19 progresser que les non-fumeurs. Les médecins et les professionnels de la santé publique doivent recueillir des données sur le tabagisme dans le cadre de la gestion clinique et ajouter le sevrage tabagique à la liste des pratiques visant à atténuer la pandémie de COVID-19.

Commentaire : ndlr : MedRχiv (prononcé med-archive)

Pediatric Emergency Care

A Comparison of Direct Laryngoscopy and Videolaryngoscopy for Endotracheal Intubation by Inexperienced Users: A Pediatric Manikin Study.
Balaban O, Hakim M, Walia H, Tumin D, Lind M, Tobias JD. | Pediatr Emerg Care.  2020 Apr;36(4):169-172
DOI: https://doi.org/10.1097/pec.0000000000001198
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : Direct laryngoscopy (DL) is the most common technique for endotracheal intubation, whereas videolaryngoscopy provides an indirect view of the glottis without the need to align the oral, pharyngeal, and tracheal axes. The current study compares videolaryngoscopy with DL among experienced and inexperienced users for endotracheal intubation using a pediatric manikin.

Méthode : Participants performed DL using Miller and Macintosh laryngoscopes and videolaryngoscopy using CMAC and GlideScope devices on a manikin (SimBaby; Laerdel, Wappingers Falls, NY). Time to endotracheal intubation, number of attempts, and successful intubation within 120 seconds were recorded.

Résultats : Among 31 experienced users, time to endotracheal intubation with the CMAC (20 ± 13 seconds) did not differ from DL with either the Miller (30 ± 28 seconds) or Macintosh (27 ± 23 seconds) laryngoscopes. However, with the GlideScope, time to endotracheal intubation (85 ± 38 seconds) was longer. The results were similar among 12 inexperienced users, as time to endotracheal intubation with the CMAC (61 ± 34 seconds) was comparable with the Miller (72 ± 45 seconds) or Macintosh (72 ± 45 seconds) laryngoscopes but was longer with the GlideScope (118 ± 6 seconds) for each comparison.

Conclusion : The standard straight or curved laryngoscope blades including the CMAC were associated with shorter procedural time and higher success rate when compared with indirect videolaryngoscopy with an unconventional blade design such as the GlideScope in both experienced and inexperienced users. However, the current study demonstrates that results may be influenced by the anatomical design of the manikin.

Conclusion (proposition de traduction) : Les lames de laryngoscope droites ou courbes standard, y compris le Vidéo-laryngoscope C-MAC®, étaient associées à un temps de procédure plus court et à un taux de réussite plus élevé par rapport à la vidéolaryngoscopie indirecte avec une conception de lame non conventionnelle telle que le GlideScope chez les utilisateurs expérimentés et inexpérimentés. Cependant, la présente étude démontre que les résultats peuvent être influencés par la conception anatomique du mannequin.

valuation of Patients With Febrile Seizure: Risk Factors, Reccurence, Treatment and Prognosis.
Renda R, Yüksel D, Gürer YKY. | Pediatr Emerg Care.  2020 Apr;36(4):173-177
DOI: https://doi.org/10.1097/pec.0000000000001173
Keywords: Aucun

Original Articles

Introduction : Febrile convulsion (FC) is the most common neurological disorder in childhood. The aim of this study was to determine the risk factors for recurrence and the development of epilepsy from the demographic data of these patients.

Méthode : A retrospective study was made of 680 patients with FC who presented to our hospital. Patients with only FC were defined as group 1 and those who developed epilepsy after FC as group 2. Comparisons were made between the 2 groups of the demographic parameters, parental consanguinity, familial history of FCs or epilepsy, criteria for starting prophylactic treatment, response to treatment, risk factors for recurrence, and results of electroencephalogram.

Résultats : The study included a total of 680 patients comprising 399 males (59%) and 281 females (41%). A diagnosis of FC was made in 652 cases (95.8%, group 1), and epilepsy was diagnosed in 28 (4.2%, group 2). A positive familial history of FCs was determined statistically significantly higher in group 1. On the other hand, a history of pathological birth and parental consanguinity was found higher in group 2. Prophylactic treatment was administered to 89.3% of group 2 and 40.3% of group 1.

Conclusion : Febrile convulsions create fear and panic in the family and are a significant health problem in Turkey. The conclusion that has been reached is that the unnecessary administration of prophylactic treatment could be prevented with education of the families on the subject of fever and correct identification of patients at risk of developing epilepsy.

Conclusion (proposition de traduction) : Les convulsions fébriles génèréent anxiété et panique dans la famille et constituent un problème de santé important en Turquie. La conclusion à laquelle on est parvenu est que l'administration inutile d'un traitement prophylactique pourrait être évitée grâce à l'éducation des familles au sujet de la fièvre et à l'identification correcte des patients à risque de développer une épilepsie.

Clinical Characteristics of Pediatric Patients With Carbon Monoxide Poisoning.
Sethuraman KN, Douglas TM, Bostick BB, Comer AC, Myers B, Rosenthal RE. | Pediatr Emerg Care.  2020 Apr;36(4):178-181
DOI: https://doi.org/10.1097/pec.0000000000001378
Keywords: Aucun

original article

Introduction : Carbon monoxide (CO) poisoning is a common and deadly form of poisoning that is often treated with hyperbaric oxygen. The characteristics of children exposed to CO and then treated with hyperbaric oxygen have not been delineated. The purpose of this study was to describe the clinical characteristics of children treated with hyperbaric oxygen therapy for CO poisoning at a regional hyperbaric referral center.

Méthode : The study is based on a retrospective review of data extracted from the medical records of children (age <19 years) who were referred to our center for hyperbaric oxygen therapy for CO poisoning between 2008 and 2013. Inferential analyses were used to compare demographic characteristics, serum carboxyhemoglobin (COHb) levels, and presenting symptoms.

Résultats : Forty-seven children met our study criteria. Their mean age was 8.9 years, and their mean COHb level was 14.3% (range, 3.4%-30.1%). Severity of symptoms did not correlate with serum COHb levels; however, neurologic symptoms at presentation were more common in patients with a COHb level greater than 25%. There was a correlation between increasing age and higher COHb levels and between COHb and lactate levels.

Conclusion : Our retrospective review of patients' records showed no correlation of serum COHb levels with symptoms on presentation; however, a correlation was found between increasing age and COHb level as well as lactate level and COHb level.

Conclusion (proposition de traduction) : Notre examen rétrospectif des dossiers des patients n'a montré aucune corrélation entre les taux sériques de carboxyhémoglobine et les symptômes à l'admission ; cependant, une corrélation a été trouvée entre l'augmentation de l'âge et les taux de carboxyhémoglobine ainsi que les taux de lactate et les taux de carboxyhémoglobine.

Emergency Department Implementation of the Brain Trauma Foundation's Pediatric Severe Brain Injury Guideline Recommendations.
Lumba-Brown A, Totten A, Kochanek PM. | Pediatr Emerg Care.  2020 Apr;36(4):e239-e241
DOI: https://doi.org/10.1097/pec.0000000000001903
Keywords: Aucun

Review Article

Editorial : The "Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines" published in Pediatric Critical Care Medicine in 2019 provides new and updated recommendations applicable to the emergency department management of children with severe traumatic brain injury. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation.

Conclusion : The emergency physician plays a critical role in the recognition and management of severe TBI. This includes guiding the initial trajectory of care to effect guideline-based prevention of secondary insults directly influencing risks of morbidity and mortality. The new evidence-based guideline provides strong support for intervention in the ED via a structured framework of recommendations. Practice-changing takeaways include specific recommendations for administration of 3% hypertonic saline, administration of seizure prophylaxis, and avoiding hyperventilation. Notably, the Approaches and Decision in Acute Pediatric TBI Trial (ADAPT), an important study of 1000 cases of severe pediatric TBI, recently completed enrollment, and the findings are thus not yet incorporated into these recommendations. It is anticipated that the results of that study will provide further insights and additional guidelines-based recommendations into the management of severe TBI among children.

