Outcomes With the Use of Bag-Valve-Mask Ventilation During Out-of-hospital Cardiac Arrest in the Pragmatic Airway Resuscitation Trial.
Lupton JR, Schmicker RH, Stephens S, Carlson JN, Callaway C, Herren H, Idris AH, Sopko G, Puyana JCJ, Daya MR, Wang H, Hansen M. | Acad Emerg Med. 2020 May;27(5):366-374
DOI: https://doi.org/10.1111/acem.13927  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTIONS

Introduction : While emergency medical services (EMS) often use endotracheal intubation (ETI) or supraglottic airways (SGA), some patients receive only bag-valve-mask (BVM) ventilation during out-of-hospital cardiac arrests (OHCA). Our objective was to compare patient characteristics and outcomes for BVM ventilation to advanced airway management (AAM) in adults with OHCA.

Méthode : Using data from the Pragmatic Airway Resuscitation Trial, we identified patients receiving AAM (ETI or a SGA), BVM ventilation only (BVM-only), and BVM ventilation as a rescue after at least one failed attempt at advanced airway placement (BVM-rescue). The outcomes were return of spontaneous circulation (ROSC), 72-hour survival, survival to hospital discharge, neurologically intact survival (Modified Rankin Scale ≤ 3), and the presence of aspiration on a chest radiograph. Comparisons were made using generalized mixed-effects models while adjusting for age, sex, initial rhythm, EMS-witnessed status, bystander cardiopulmonary resuscitation, response time, study cluster, and advanced life support first on scene.

Résultats : Of 3,004 patients enrolled, there were 282 BVM-only, 2,129 AAM, and 156 BVM-rescue patients with complete covariates. Shockable initial rhythms (34% vs. 18.6%) and EMS-witnessed arrests (21.6% vs. 11.3%) were more likely in BVM-only than AAM but similar between BVM-rescue and AAM. Compared to AAM, BVM-only patients had similar ROSC (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 0.96 to 1.73), but higher 72-hour survival (OR = 1.96, 95% CI = 1.42 to 2.69), survival to discharge (OR = 4.47, 95% CI = 3.03 to 6.59), and neurologically intact survival (OR = 7.05, 95% CI = 4.40 to 11.3). Compared to AAM, BVM-rescue patients had similar ROSC (OR = 0.73, 95% CI = 0.47 to 1.12) and 72-hour survival (OR = 1.08, 95% CI = 0.66 to 1.77) but higher survival to discharge (OR = 2.15, 95% CI = 1.17 to 3.95) and neurologically intact survival (OR = 2.64, 95% CI = 1.20 to 5.81). Aspiration incidence was similar.

Conclusion : Bag-valve-mask-only ventilation is associated with improved OHCA outcomes. Despite similar rates of ROSC and 72-hour survival, BVM-rescue ventilation was associated with improved survival to discharge and neurologically intact survival compared to successful AAM.

Conclusion (proposition de traduction) : La ventilation avec un insufflateur à valve unidirectionnelle est associée à de meilleurs résultats en matière d'arrêt cardiaque extra-hospitalier. Malgré des taux similaires de récupération cardiaque spontanée et de survie à 72 heures similaire, la ventilation de sauvetage par masque à valve avec réservoir a été associée à une amélioration de la survie jusqu'à la sortie et à une survie neurologiquement de qualité par rapport à la gestion avancée des voies aériennes.

Commentaire : Résultats différents de ceux trouvés par une étude française randomisée, coordonnée par le Pr Frédérique Adnet :
Jabre P, Penaloza A, Pinero D, Duchateau FX, Borron SW, Javaudin F, Richard O, de Longueville D, Bouilleau G, Devaud ML, Heidet M, Lejeune C, Fauroux S, Greingor JL, Manara A, Hubert JC, Guihard B, Vermylen O, Lievens P, Auffret Y, Maisondieu C, Huet S, Claessens B, Lapostolle F, Javaud N, Reuter PG, Baker E, Vicaut E, Adnet F. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018 Feb 27;319(8):779-787  . doi: 10.1001/jama.2018.0156. PMID: 29486039; PMCID: PMC5838565.

Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post-CRASH-2 Era.
Erramouspe PJ, García-Pintos MF, Benipal S, Manoukian MAC, Santamarina JL, Shawagga HG, Vo LL, Galante JM, Nishijima D. | Acad Emerg Med. 2020 May;27(5):358-365
DOI: https://doi.org/10.1111/acem.13883  | Télécharger l'article au format  
Keywords: Aucun

Original Contribution

Introduction : The CRASH-2 trial demonstrated that tranexamic acid (TXA) in adults with significant traumatic hemorrhage safely reduces mortality. Given that the CRASH-2 trial did not include U.S. sites, our objective was to evaluate patient characteristics, TXA dosing strategies, and the incidence of mortality and adverse events in adult trauma patients receiving TXA at a U.S. Level I trauma center in the post-CRASH-2 era.

Méthode : We conducted a retrospective study that included patients aged 18 years or older who received TXA after an acute injury from July 2014 to June 2017. We excluded patients who received TXA orally, patients who received TXA for elective surgical procedures or nontrauma indications, patients who received it 8 hours or longer after the time of injury, and patients with cardiac arrest at time of emergency department arrival. Trained abstractors collected data from the trauma registry and hospital electronic medical records. Our primary outcome measures were in-hospital death and acute thromboembolic events within 28 days from injury.

Résultats : We included 273 patients with a mean (±SD) age of 43.8 (±18.7) years. The mean (±SD) time of administration of TXA from time of injury was 1.55 (±1.2) hours with 229 patients (83.9%) receiving TXA within 3 hours. The overall mortality within 28 days from injury was 12.8% (95% confidence interval [CI] = 8.9% to 16.7%), which was similar compared to that in the CRASH-2 trial (14.5%, 95% CI = 13.9% to 15.2%). The incidence of acute thromboembolic events was 6.6% (95% CI = 3.7% to 9.5%), which was higher than that in the CRASH-2 trial (2.0%, 95% CI = 1.73% to 2.27%). Patients in our cohort also received surgery (64.8% vs. 47.9%) and blood transfusions (74.0% vs. 50.4%) more frequently than those in the CRASH-2 cohort.

Conclusion : Adult trauma patients receiving TXA had similar incidences of death but higher incidences of thromboembolic events compared to the CRASH-2 trial. Variation in patient characteristics, injury severity, TXA dosing, and surgery and transfusion rates could explain these observed differences. Further research is necessary to provide additional insight into the incidence and risk factors of thromboembolic events in TXA use.

Conclusion (proposition de traduction) : Les patients adultes ayant subi un traumatisme et recevant de l'acide tranexamique ont eu une incidence similaire de décès mais une incidence plus élevée d'événements thromboemboliques par rapport à l'essai CRASH-2. La variation des caractéristiques des patients, de la gravité des blessures, du dosage de l'acide tranexamique et des taux de chirurgie et de transfusion pourrait expliquer ces différences observées. Des recherches supplémentaires sont nécessaires pour mieux comprendre l'incidence et les facteurs de risque des événements thromboemboliques lors de l'utilisation de l'acide tranexamique.

Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations.
Kaji AH, Shover C, Lee J, Yee L, Pallin DJ, April MD, Carlson JN, Fantegrossi A, Brown CA 3rd. | Acad Emerg Med. 2020 May;27(5):394-402
DOI: https://doi.org/10.1111/acem.13869
Keywords: Aucun

ORIGINAL CONTRIBUTIONS

Introduction : With respect to first-attempt intubation success, the pediatric literature demonstrates either clinical equipoise or superiority of direct laryngoscopy (DL) when compared to video laryngoscopy (VL). Furthermore, it is unknown how VL compares to DL, when DL is "augmented" by maneuvers, such as optimal external laryngeal manipulation (OELM), upright or ramped positioning, or the use of the bougie. The objective of our study was to compare first-attempt success between VL and all DL, including "augmented DL" for pediatric intubations.

Méthode : We analyzed the National Emergency Airway Registry database of intubations of patients < 16 years. Variables collected included patient demographics, body habitus, impression of airway difficulty, intubating position, reduced neck mobility, airway characteristics, device, medications, and operator characteristics, adjusted for clustering by center. Primary outcome was the difference in first-attempt success for DL and augmented DL versus VL. Secondary outcomes included adverse events. In a planned sensitivity analysis, a propensity-adjusted analysis for first-attempt success and a subgroup analysis of children < 2 years was also performed.