Conclusion (proposition de traduction) : Le médecin urgentiste joue un rôle essentiel dans la détection et la prise en charge des traumatismes crâniens graves. Il s'agit notamment de guider l'organisation initiale des soins pour effectuer une prévention des complications secondaires basée sur des lignes directrices influençant directement les risques de morbi-mortalité. La nouvelle recommandation fondée sur des données probantes fournit une aide solide pour la prise en charge dans le service d'urgence via un cadre structuré de recommandations. Parmi les changements de pratique, on peut citer des recommandations spécifiques pour l'administration de solution saline hypertonique à 3 %, l'administration d'une prophylaxie des crises et la prévention de l'hyperventilation. Notamment, l’étude Approaches and Decision in Acute Pediatric TBI (ADAPT), une étude importante de 1000 ,cas de traumatismes crâniens graves pédiatrique récemment achevée, et les résultats ne sont donc pas encore intégrés dans ces recommandations. On s’attend à ce que les résultats de cette étude permettent de mieux comprendre la prise en charge des traumatismes crâniens graves chez les enfants et de formuler d’autres recommandations fondées sur des lignes directrices.

Prehospital and Disaster Medicine

Utilizing End-Tidal Carbon Dioxide to Diagnose Diabetic Ketoacidosis in Prehospital Patients With Hyperglycemia.
Hunter C, Putman M, Foster J, Souers A, Rodriguez A, Zuver C, Papa L. | Prehosp Disaster Med.  2020 Apr 15:1-4
DOI: https://doi.org/10.1017/s1049023x20000485
Keywords: DKA; ETCO2; prehospital.

First View

Introduction : Early identification of diabetic ketoacidosis (DKA) may improve clinical outcomes. Prior studies suggest exhaled end tidal carbon dioxide (ETCO2) provides a non-invasive, real-time method to screen for DKA in the emergency department (ED).

Méthode : This a retrospective cohort study among patients who activated Emergency Medical Services (EMS) during a one-year period. Initial out-of-hospital vital signs documented by EMS personnel, including ETCO2 and first recorded blood glucose level (BGL), as well as in-hospital records, including laboratory values and diagnosis, were collected. The main outcome was the association between ETCO2 and the diagnosis of DKA.

Résultats : Of the 118 patients transported with hyperglycemia (defined by BGL >200), six (5%) were diagnosed with DKA. The mean level of ETCO2 in those without DKA was 35mmHg (95% CI, 33-38mmHg) compared to mean levels of 15mmHg (95% CI, 8-21mmHg) in those with DKA (P <.001). The Area Under the Receiver Operating Characteristics (ROC) Curve (AUC) for ETCO2 identifying DKA was 0.96 (95% CI, 0.92-1.00). The correlation coefficient between ETCO2 and serum bicarbonate (HCO3) was 0.436 (P <.001) and the correlation coefficient between ETCO2 and anion gap was -0.397 (P <.001).

Conclusion : Among patients with hyperglycemia, prehospital levels of ETCO2 were significantly lower in patients with DKA compared to those without and were predictive of the diagnosis of DKA. Furthermore, out-of-hospital ETCO2 was significantly correlated with measures of metabolic acidosis.

Conclusion (proposition de traduction) : Parmi les patients présentant une hyperglycémie, les taux préhospitaliers d'ETCO2 étaient significativement plus faibles chez les patients atteints d'acidocétose diabétique par rapport à ceux sans et prédisaient le diagnostic 'acidocétose diabétique. De plus, l'ETCO2 extra-hospitalier était significativement corrélé aux mesures de l'acidose métabolique.

Ketamine as a Prehospital Analgesic: A Systematic Review.
Bansal A, Miller M, Ferguson I, Burns B. | Prehosp Disaster Med.  2020 Apr 15:1-8
DOI: https://doi.org/10.1017/s1049023x20000448
Keywords: analgesia; ketamine; prehospital.

First View

Introduction : Analgesia in the prehospital setting is an extremely important, yet controversial topic. Ketamine, a N-methyl D-aspartate (NMDA) receptor antagonist, has been commonly used in the prehospital setting, including recommendations by the US Department of Defense and by the Royal Australian College of Pain Medicine, despite the paucity of high-level evidence.

Méthode : Accordingly, a review of the literature was conducted using several electronic medical literature databases from the earliest available records to the time at which the search was conducted (October 2018).

Résultats : The search strategy yielded a total of 707 unique papers, of which 43 were short-listed for full review, and ultimately, ten papers were identified as meeting all the relevant inclusion criteria. The included studies varied significantly in the prehospital context and in the means of administering ketamine. There was only low-grade evidence that ketamine offered a safe and effective analgesia when used as the only analgesic, and only low-grade evidence that it was as effective as alternative opioid options. However, there was moderate evidence that co-administration of ketamine with morphine may improve analgesic efficacy and reduce morphine requirement.

Conclusion : Overall, ketamine as a prehospital analgesic may be best used in combination with opioids to reduce opioid requirement. It is suggested that future studies should use a standardized approach to measuring pain reduction. Future studies should also investigate short-term side effects and long-term complications or benefits of prehospital ketamine.

Conclusion (proposition de traduction) : Dans l'ensemble, la kétamine comme analgésique préhospitalier peut être mieux utilisée en combinaison avec des opioïdes pour réduire les besoins en opioïdes. Il est suggéré que les études futures devraient utiliser une approche standardisée pour mesurer la réduction de la douleur. Les études futures devraient également étudier les effets secondaires à court terme et les complications ou avantages à long terme de la kétamine préhospitalière.

Prehospital Emergency Care

Control of Severe, Life-Threatening External Bleeding in the Out-of-Hospital Setting: A Systematic Review.
Charlton NP, 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. | Prehosp Emerg Care.  2020 Apr 27:1-33
DOI: https://doi.org/10.1080/10903127.2020.1743801
Keywords: bleeding; hemorrhage; tourniquet; hemostatic dressing; direct pressure.

Article

Introduction : rauma, 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 2 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 saignements potentiellement mortels sont d'une très faible certitude, 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 soins des saignements potentiellement mortels, cette revue systématique regroupe les plus complètes à ce jour pour guider les recommandations.

Resuscitation

Tracheal Suctioning of Meconium at Birth for Non-Vigorous Infants: A Systematic Review and Meta-Analysis.
Trevisanuto D, Strand ML, Kawakami MD, Fabres J, Szyld E, Nation K, Wyckoff MH, Rabi Y, Lee HC; International Liaison Committee on Resuscitation Neonatal Life Support Task Force. | Resuscitation.  2020 Apr;149:117-126
DOI: https://doi.org/10.1016/j.resuscitation.2020.01.038
Keywords: Infant newborn; Meconium aspiration syndrome; Meta-analysis; Non-vigorous infant; Review; Tracheal suctioning.

Clinical papers

Introduction : The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF).
Objective: To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF.

Méthode : Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019.
Study selection: Studies were selected by pairs of independent reviewers in 2 stages.
Data extraction: Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome.

Résultats : Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96-1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome.
Limitations : The certainty of evidence was low for survival at discharge and very low for all other outcomes.

Conclusion : For non-vigorous newborns delivered through meconium stained amniotic fluid , there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning.

Conclusion (proposition de traduction) : Pour les nouveau-nés en détresse accouchés avec du liquide amniotique coloré au méconium, les preuves sont insuffisantes pour suggérer une laryngoscopie directe immédiate après l'aspiration trachéale.

Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review.
Granfeldt A, Avis SR, Lind PC, Holmberg MJ, Kleinman M, Maconochie I, Hsu CH, Fernanda de Almeida M, Wang TL, Neumar RW, Andersen LW. | Resuscitation.  2020 Apr;149:150-157
DOI: https://doi.org/10.1016/j.resuscitation.2020.02.025
Keywords: Cardiopulmonary resuscitation; Drugs; Intraosseous; Intravenous; Systematic review.

Reviews

Introduction : To perform a systematic review of the literature on intravenous (IV) vs. intraosseous (IO) administration of drugs during cardiac arrest in order to inform an update of international guidelines.

Méthode : To perform a systematic review of the literature on intravenous (IV) vs. intraosseous (IO) administration of drugs during cardiac arrest in order to inform an update of international guidelines.

Résultats : We included six observational studies comparing IV to IO administration of drugs and two randomized trials assessing the effect of specific drugs in subgroups related to IV vs. IO administration. All studies included adult out-of-hospital cardiac arrest patients. No studies were identified in neonatal or paediatric patients. The risk of bias for the observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. The meta-analyses excluding studies with a critical risk of bias favoured IV access for all outcomes. Using GRADE, the certainty of evidence was judged at very low. Subgroup analyses of the two randomized trials demonstrated no statistically significant interactions between the route of access and study drugs on outcomes. However, these trials were underpowered to assess such interactions.

Conclusion : We identified a limited number of studies comparing IV vs. IO administration of drugs during cardiac arrest. Pooled results from four observational studies favoured IV access with very low certainty of evidence. From the subgroup analyses of two randomized clinical trials, there was no statistically significant interaction between the route of access and study drug on outcomes.

Conclusion (proposition de traduction) : Nous avons identifié un nombre limité d'études comparant l'administration de médicaments par voie intraveineuse et par voie intra-osseuse pendant un arrêt cardiaque. Les résultats regroupés de quatre études d'observation ont favorisé l'accès à la perfusion IV avec une très faible certitude de preuve. Les analyses de sous-groupes de deux essais cliniques randomisés n'ont révélé aucune interaction statistiquement significative entre la voie d'accès et le médicament étudié sur les résultats.

Association of Ultrasound-Related Interruption During Cardiopulmonary Resuscitation With Adult Cardiac Arrest Outcomes: A Video-Reviewed Retrospective Study.
Chou EH, Wang CH, Monfort R, Likourezos A, Wolfshohl J, Lu TC, Hsieh YL, Haines L, Dickman E, Lin J. | Resuscitation.  2020 Apr;149:74-80
DOI: https://doi.org/10.1016/j.resuscitation.2020.02.004
Keywords: CPR; Cardiac arrest; ECHO; Interruptions; No-flow time; ROSC; Survival to discharge.

Clinical papers

Introduction : To determine the association of focused transthoracic echocardiography (ECHO) related interruption during cardiopulmonary resuscitation (CPR) with patient outcomes in the Emergency Department (ED).

Méthode : This was a retrospective, single center, cohort study, conducted in an urban community teaching ED. Eligible study subjects were adult patients in the ED with sustained cardiac arrest. Exclusion criteria include traumatic cardiac arrest and age less than 18. All resuscitations were video recorded and were subsequently reviewed by 2 study investigators. The no-flow time from chest compression interruption was analyzed using video review and separated into ECHO-related and non-ECHO related. Our primary outcome was patient survival to hospital discharge and the secondary outcome was the rate of return of spontaneous circulation (ROSC). Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes.

Résultats : From January 2016 to May 2017, a total of 210 patients were included for final analysis. The median total no-flow time observed on video was 99.5 s (IQR: 54.0-160.0 s). Among these, a median of 26.5 s (IQR: 0.0-59.0 s) was ECHO-related and a median of 60.5 s (IQR: 34.0-101.9) was non-ECHO-related. The ECHO-related no-flow time between 77 and 122 s (OR: 7.31, 95 % confidence interval [CI]: 1.59-33.59; p-value = 0.01) and ECHO-related interruption ≦ 2 times (OR: 8.22, 95% CI: 1.51-44.64; p-value = 0.01) were positively associated with survival to hospital discharge. ECHO-related interruption ≦ 2 times (OR: 5.55, 95% CI: 2.44-12.61; p-value < 0.001) was also positively associated with ROSC.

Conclusion : Short ECHO-related interruption during CPR was positively associated with ROSC and survival to hospital discharge. While ECHO can be a valuable diagnostic tool during CPR, the no-flow time associated with ECHO should be minimized.

Conclusion (proposition de traduction) : Une brève interruption liée à l'échocardiographie transthoracique focalisée pendant la RCP a été associée positivement à une récupération d'activité cardiaque spontanée et à la survie à la sortie de l'hôpital. Si l'échocardiographie transthoracique focalisée peut être un outil de diagnostic précieux pendant la RCP, le temps d'arrêt associé à l'échocardiographie transthoracique focalisée doit être réduit au minimum.

Lidocaine Versus Amiodarone for Pediatric In-Hospital Cardiac Arrest: An Observational Study.
Holmberg MJ, Ross CE, Atkins DL, Valdes SO, Donnino MW, Andersen LW; American Heart Association’s for the AHA’s Get With The Guidelines®-Resuscitation Pediatric Research Task Force. | Resuscitation.  2020 Apr;149:191-201
DOI: https://doi.org/10.1016/j.resuscitation.2019.12.033
Keywords: Amiodarone; Antiarrhythmics; Cardiac arrest; Heart arrest; Lidocaine; Pediatrics.

Clinical papers

Introduction : Lidocaine and amiodarone are both included in the pediatric cardiac arrest guidelines as treatments of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, although there is limited evidence to support this recommendation.

Méthode : In this cohort study from the Get With The Guidelines - Resuscitation registry, we included pediatric patients (≤18 years) with an in-hospital cardiac arrest between 2000 and 2018, who presented with an initial or subsequent shockable rhythm (ventricular fibrillation and pulseless ventricular tachycardia). Patients receiving amiodarone were matched to patients receiving lidocaine based on a propensity score, calculated from multiple patient, event, and hospital characteristics.

Résultats : A total of 365 patients were available for the analysis, of which 180 (49%) patients were matched on the propensity score. The median age in the raw cohort was 6 (quartiles, 0.5-14) years, 164 (45%) patients were female, and 238 (65%) patients received an antiarrhythmic for an initial shockable rhythm. In the matched cohort, there were no statistically significant differences between patients receiving lidocaine compared to amiodarone in return of spontaneous circulation (RR, 0.99 [95%CI, 0.82-1.19]; p = 0.88), survival to 24 h (RR, 1.02 [95%CI, 0.76-1.38]; p = 0.88), survival to hospital discharge (RR, 1.01 [95%CI, 0.63-1.63]; p = 0.96), and favorable neurological outcome (RR, 0.65 [95%CI, 0.35-1.21]; p = 0.17). The results remained consistent in multiple sensitivity analyses.

Conclusion : In children with cardiac arrest receiving antiarrhythmics for a shockable rhythm, there was no significant difference in clinical outcomes between those receiving lidocaine compared to amiodarone.

Conclusion (proposition de traduction) : hez les enfants victimes d'un arrêt cardiaque qui recevaient des antiarythmiques pour un rythme choquable, il n'y avait pas de différence significative dans les résultats cliniques entre ceux qui recevaient de la lidocaïne et ceux qui recevaient de l'amiodarone.

Intravenous Versus Intraosseous Adrenaline Administration in Out-Of-Hospital Cardiac Arrest: A Retrospective Cohort Study.
Zhang Y, Zhu J, Liu Z, Gu L, Zhang W, Zhan H, Hu C, Liao J, Xiong Y, Idris AH. | Resuscitation.  2020 Apr;149:209-216
DOI: https://doi.org/10.1016/j.resuscitation.2020.01.009
Keywords: Adrenaline; Intraosseous; Intravenous; Out-of-hospital cardiac arrest; Outcomes.

Clinical papers

Introduction : Adrenaline is an important component in the resuscitation of individuals experiencing out-of-hospital cardiac arrest (OHCA). The 2018 Advanced Cardiac Life Support (ACLS) algorithm gives the option of either intravenous (IV) or intraosseous (IO) routes for adrenaline administration during cardiac arrest. However, the optimal route during prehospital resuscitation remains controversial. This study aims to investigate whether IV and IO routes lead to different outcomes in OHCA patients who received prehospital adrenaline.