Résultats : Of 625 analyzable pediatric encounters, 294 (47.0%, 95% confidence interval [CI] = 25.1% to 69.0%) were DL; 332 (53.1%, 95% CI = 31.0% to 74.9%) were VL. Median age was 4 years (interquartile range = 1 to 10 years); 225 (36.0%, 95% CI = 30.8% to 41.2%) were < 2 years. Overall first-pass success was 79.6% (95% CI = 74.1% to 84.9%). VL first-pass success was 278/331 (84.0%) versus 219/294 for DL (74.5%), adjusted for clustering (odds ratio [OR] = 1.7, 95% CI = 1.3 to 2.5). Multivariable regression showed that VL yielded a higher odds of first-attempt success than DL augmented by OELM or use of a bougie (adjusted OR = 5.5, 95% CI = 1.7 to 18.1). Propensity-adjusted analyses supported the main results. Subgroup analysis of age < 2 years also demonstrated VL superiority (OR = 2.0, 95% CI = 1.1 to 3.3) compared with DL. Adverse events were comparable in both univariate and multivariable analysis.

Conclusion : When compared to DL, VL was associated with higher first-pass success in this pediatric population, even in the subgroup of patients < 2 years, as well as when DL was augmented. There were no differences in adverse effects between DL and VL.

Conclusion (proposition de traduction) : Par rapport à la laryngoscopie directe, la vidéolaryngoscopie a été associée à un succès au premier essai plus élevé dans cette population pédiatrique, même dans le sous-groupe de patients de moins de 2 ans, ainsi que lorsque la laryngoscopie directe a été augmentée. Il n'y a pas eu de différences dans les effets négatifs entre la laryngoscopie directe et la vidéolaryngoscopie.

Commentaire : La laryngoscopie directe « augmentée » regroupe les techniques qui permettent d’améliorer l’exposition de la glotte :
manipulation laryngée externe optimale (OELM ou BURP), positionnement du patient debout ou déclive (« ramped »), utilisation d'un mandrin…

Risk of Venous Thromboembolism After Carbon Monoxide Poisoning: A Nationwide Population-Based Study.
Cho Y, Kang H, Oh J, Lim TH, Ryu J, Ko BS. | Ann Emerg Med. 2020 May;75(5):587-596
DOI: https://doi.org/10.1016/j.annemergmed.2019.08.454
Keywords: Aucun

Toxicology

Introduction : Few studies have investigated the association between carbon monoxide (CO) poisoning and risk of venous thromboembolism. We aim to identify the risk of pulmonary embolism and deep venous thrombosis after CO poisoning.

Méthode : We conducted a nationwide cohort-crossover study using administrative claims data in Korea. We compared the risk of venous thromboembolism (pulmonary embolism or deep venous thrombosis) in the cohort period after CO poisoning to that of the same period 1 year later (crossover period), using conditional logistic regression analysis.

Résultats : We included 22,699 patients with a diagnosis of CO poisoning during the study period between 2004 and 2015. The risk of venous thromboembolism was significantly elevated during days 0 to 90 after CO poisoning (odds ratio 3.96; 95% confidence interval 2.50 to 6.25). However, this risk was not significantly elevated during subsequent postexposure periods through 360 days. During days 0 to 30 after CO poisoning, the risks of pulmonary embolism (odds ratio 22.00; 95% confidence interval 5.33 to 90.75) and deep venous thrombosis (odds ratio 10.33; 95% confidence interval 3.16 to 33.80) were significantly elevated.

Conclusion : We found that the risk of venous thromboembolism persisted for up to 90 days after CO poisoning. The risk was increased 22-fold for pulmonary embolism and 10-fold for deep venous thrombosis, especially in the first month after CO poisoning. Patients should be monitored for venous thromboembolism risk after CO poisoning.

Conclusion (proposition de traduction) : Nous avons constaté que le risque thromboembolique veineux persistait jusqu'à 90 jours après l'intoxication au CO. Le risque a été multiplié par 22 pour les embolies pulmonaires et par 10 pour les thromboses veineuses profondes, surtout au cours du premier mois suivant l'intoxication au CO. Les patients doivent être surveillés pour détecter le risque thromboembolique veineux après une intoxication au CO.