Méthode : This retrospective analysis included adult patients with OHCA of presumed cardiac origin who had Emergency Medical Services (EMS) CPR, received adrenaline, and were enrolled in the Resuscitation Outcomes Consortium (ROC) Cardiac Epistry version 3 database between 2011 and 2015. We divided the study population into IV and IO groups based on the administration route. Logistic regression analysis was performed to evaluate the association between adrenaline delivery routes and prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and favorable neurological outcome.

Résultats : Of the 35,733 patients included, 27,758 (77.7%) had adrenaline administered via IV access and 7975 (22.3%) via IO access. With the IO group as a reference in the logistic regression model, the adjusted odds ratios of the IV group for prehospital ROSC, survival and favorable neurological outcome were 1.367 (95%CI, 1.276-1.464), 1.468 (95%CI, 1.264-1.705) and 1.849 (95%CI, 1.526-2.240), respectively. Similar results were found in the propensity score matched population and subgroup analysis.

Conclusion : Compared with the IO approach, the IV approach appears to be the optimal route for adrenaline administration in advanced life support for OHCA during prehospital resuscitation.

Conclusion (proposition de traduction) : Par rapport à l'approche intra-osseuse, l'approche intraveineuse semble être la voie optimale pour l'administration d'adrénaline dans le cadre d'une réanimation avancée en cas d'arrêt cardiaque hors hôpital lors d'une réanimation préhospitalière.

Effect of Controlled Sequential Elevation Timing of the Head and Thorax During Cardiopulmonary Resuscitation on Cerebral Perfusion Pressures in a Porcine Model of Cardiac Arrest.
Rojas-Salvador C, Moore JC, Salverda B, Lick M, Debaty G, Lurie KG. | Resuscitation.  2020 Apr;149:162-169
DOI: https://doi.org/10.1016/j.resuscitation.2019.12.011
Keywords: Active compression–decompression CPR; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral perfusion pressure; Coronary perfusion pressure; Head Up CPR; Head and thorax elevation; Impedance threshold device; Medical device; Patient positioning.

Experimental

Introduction : Controlled sequential elevation of the head and thorax (CSE) during active compression-decompression (ACD) CPR with an impedance threshold device (ITD) augments cerebral (CerPP) and coronary (CorPP) perfusion pressures. The optimal CSE is unknown.

Méthode : After 8 minutes of untreated VF, 40 kg anesthetized female pigs were positioned on a customized head and thorax elevation device (CED). After 2 min of automated ACD + ITD-16 CPR to 'prime the system', 12 pigs were randomized to CSE to the highest CED position over 4-min or 10-min. The primary outcome was CerPP after 7 minutes of CPR. Secondarily, 24-sec (without a priming step) and 2-min CSE times were similarly tested (n = 6 group) in a non-randomized order. Values expressed as mean ± SD.

Résultats : After 7 min of CPR, CerPPs were significantly higher in the 4-min vs 10-min CSE groups (53 ± 14.4 vs 38.5 ± 3.6 mmHg respectively, p = 0.03) whereas CorPP trended higher. The 4-min CSE group achieved 50% of baseline (50% BL) CerPP faster than the 10-min group (2.5 ± 1.2 vs 6 ± 3.1 minutes, p = 0.03). CerPP values in the 2-min and 4-min CSE groups were significantly higher than in the 24-sec group. With CSE, CerPPs and CorPPs increased over time in all groups.

Conclusion : By optimizing controlled sequential elevation timing, CerPP values achieved 50% of baseline within less than 2.5 minutes and >80% of baseline after 7 minutes of CPR. This novel CPR approach rapidly restored CerPPs to near normal values non-invasively and without vasopressors.

Conclusion (proposition de traduction) : En optimisant le temps d'élévation séquentielle contrôlée, les valeurs des pressions de perfusion cérébrale ont atteint 50% de la ligne de base en moins de 2,5 minutes et >80% de la ligne de base après 7 minutes de RCP. Cette nouvelle approche de RCP a rapidement rétabli la pression de la perfusion cérébrale à des valeurs proches de la normale, de manière non invasive et sans vasopresseurs.

Out-of-hospital Cardiac Arrest Across the World: First Report From the International Liaison Committee on Resuscitation (ILCOR).
Kiguchi T, Okubo M, Nishiyama C, Maconochie I, Ong MEH, Kern KB, Wyckoff MH, McNally B, Christensen E, Tjelmeland I, Herlitz J, Perkins GD, Booth S, Finn J, Shahidah N, Shin SD, Bobrow BJ, Morrison LJ, Salo A, Baldi E, Burkart R, Lin CH, Jouven X, Soar J, Nolan JP, Iwami T.. | Resuscitation.  2020 Apr 6:S0300-9572(20)30129-5
DOI: https://doi.org/10.1016/j.resuscitation.2020.02.044
Keywords: Epidemiology; Out-of-hospital cardiac arrest; Registry; Resuscitation; Utstein template.

Online ahead of print

Introduction : Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.

Méthode : We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.

Résultats : Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0 to 97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1% to 79.0% in all registries and 2.0% to 37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1% to 20.4% across all registries. Favourable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8% to 18.2%. Survival to hospital discharge or 30-day survival after bystander witnessed shockable OHCA ranged from 11.7% to 47.4% and favourable neurological outcome from 9.9% to 33.3%.

Conclusion : This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.

Conclusion (proposition de traduction) : Ce rapport de l'ILCOR décrit les données sur les systèmes de soins et les résultats à la suite d'un arrêt cardiaque extra-hospitalier provenant de neuf registres nationaux et sept registres régionaux à travers le monde. Nous avons constaté des variations dans les résultats de survie déclarés et d'autres éléments fondamentaux des recommandations actuelles de style Utstein pour l'arrêt cardiaque extra-hospitalier à travers les nations et les régions.

An Islamic Cultural Perspective of Family Presence during Resuscitation.
Othmana EH, Al Omar S, Abualruz H, Safadi R. | Resuscitation.  2020 April;
DOI: https://doi.org/doi:10.1016/j.resuscitation.2020.04.007  | Télécharger l'article au format  
Keywords: Aucun

To the editor

Editorial : Cardiac arrest followed by cardiopulmonary resuscitation (CPR) is a stressful situation that is frequently faced by healthcare providers (HCPs) and patient’s family. During CPR, nurses are challenged by a controversy of either allowing the family members to attend the resuscitation or to leave the room.

Conclusion : In cases of anticipated cardiopulmonary resuscitation, healthcare providers should assess the expectations, perceptions, values, and beliefs of the family members regarding attending cardiopulmonary resuscitation. One staff member should stay with family to console them, give support, and allow those who are willing to attend. Allowing a family member to witness cardiopulmonary resuscitation provides a successful way of communicating the event to other family members. When a patient survives cardiopulmonary resuscitation, the family witness will relay the heroic performance of healthcare providers to the patient and the family.

Conclusion (proposition de traduction) : En cas de réanimation cardio-pulmonaire prévisible, les prestataires de soins de santé devraient évaluer les attentes, les perceptions, les valeurs et les croyances des membres de la famille concernant la réanimation cardio-pulmonaire. Un membre du personnel doit rester avec sa famille pour les consoler, apporter son soutien et permettre à ceux qui sont prêts à y assister. Permettre à un membre de la famille d'assister à la réanimation cardio-pulmonaire est un moyen efficace de communiquer l'événement aux autres membres de la famille. Lorsqu'un patient survit à une réanimation cardio-pulmonaire, le témoin familial transmet la performance héroïque des prestataires de soins au patient et à la famille.

Which intravascular access should we use in patients with suspected/confirmed COVID-19?.
J. Smereka, L. Szarpak, K.J. Filipiak. | Resuscitation.  2020 April;
DOI: https://doi.org/10.1016/j.resuscitation.2020.04.014  | Télécharger l'article au format  
Keywords: Aucun

Letter to the Editor

Editorial : The current SARS-CoV-2 pandemic is challenging the healthcare system around the world. Control of the pandemic is based on isolation, social distancing, the use of personal protective equipment (PPE), as well as testing to detect the virus, which results make it possible to isolate COVID-19 positive patients.

Conclusion : To summarize, medical personnel dressed in full protective gear as the preferred method of gaining intravascular access in patients with suspected/confirmed COVID-19 should choose intraosseous access.