Commentaire : Voir l'analyse de l'article :
Xu Y, Li W. Is Carbon Monoxide Poisoning a Risk Factor or a Bystander of Deep Venous Thrombosis? Ann Emerg Med. 2020 Jun;75(6):781-782  .

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study.
Ruangsomboon O, Dorongthom T, Chakorn T, Monsomboon A, Praphruetkit N, Limsuwat C, Surabenjawong U, Riyapan S, Nakornchai T, Chaisirin W. | Ann Emerg Med. 2020 May;75(5):615-626
DOI: https://doi.org/10.1016/j.annemergmed.2019.09.009  | Télécharger l'article au format  
Keywords: Aucun

Airway

Introduction : Palliative patients often visit the emergency department (ED) with respiratory distress during their end-of-life period. The goal of management is alleviating dyspnea and providing comfort. High-flow nasal cannula may be an alternative oxygen-delivering method for palliative patients with do-not-intubate status. We therefore aim to compare the efficacy of high-flow nasal cannula with conventional oxygen therapy in improving dyspnea of palliative patients with do-not-intubate status who have hypoxemic respiratory failure in the ED.

Méthode : This randomized, nonblinded, crossover study was conducted with 48 palliative patients aged 18 years or older with do-not-intubate status who presented with hypoxemic respiratory failure to the ED of Siriraj Hospital, Bangkok, Thailand. The participants were randomly allocated to conventional oxygen therapy for 60 minutes, followed by high-flow nasal cannula for 60 minutes (n=24) or vice versa (n=24). The primary outcome was modified Borg scale score. The secondary outcomes were numeric rating scale score of dyspnea and vital signs.

Résultats : Intention-to-treat analysis included 44 patients, 22 in each group. Baseline mean modified Borg scale score was 7.6 (SD 2.2) (conventional oxygen therapy first) and 8.2 (SD 1.8) (high-flow nasal cannula first). At 60 minutes, mean modified Borg scale score in patients receiving conventional oxygen therapy and high-flow nasal cannula was 4.9 (standard of mean 0.3) and 2.9 (standard of mean 0.3), respectively (mean difference 2.0; 95% confidence interval 1.4 to 2.6). Results for the numeric rating scale score of dyspnea were similar to those for the modified Borg scale score. Respiratory rates were lower with high-flow nasal cannula (mean difference 5.9; 95% confidence interval 3.5 to 8.3), and high-flow nasal cannula was associated with a significantly lower first-hour morphine dose.

Conclusion : High-flow nasal cannula was superior to conventional oxygen therapy in reducing the severity of dyspnea in the first hour of treatment in patients with do-not-intubate status and hypoxemic respiratory failure.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit type Optiflow™ était supérieure à l'oxygénothérapie conventionnelle pour réduire la gravité de la dyspnée au cours de la première heure de traitement chez les patients présentant insuffisance respiratoire hypoxémique avec un statut de ne-pas-intuber.

Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials.
Wang CH, Lee AF, Chang WT, Huang CH, Tsai MS, Chou E, Lee CC, Chen SC, Chen WJ. | Ann Emerg Med. 2020 May;75(5):627-636
DOI: https://doi.org/10.1016/j.annemergmed.2019.12.003
Keywords: Aucun

Airway

Introduction : We compare effectiveness of different airway interventions during cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest.

Méthode : We systematically searched the PubMed and EMBASE databases from their inception through August 2018 and selected randomized controlled trials or quasi randomized controlled trials comparing intubation, supraglottic airways, or bag-valve-mask ventilation for treating adult out-of-hospital cardiac arrest patients. We performed a network meta-analysis along with sensitivity analyses to investigate the influence of high intubation success rate on meta-analytic results.

Résultats : A total of 8 randomized controlled trials and 3 quasi randomized controlled trials were included in the network meta-analysis: 7,361 patients received intubation, 7,475 received supraglottic airway, and 1,201 received bag-valve-mask ventilation. The network meta-analysis indicated no differences among these interventions for survival or neurologic outcomes at hospital discharge. Rather, network meta-analysis suggested that supraglottic airway improved the rate of return of spontaneous circulation compared with intubation (odds ratio 1.11; 95% confidence interval 1.03 to 1.20) or bag-valve-mask ventilation (odds ratio 1.35; 95% confidence interval 1.11 to 1.63). Furthermore, intubation improved the rate of return of spontaneous circulation compared with bag-valve-mask ventilation (odds ratio 1.21; 95% confidence interval 1.01 to 1.44). The sensitivity analyses revealed that the meta-analytic results were sensitive to the intubation success rates across different out-of-hospital care systems.