Conclusion (proposition de traduction) : Pour résumer, le personnel médical vêtu d'un équipement de protection complet est la méthode privilégiée pour obtenir un accès intravasculaire chez les patients dont la COVID-19 est suspecte/confirmée et qui doivent choisir un accès intra-osseux.

COVID-19 in cardiac arrest and infection risk to rescuers: a systematic review.
Couper K, Taylor-Phillips S, Grove A, Freeman K, Osokogu O, Court R and al. | Resuscitation.  2020 Apr 22;
DOI: https://doi.org/10.1016/j.resuscitation.2020.04.022  | Télécharger l'article au format  
Keywords: COVID-19; Coronavirus; Infection transmission; Aerosol; Personal protective equipment; Cardiopulmonary resuscitation; Chest compression; Defibrillation

Article in Press

Introduction : There may be a risk of COVID-19 transmission to rescuers delivering treatment for cardiac arrest. The aim of this review was to identify the potential risk of transmission associated with key interventions (chest compressions, defibrillation, cardiopulmonary resuscitation) to inform international treatment recommendations.

Méthode : We undertook a systematic review comprising three questions: 1) aerosol generation associated with key interventions; 2) risk of airborne infection transmission associated with key interventions; and 3) the effect of different personal protective equipment strategies. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and the World Health Organisation COVID-19 database on 24th March 2020. Eligibility criteria were developed individually for each question. We assessed risk of bias for individual studies, and used the GRADE process to assess evidence certainty by outcome.

Résultats : We included eleven studies: two cohort studies, one case control study, five case reports, and three manikin randomised controlled trials. We did not find any direct evidence that chest compressions or defibrillation either are or are not associated with aerosol generation or transmission of infection. Data from manikin studies indicates that donning of personal protective equipment delays treatment delivery. Studies provided only indirect evidence, with no study describing patients with COVID-19. Evidence certainty was low or very low for all outcomes.

Conclusion : It is uncertain whether chest compressions or defibrillation cause aerosol generation or transmission of COVID-19 to rescuers. There is very limited evidence and a rapid need for further studies.

Conclusion (proposition de traduction) : Il n'est pas certain que les compressions thoraciques ou la défibrillation provoquent la génération d'aérosols ou la transmission du COVID-19 aux sauveteurs. Il existe des preuves très limitées et un besoin rapide d'études complémentaires.

Commentaire : Pas de certitude sur une éventuelle transmission virale aux sauveteurs (le principe de précaution devrait s'appliquer dans ce cas), toutefois les données des études sur les mannequins indiquent que le port de l'équipement de protection individuelle retarde la mise en oeuvre de la réanimation cardiopulmonaire.

Characteristics of Paediatric Out-of-hospital Cardiac Arrest in the United States.
Okubo M, Chan HK, Callaway CW, Mann NC, Wang HE. | Resuscitation.  2020 Apr 26:S0300-9572(20)30160-X
DOI: https://doi.org/10.1016/j.resuscitation.2020.04.023
Keywords: Cardiopulmonary resuscitation; Emergency medical service; Paediatric out-of-hospital cardiac arrest.

Article in Press

Introduction : The absence of nationwide surveillance data on out-of-hospital cardiac arrest (OHCA) in the United States (US) limits understanding of the epidemiology of paediatric OHCA. We investigated the national characteristics of paediatric OHCA using the National Emergency Medical Services Information System (NEMSIS).

Méthode : We conducted a cross-sectional study using the 2016 NEMSIS dataset, a national registry of emergency medical services (EMS) activations at 46 states in the US. We included paediatric patients (age <18 years) with "9-1-1" EMS responses to OHCA. We defined OHCA as a) presence of cardiac arrest; b) EMS reported initiation of cardiac arrest resuscitation; c) performance of chest compressions; or d) performance of defibrillation. We reported the incidence and characteristics of paediatric OHCA, stratified by age group: <1 year: infants, 1-5 years: young children, 6-12 years: older children, and 13-17 years: adolescents.

Résultats : Among 1,531,469 paediatric EMS responses, we identified a total of 23,514 EMS responses to paediatric OHCA (95% confidence interval [CI], 23,217-23,814), incidence of 15.4 per 1,000 paediatric EMS responses (95% CI, 15.2-15.5), and estimated national incidence of 37.9 per 100,000 child-years (95% CI, 37.4-38.4). Among 23,514 EMS responses to paediatric OHCA, we observed 4,515 (19.2%) of EMS responses in infants, 5,588 (23.8%) in young children, 4,976 (21.2%) in older children, and 8,435 (35.9%) in adolescents.

Conclusion : Using data from the NEMSIS, we estimate that there are over 23,000 annual paediatric OHCA in the US. These data provide key insights of paediatric OHCA in the US.

Conclusion (proposition de traduction) : En utilisant les données de NEMSIS, nous estimons qu'il y a plus de 23 000 arrêts cardiaques extra-hospitaliers pédiatriques annuels aux États-Unis. Ces données fournissent des informations clés sur l'arrêt cardiaque extra-hospitalier pédiatrique aux États-Unis.

The American Journal of Emergency Medicine

Adoption of low tidal volume ventilation in the emergency department: A quality improvement intervention.
Prekker ME, Donelan C, Ambur S, Driver BE, O'Brien-Lambert A, Hottinger DG, Adams AB. | Am J Emerg Med.  2020 Apr;38(4):763-767
DOI: https://doi.org/10.1016/j.ajem.2019.06.026
Keywords: Emergency department; Mechanical ventilation; Quality improvement; Tidal volume.

Original Contribution

Introduction : Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation.

Méthode : In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists.

Résultats : Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW).

Conclusion : Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.

Conclusion (proposition de traduction) : L'association d'un protocole d'initiation au ventilateur avec une formation et des ressources ciblées pour les médecins d'urgence et les inhalothérapeutes a été associée à une réduction significative du volume courant administré aux patients aux urgences.

Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study.
Yamanaka S, Goldman RD, Goto T, Hayashi H. | Am J Emerg Med.  2020 Apr;38(4):768-773
DOI: https://doi.org/10.1016/j.ajem.2019.06.028
Keywords: Aucun

Original contribution

Introduction :  Multiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization.

Méthode : We conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED.

Résultats : Of 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1-0.45, p < 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24-2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93-0.98, p < 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04-0.56, p < 0.01) were independent prognostic variables.

Conclusion : We found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization.

Conclusion (proposition de traduction) : ous avons constaté que de multiples tentatives d'intubation n'étaient pas associées à une augmentation de la mortalité et de la morbidité pendant l'hospitalisation.

The effects of emergency department crowding on triage and hospital admission decisions.
hen W, Linthicum B, Argon NT, Bohrmann T, Lopiano K, Mehrotra A, Travers D, Ziya S. | Am J Emerg Med.  2020 Apr;38(4):774-779
DOI: https://doi.org/10.1016/j.ajem.2019.06.039
Keywords: Admission decision; Crowding; Triage.

Original contribution

Introduction : Emergency department (ED) crowding is a recognized issue and it has been suggested that it can affect clinician decision-making.
Objectives: Our objective was to determine whether ED census was associated with changes in triage or disposition decisions made by ED nurses and physicians.

Méthode : We performed a retrospective study using one year of data obtained from a US academic center ED (65,065 patient encounters after cleaning). Using a cumulative logit model, we investigated the association between a patient's acuity group (low, medium, and high) and ED census at triage time. We also used multivariate logistic regression to investigate the association between the disposition decision for a patient (admit or discharge) and the ED census at the disposition decision time. In both studies, control variables included census, age, gender, race, place of treatment, chief complaint, and certain interaction terms.

Résultats : We found statistically significant correlation between ED census and triage/disposition decisions. For each additional patient in the ED, the odds of being assigned a high acuity versus medium or low acuity at triage is 1.011 times higher (95% confidence interval [CI] for Odds Ratio [OR] = [1.009,1.012]), and the odds of being assigned medium or high acuity versus low acuity at triage is 1.009 times higher (95% CI for OR = [1.008,1.010]). Similarly, the odds of being admitted versus discharged increases by 1.007 times (95% CI for OR = [1.006,1.008]) per additional patient in the ED at the time of disposition decision.