Conclusion : Although there were no differences in long-term survival or neurologic outcome among these airway interventions, these system-based comparisons demonstrated that supraglottic airway was better than intubation or bag-valve-mask ventilation and intubation was better than bag-valve-mask ventilation in improving return of spontaneous circulation. The intubation success rate greatly influenced the meta-analytic results, and therefore these comparison results should be interpreted with these system differences in mind.

Conclusion (proposition de traduction) : Bien qu'il n'y ait pas de différence de survie à long terme ou de résultat neurologique entre ces interventions sur les voies aériennes, les comparaisons basées sur les différents systèmes ont démontré que la gestion des voies aériennes supraglottiques étaient meilleures que l'intubation ou la ventilation au BAVU et que l'intubation était meilleure que la ventilation au BAVU pour améliorer le retour à une circulation spontanée (RACS). Le taux de réussite de l'intubation a grandement influencé les résultats des méta-analyses et, par conséquent, ces résultats de comparaison doivent être interprétés en tenant compte de ces différences de système.

Commentaire : (…) La plupart des travaux ayant trait à l’intubation en situation d’urgence réalisée dans des systèmes de soins pré-hospitaliers médicalisés rapportent des taux de succès d’intubation trachéale très élevés, le plus souvent supérieur à 99 %.
À l’opposé, dans les études menées dans des systèmes de soins paramédicalisés, notamment aux Etats Unis, les pourcentages de succès d’intubation rapportés sont beaucoup moins bons, rarement supérieurs à 95 % et parfois très bas, jusqu’à 50%. Ces différences peuvent être expliquées par plusieurs facteurs tels que la formation des opérateurs et le type de sédation utilisée pour faciliter l’intubation.
Combes X, Jabre P. Prise en charge d’une intubation difficile en pré-hospitalier. Réanimation 2010;19:627—632  .
Voir l'éditorial dans le même numéro du journal :
Benoit JL, Wang HE. Intubation for Out-of-Hospital Cardiac Arrest: The Elephant Is in the Room. Ann Emerg Med. 2020 May;75(5):637-639  .

Rocuronium or Succinylcholine for Rapid Sequence Intubation: Does Noninferior Mean They Are the Same?: May 2020 Annals of Emergency Medicine Journal Club.
Swaminathan AK, Hochman SM, Saleem K. | Ann Emerg Med. 2020 May;75(5):670-672
DOI: https://doi.org/10.1016/j.annemergmed.2020.04.001  | Télécharger l'article au format  
Keywords: Aucun

Annals of Emergency Medicine Journal Club

Editorial : Is rocuronium noninferior to succinylcholine for facilitating out-of-hospital intubation?
Article in review:
Guihard B, Chollet-Xemard C, Lakhnati P, et al. Effect of rocuronium vs succinylcholine on endotracheal intubation success rate among patients undergoing out-of- hospital rapid sequence intubation: a randomized clinical trial. JAMA. 2019;322:2302-2312.
Authors’ Conclusion:
Among patients undergoing intubation in an out-of- hospital setting, rocuronium compared with succinylcholine did not demonstrate noninferiority in regard to first-attempt intubation success.

Conclusion : If the new treatment is found to be noninferior to the standard treatment within the margin of noninferiority, we can conclude the new treatment may be an acceptable alternative to the standard treatment. Once noninferiority is established, other factors (eg, cost, ease of use, accessibility, adverse effects) may be assessed to determine the desirability of the new treatment over the standard treatment. Some of these factors may be studied as secondary outcomes within the noninferiority study design.

Conclusion (proposition de traduction) : Si le nouveau traitement s'avère non-inférieur au traitement standard dans la marge de non-infériorité, nous pouvons conclure que le nouveau traitement peut être une alternative acceptable au traitement standard. Une fois la non-infériorité établie, d'autres facteurs (par exemple : coût, facilité d'utilisation, accessibilité, effets indésirables) peuvent être évalués pour déterminer l'opportunité du nouveau traitement par rapport au traitement standard. Certains de ces facteurs peuvent être étudiés comme résultats secondaires dans le cadre de l'étude de non-infériorité.