Conclusion : Increased ED occupancy was found to be associated with more patients being classified as higher acuity as well as higher hospital admission rates. As an example, for a commonly observed patient category, our model predicts that as the ED occupancy increases from 25 to 75 patients, the probability of a patient being triaged as high acuity increases by about 50% and the probability of a patient being categorized as admit increases by around 25%.

Conclusion (proposition de traduction) : L'augmentation du taux d'occupation des urgences était associée à un plus grand nombre de patients classés comme ayant une gravité plus élevée ainsi qu'à des taux d'admission à l'hôpital plus élevés. À titre d'exemple, pour une catégorie de patients couramment observée, notre modèle prédit qu'à mesure que le taux d'occupation des urgences augmente de 25 à 75 patients, la probabilité qu'un patient soit trié comme une gravité élevée augmente d'environ 50 % et la probabilité qu'un patient soit classé comme devant être hospitalisé en service augmente d'environ 25 %.

The utility of S100B level in detecting mild traumatic brain injury in intoxicated patients.
Rahimian S, Potteiger S, Loynd R, Mercogliano C, Sigal A, Short A, Donato A. | Am J Emerg Med.  2020 Apr;38(4):799-805
DOI: https://doi.org/10.1016/j.ajem.2019.12.004
Keywords: Intoxicated; Mild traumatic brain injury; S100B.

Brief Reports

Introduction : S100B is a serum protein known to elevate in patients with brain injury, but it is unknown whether it can predict intracranial pathology in intoxicated patients following mild traumatic brain injury (MTBI). We performed a systematic review and meta-analysis of the English language literature to address this question.

Résultats : Four prospective cohort trials of serum S100B levels on acutely intoxicated patients with MTBI were included in this meta-analysis. Prevalence of intracranial pathology in the pooled cohort of the intoxicated MTBI patients was 10%, lower than the 15-30% reported in the literature for the general MTBI population. Standard mean difference of serum S100B levels between patients with and without intracranial pathology on CT was 0.73 μg/L (Z = 18.33, P < 0.001). Following sensitivity analysis and hierarchical summary receiver-operating characteristic models, three remaining articles were used for pooled estimates that found that S100B had a sensitivity of 0.96 (95% CI: 0.84-1.00, I2 = 0%) and specificity of 0.63 (95% CI: 0.58-0.68, I2 = 86.8%) with a high negative predictive value (100%, 95% CI: 95.14-100, I2 = 0%) and a negative LR of 0.06 (95% CI: 0.01-0.31).

Conclusion : Serum S100B levels may have utility in ruling out intracranial pathology in intoxicated patients, however more study and comparison with other serum biomarkers of brain injury are necessary before this becomes the accepted standard of care.

Conclusion (proposition de traduction) : Les taux sériques de S100B peuvent avoir une utilité pour exclure une pathologie intracrânienne chez les patients en état d'ébriété, mais plus d'études et de comparaisons avec d'autres biomarqueurs sériques des lésions cérébrales sont nécessaires avant que cela ne devienne la norme de soins validée.

Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: A randomized controlled trial.
Moussa M, Papatsoris AG, Chakra MA. | Am J Emerg Med.  2020 Apr 29:S0735-6757(20)30309-0
DOI: https://doi.org/10.1016/j.ajem.2020.04.079
Keywords: Diclofenac; Renal colic; Sterile water injection.

ARTICLES IN PRESS

Introduction : We aimed to evaluate the efficacy of intracutaneous sterile water injection (ISWI) to relieve the pain of acute renal colic compared with diclofenac and placebo.

Méthode : The study included 150 patients presented to the Emergency Department with renal colic randomized into 3 groups: control group received intracutaneous injections of 0.5 cm3 isotonic saline in the flank, group A received intracutaneous injections of 0.5 cm3 ISWI in the flank, and group B received an intramuscular injection of 75 mg Diclofenac in the gluteal region. The severity of the pain was assessed by a visual analogue scale system at baseline and 30, 45 min, and 60 min after injections. Subjects with inadequate pain relief at 1 h received rescue analgesia.

Résultats : The mean baseline pain score was 9.6 ± 0.61 in the ISWI group, 9.72 ± 0.64 in the diclofenac group and 9.26 ± 0.89 in the control group. The mean pain score at 30 min of the control group was reduced to 6.9 ± 1.56. This mean at 30 min after ISWI and diclofenac injections were reduced to 1.98 ± 1.41 and 1.88 ± 1.19 respectively. The mean of pain sore of the ISWI and diclofenac group at 45 and 60 min was constant. Rescue analgesics at 1 h were required by 47 patients receiving the saline injection and by 4 patients and by 7 patients receiving ISWI and diclofenac injection respectively.

Conclusion : ISWI and diclofenac were equally effective for the pain relief of acute renal colic.

Conclusion (proposition de traduction) : L'injection d'eau stérile intradermique et le diclofénac étaient également efficaces pour le soulagement de la douleur des coliques rénales aiguës.

Commentaire : Voir la correspondance :
Aras B, Uruç F. Intradermal sterile water injection for acute renal colic pain. Am J Emerg Med. 2020 Sep;38(9):1938  .

Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study.
Lin J, Figuerado Y, Montgomery A, Lee J, Cannis M, Norton VC, Calvo R, Sikand H. | Am J Emerg Med.  2020 Apr 11:S0735-6757(20)30241-2
DOI: https://doi.org/10.1016/j.ajem.2020.04.013
Keywords: Agitation; Haloperidol; Ketamine; Lorazepam; Sedation.

Article

Introduction : Clinicians often encounter agitated patients, and current treatment options include benzodiazepines and antipsychotics. Ketamine rapidly induces dissociation, maintains cardiovascular stability, spontaneous respirations, and airway reflexes. There are no prospective, randomized studies comparing ketamine to other agents in the initial management of acute agitation in the Emergency Department (ED).
Objective: Determine the efficacy and safety of ketamine compared to parenteral haloperidol plus lorazepam for initial control of acute agitation.

Méthode : This study was a prospective, single-institution, randomized, open-label, real world, standard of care pilot study. Adult patients with combative agitation were randomized to ketamine (4 mg/kg IM or 1 mg/kg IV) or haloperidol/lorazepam (haloperidol 5-10 mg IM or IV + lorazepam 1-2 mg IM or IV). The primary outcome was sedation within 5 min, and secondary outcomes included sedation within 15 min, time to sedation, and safety.

Résultats : Ninety three patients were enrolled from January 15, 2018 to October 10, 2018. Significantly more patients who received ketamine compared to haloperidol/lorazepam were sedated within 5 min (22% vs 0%, p = 0.001) and 15 min (66% vs 7%, p < 0.001). The median time to sedation in patients who received ketamine compared to haloperidol/lorazepam was 15 vs 36 min respectively (p < 0.001). Patients who received ketamine experienced a significant, but transient tachycardia (p = 0.01) and hypertension (p = 0.01).

Conclusion : In patients with combative agitation, ketamine was significantly more effective than haloperidol/lorazepam for initial control of acute agitation, and was not associated with any significant adverse effects.

Conclusion (proposition de traduction) : Chez les patients présentant une agitation avec hétéroagressivité, la kétamine s'est avérée significativement plus efficace que l'halopéridol/lorazépam pour le contrôle initial de l'agitation aiguë et n'a été associée à aucun effet indésirable significatif.

The International Journal of Surgery

Evidence Based Management Guideline for the COVID-19 Pandemic - Review Article.
Nicola M, O'Neill N, Sohrabi C, Khan M, Agha M, Agha R. | Int J Surg.  2020 Apr 11:S1743-9191(20)30284-3
DOI: https://doi.org/10.1016/j.ijsu.2020.04.001  | Télécharger l'article au format  
Keywords: Aucun

Online ahead of print

Editorial : COVID-19 has now been declared a pandemic. To date, COVID-19 has affected over 944,181 people worldwide, resulting in over 47,312 reported deaths. Numerous preventative strategies and non-pharmaceutical interventions have been employed to mitigate the spread of disease including careful infection control, the isolation of patients, and social distancing. Management is predominantly focused on the provision of supportive care, with oxygen therapy representing the major treatment intervention. Medical therapy involving corticosteroids and antivirals have also been encouraged as part of critical management schemes. However, there is at present no specific antiviral recommended for the treatment of COVID-19, and no vaccine is currently available. Despite the strategic implementation of these measures, the number of new reported cases continues to rise at a profoundly alarming rate. As new findings emerge, there is an urgent need for up-to-date management guidelines. In response to this call, we review what is currently known regarding the management of COVID-19, and offer an evidence-based review of current practice.

Conclusion : With over 76,836 new cases confirmed on 1st April 2020 alone (69), there are fears that these findings could indicate exponential spread of the disease. Implementation and adherence to tighter restrictions of social distancing to suppress and mitigate the spread of COVID-19 will prove to be crucial in the months to come. Up-to-date, evidence-based guidelines for acute management of COVID-19 are imperative to guide clinicians through the rapidly evolving pandemic. As new evidence emerges, it is imperative that current and potential treatment options are frequently re-evaluated in order to offer the best possible care under such unprecedented circumstances.

Conclusion (proposition de traduction) : Avec plus de 76 836 nouveaux cas confirmés au 1er avril 2020 seulement, on craint que ces résultats n'indiquent une propagation exponentielle de la maladie. La mise en œuvre et le respect de restrictions plus strictes de l'éloignement social pour supprimer et atténuer la propagation du COVID-19 s'avéreront cruciaux dans les mois à venir. Des lignes directrices à jour et fondées sur des données probantes pour la prise en charge aiguë du COVID-19 sont impératives pour guider les cliniciens à travers l'évolution rapide de la pandémie. Au fur et à mesure que de nouvelles preuves émergent, il est impératif que les options de traitement actuelles et potentielles soient fréquemment réévaluées afin d'offrir les meilleurs soins possibles dans de telles circonstances sans précédent.

The Journal of Emergency Medicine

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures.
Topal FE, Bilgin S, Yamanoglu A, Karakaya Z, Payza U, Akyol PY, Aslan C, Aksun M. | J Emerg Med.  2020 Apr;58(4):553-561
DOI: https://doi.org/10.1016/j.jemermed.2019.12.033
Keywords: analgesia; bedside ultrasound; pain control; regional block; ultrasound-guided femoral nerve block.

Original Contribution

Introduction : The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management.
Objectives: The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED.

Méthode : Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction.

Résultats : Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups.

Conclusion : The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.

Conclusion (proposition de traduction) : L'administration de 5 mL de prilocaïne à 2 % pour le contrôle de la douleur dans les fractures du col du fémur chez les patients âgés au service des urgences peut réduire les besoins analgésiques systémiques en établissant une analgésie efficace dans les fractures intracapsulaires et extracapsulaires.

Evaluation of Spodick's Sign and Other Electrocardiographic Findings as Indicators of STEMI and Pericarditis.
Witting MD, Hu KM, Westreich AA, Tewelde S, Farzad A, Mattu A. | J Emerg Med.  2020 Apr;58(4):562-569
DOI: https://doi.org/10.1016/j.jemermed.2020.01.017
Keywords: ST elevation myocardial infarction; chest pain; electrocardiography; emergency service; hospital; pericarditis.

original contribution

Introduction : Patients with ST elevation on electrocardiogram (ECG) could have ST elevation myocardial infarction (STEMI) or pericarditis. Spodick's sign, a downsloping of the ECG baseline (the T-P segment), has been described, but not validated, as a sign of pericarditis. Objective: This study estimates the frequency of Spodick's sign and other findings in patients diagnosed with STEMI and those with pericarditis.

Méthode : In this retrospective review, we selected charts that met prospective definitions of STEMI (cases) and pericarditis (controls). We excluded patients whose ECGs lacked ST elevation. An authority on electrocardiography reviewed all ECGs, noting the presence or absence of Spodick's sign, ST depression (in leads besides V1 and aVR), PR depression, greater ST elevation in lead III than in lead II (III > II), abrupt take-off of ST segment (the RT checkmark sign), and upward or horizontal ST convexity. We quantified strength of association using odds ratio (OR) with 95% confidence interval (CI).

Résultats : One hundred and sixty-five patients met criteria for STEMI and 42 met those for pericarditis. Spodick's sign occurred in 5% of patients with STEMI (95% CI 3-10%) and 29% of patients with pericarditis (95% CI 16-45%). All other findings statistically distinguished STEMI from pericarditis, but ST depression (OR 31), III > II (OR 21), and absence of PR depression (OR 12) had the greatest OR values.

Conclusion : Spodick's sign is statistically associated with pericarditis, but it is seen in 5% of patients with STEMI. Among other findings, ST depression, III > II, and absence of PR depression were the most discriminating.

Conclusion (proposition de traduction) : Le signe de Spodick est statistiquement associé à la péricardite, mais il est observé chez 5 % des patients présentant un STEMI.
Parmi les autres signes, le sous-décalage du ST en DIII > DII et l'absence de sous-décalage du PR étaient les plus discriminantes.

Commentaire : 

Shoulder Dislocations in the Emergency Department: A Comprehensive Review of Reduction Techniques.
Gottlieb M | J Emerg Med.  2020 Apr;58(4):647-666
DOI: https://doi.org/10.1016/j.jemermed.2019.11.031
Keywords: dislocation; glenohumeral; reduction; relocation; shoulder

Techniques and Procedures

Introduction : Shoulder dislocations are a common presentation to the emergency department and one of the most frequent types of joint dislocations. Studies have found that delays from presentation to first reduction attempt and failed attempt at initial reduction are associated with lower rates of overall reduction success.

Discussion : This article reviews 26 total reduction techniques, as well as a variety of modifications to these techniques. Each technique has distinct advantages and limitations associated with its use. While there are limited data comparing specific techniques, the individual success rates of most maneuvers range from 60-100%.

Conclusion : It is essential for emergency physicians to be familiar with multiple different reduction techniques in case the initial reduction attempt is unsuccessful or patient-specific characteristics limit the ability to perform certain techniques. This article reviews several reduction maneuvers for shoulder dislocations, variations on these techniques, and advantages and disadvantages for each approach. It is intended to serve as a resource for those interested in expanding their knowledge of shoulder reduction techniques.

Conclusion (proposition de traduction) : Il est essentiel que les médecins urgentistes se familiarisent avec plusieurs techniques de réduction différentes au cas où la tentative de réduction initiale échouerait ou que les caractéristiques propres au patient limitent la capacité à exécuter certaines techniques. Cet article passe en revue plusieurs manœuvres de réduction pour les luxations de l'épaule, les variations de ces techniques et les avantages et inconvénients de chaque approche. Il est destiné à servir de ressource pour ceux qui souhaitent approfondir leurs connaissances sur les techniques de réduction des épaules.

Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee.
Rowland KD, Fuehrer J, Motov SM, Vilke G, Rosenbaum SB, Quenzer F. | J Emerg Med.  2020 Apr;58(4):706-709
DOI: https://doi.org/10.1016/j.jemermed.2019.12.024
Keywords: adverse effects of opioids; antiemetics; metoclopramide; ondansetron; opioid-induced nausea and vomiting; opioids; prophylactic antiemetics.

AAEM Clinical Practice

Introduction : It is common practice for emergency physicians to give parenteral opioids for acute pain, however, some treating physicians have concerns that using parenteral opioids can lead to nausea and vomiting when used alone. Therefore, antiemetics are often given prophylactically with opioids for nausea and vomiting in the emergency department (ED). This systematic review evaluates the use of prophylactic antiemetics with parenteral opioids for the treatment of acute pain in the ED.

Méthode : A 10-year literature search using keywords was performed in PubMed for English-language human studies. Abstracts were screened to identify high-quality studies, which then underwent a more rigorous structured review. The recommendations are made based on the literature review.

Résultats : Eight articles met criteria for structured review and citation in this article. These include one review article, two randomized controlled trials, three prospective observational trials, one retrospective study, and one pre- and post-intervention trial.

Conclusion : Based on the literature review, routine use of prophylactic antiemetics are not indicated with administration of parenteral opioids for treatment of acute pain in the ED, as nausea and vomiting are infrequent side effects. The recent literature clearly demonstrates that there are potential undesirable side effects from the use of antiemetics when using opioids. However, one subgroup of patients, those with a known history of nausea and vomiting after opioid use or a history of travel sickness, may benefit from the use of prophylactic antiemetic when being treated with parenteral opioids.

Conclusion (proposition de traduction) : D'après la revue de la littérature, l'utilisation systématique d'antiémétiques prophylactiques n'est pas indiquée lors de l'administration d'opioïdes parentéraux pour le traitement de la douleur aiguë au service des urgences, car les nausées et les vomissements sont des effets secondaires peu fréquents. La littérature récente démontre clairement qu'il existe des effets secondaires indésirables potentiels liés à l'utilisation d'antiémétiques lors de l'utilisation d'opioïdes. Cependant, un sous-groupe de patients, ceux ayant des antécédents connus de nausées et de vomissements après l'utilisation d'opioïdes ou des antécédents de mal des transports, peuvent bénéficier de l'utilisation d'un antiémétique prophylactique lorsqu'ils sont traités par opioïdes parentéraux.

The Lancet Respiratory Medicine

COVID-19: Respiratory support outside the intensive care unit.
McEnery T, Gough C, Costello RW. | Lancet Respir Med.  2020 Apr;
DOI: https://doi.org/10.1016/s2213-2600(20)30176-4  | Télécharger l'article au format  
Keywords: Aucun

Comment

Editorial : The optimal mode of respiratory support for individuals with severe coronavirus disease 2019 (COVID-19) before invasive mechanical ventilation (IMV) is currently a subject of much debate. Recently published guidelines1 and a Comment differ substantially to other guidelines in this regard, with some advocating high flow nasal cannulae (HFNC) over non-invasive ventilation (NIV) or vice versa (NHS guidance). This debate is understandable given the paucity of data and need for rapid generation of guidance, but it is a cause of confusion among respiratory physicians.

Conclusion : The debate about the optimal mode of respiratory support before invasive mechanical ventilation in AHRF has not been settled, much less in the setting of coronavirus, and it is important to note that harm can be caused if inappropriate treatment is used. Evidence from China suggests that a large minority of patients with severe respiratory failure due to SARS coronavirus 2 (SARS-CoV-2) can avoid intubation via use of non-invasive ventilation however. non-invasive ventilation is a well-established therapy with which general respiratory physicians and nurses are familiar, and which is readily applicable in the non-critical care setting. Caveats would include careful patient selection so as not to delay invasive mechanical ventilation where appropriate, modified settings specific to the pathophysiology of COVID-19, and mitigation against infection transmission by aerosol.

Conclusion (proposition de traduction) : Le débat sur le mode optimal de soutien respiratoire avant la ventilation mécanique invasive dans la BPCO n'est pas réglé, encore moins dans le contexte du coronavirus, et il est important de noter que des dommages peuvent être causés si un traitement inapproprié est utilisé. Les preuves en provenance de Chine suggèrent qu'une large minorité de patients souffrant d'insuffisance respiratoire sévère due au coronavirus SRAS 2 (SARS-CoV-2) peuvent cependant éviter l'intubation via l'utilisation d'une ventilation non invasive. la ventilation non invasive est une thérapie bien établie avec laquelle les médecins généralistes et les infirmières sont familiers et qui est facilement applicable dans le cadre des soins non critiques. Les mises en garde devraient inclure une sélection soigneuse des patients afin de ne pas retarder la ventilation mécanique invasive, le cas échéant, des paramètres modifiés spécifiques à la physiopathologie du COVID-19, et l'atténuation de la transmission des infections par aérosol.

The New England Journal of Medicine

Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer.
Agnelli G, Becattini C, Meyer G, Muñoz A, Huisman MV, Connors JM, Cohen A, Bauersachs R, Brenner B, Torbicki A, Sueiro MR, Lambert C, Gussoni G, Campanini M, Fontanella A, Vescovo G, Verso M; Caravaggio Investigators. | N Engl J Med.  2020 Apr 23;382(17):1599-1607
DOI: https://doi.org/10.1056/nejmoa1915103
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Recent guidelines recommend consideration of the use of oral edoxaban or rivaroxaban for the treatment of venous thromboembolism in patients with cancer. However, the benefit of these oral agents is limited by the increased risk of bleeding associated with their use.

Méthode : This was a multinational, randomized, investigator-initiated, open-label, noninferiority trial with blinded central outcome adjudication. We randomly assigned consecutive patients with cancer who had symptomatic or incidental acute proximal deep-vein thrombosis or pulmonary embolism to receive oral apixaban (at a dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily) or subcutaneous dalteparin (at a dose of 200 IU per kilogram of body weight once daily for the first month, followed by 150 IU per kilogram once daily). The treatments were administered for 6 months. The primary outcome was objectively confirmed recurrent venous thromboembolism during the trial period. The principal safety outcome was major bleeding.

Résultats : Recurrent venous thromboembolism occurred in 32 of 576 patients (5.6%) in the apixaban group and in 46 of 579 patients (7.9%) in the dalteparin group (hazard ratio, 0.63; 95% confidence interval [CI], 0.37 to 1.07; P<0.001 for noninferiority). Major bleeding occurred in 22 patients (3.8%) in the apixaban group and in 23 patients (4.0%) in the dalteparin group (hazard ratio, 0.82; 95% CI, 0.40 to 1.69; P = 0.60).

Conclusion : Oral apixaban was noninferior to subcutaneous dalteparin for the treatment of cancer-associated venous thromboembolism without an increased risk of major bleeding.

Conclusion (proposition de traduction) : L'apixaban (Eliquis®) par voie orale n'était pas inférieur à la daltéparine (Fragmine®) sous-cutanée pour le traitement de la thrombophlébite veineuse associée au cancer sans risque accru de saignement majeur.

Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy.
Baldi E, Sechi GM, Mare C, Canevari F, Brancaglione A, Primi R, Klersy C, Palo A, Contri E, Ronchi V, Beretta G, Reali F, Parogni P, Facchin F, Bua D, Rizzi U, Bussi D, Ruggeri S, Oltrona Visconti L, Savastano S; Lombardia CARe Researchers. | N Engl J Med.  2020 Apr 29:NEJMc2010418
DOI: https://doi.org/10.1056/nejmc2010418  | Télécharger l'article au format  
Keywords: Aucun

Correspondance

Editorial : Despite the risk of rapid respiratory failure and cardiac complications due to Covid-19, it is unclear whether there is an association between Covid-19 and out-of-hospital cardiac arrest. The Lombardy region of Italy was among the first areas to have an outbreak of Covid-19 outside China, and the first case there was diagnosed on February 20, 2020, in Lodi Province.

Conclusion : A total of 103 patients who had out-of-hospital cardiac arrest were suspected to have or had received a diagnosis of Covid-19 (87 and 16 patients, respectively); these numbers account for 77.4% of the increase in cases of out-of-hospital cardiac arrest observed in these provinces in 2020.

Conclusion (proposition de traduction) : Au total, 103 patients ayant subi un arrêt cardiaque extra-hospitalier étaient soupçonnés d'avoir ou avaient reçu un diagnostic de Covid-19 (87 et 16 patients, respectivement) ; ces chiffres représentent 77,4 % de l'augmentation des cas d'arrêt cardiaque extra-hospitalier observés dans ces provinces en 2020.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Ile-de-France : doublement des arrêts cardiaques extra-hospitaliers pendant le confinement  . Rédigé par le Dr Jean-Pierre Usdin le 2 juin 2020.


Mois d'avril 2020