Evaluating the Impact of Point-Of-Care Ultrasonography on Patients With Suspected Acute Heart Failure or Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department: A Prospective Observational Study.
Nakao S, Vaillancourt C, Taljaard M, Nemnom MJ, Woo MY, Stiell IG. | CJEM. 2020 May;22(3):342-349
DOI: https://doi.org/10.1017/cem.2019.499
Keywords: Acute heart failure; emergency medicine; point-of-care ultrasonography; shortness of breath.

Original Research

Introduction : Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD.

Méthode : We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses.

Résultats : There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05-2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events.

Conclusion : In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.

Conclusion (proposition de traduction) : Dans cette étude, l'utilisation de échographie pulmonaire au point d'intervention n'a entraîné aucune différence dans la durée du séjour aux urgences et le délai de décision, mais a été associée à une administration plus rapide de traitements spécifiques à la maladie pour les patients âgés suspectés d'insuffisance cardiaque aiguë ou de BPCO.

Lung point-of-care ultrasound, an opportunity to improve patient care and patient-oriented outcomes.
Barbic D, Jelic T, Chenkin J, Heslop C, Atkinson P. | CJEM. 2020 May;22(3):271-272
DOI: https://doi.org/10.1017/cem.2020.52  | Télécharger l'article au format  
Keywords: Dyspnea; emergency medicine; ultrasound

https://doi.org/10.1017/cem.2020.52

Editorial : Point-of-care ultrasound (POCUS) has a substantial evidence base demonstrating high levels of diagnostic accuracy and reliability in emergency medicine (EM).

Conclusion : The opportunity thus exists to work collaboratively with leaders in cardiology to incorporate the most up to date and relevant evidence into the next iteration of the Canadian Cardiovascular Society heart failure guidelines to improve the care of patients presenting to the ED with undifferentiated, acute dyspnea.

Conclusion (proposition de traduction) : L'occasion se présente de travailler en collaboration avec des chefs de file en cardiologie afin d'incorporer les données probantes les plus récentes et pertinentes dans la prochaine version des lignes directrices sur l'insuffisance cardiaque de la Société canadienne de cardiologie afin d'améliorer les soins aux patients se présentant au service des urgences pour une dyspnée aiguë avec une présentation indifférenciée.

Does tranexamic acid reduce traumatic brain injury-related death?.
Blanchard PG, Paré D, Truchot J, Mercier E. | CJEM. 2020 May;22(3):297-298
DOI: https://doi.org/10.1017/cem.2020.19
Keywords: Neurosurgery; tranexamic acid; trauma; traumatic brain injury

Commentary

Editorial : Previous reports suggest that tranexamic acid (TXA) reduces bleeding death in patients with extracranial hemor- rhage and led to its adoption in trauma protocols. The role ofTXA in traumatic brain injury (TBI) remains unclear.

Conclusion : CRASH-3 trial collaborators conclude that TXA is safe in patients with TBI and reduces head injury-related death. However, this interpretation is misleading because the primary outcome is negative, and only one subgroup analysis supports this conclusion. Despite no statistical difference in the rate of adverse events, the RR of TXA administration was 1.31 for non-head injury-related death, calling for caution in the interpretation of results. The CRASH-3 trial is a robust study underlining the need for further research to identify the subgroup of patients, if any, that could benefit from TXA after traumatic intracranial bleeding in our population.

Conclusion (proposition de traduction) : Les collaborateurs de l'essai CRASH-3 concluent que l'acide tranexamique est sans danger chez les patients souffrant d'une lésion cérébrale traumatique et réduit les décès liés à une blessure à la tête. Cependant, cette interprétation est trompeuse car le résultat principal est négatif et une seule analyse de sous-groupe soutient cette conclusion. Malgré aucune différence statistique dans le taux d'événements indésirables, le rapport de risque de l'administration d'acide tranexamique était de 1,31 pour les décès non liés à une blessure à la tête, ce qui appelle à la prudence dans l'interprétation des résultats. L'essai CRASH-3 est une étude solide soulignant la nécessité de poursuivre les recherches pour identifier le sous-groupe de patients, le cas échéant, qui pourraient bénéficier de l'acide tranexamique après un saignement intracrânien traumatique dans notre population.

Evaluating the impact of point-of-care ultrasonography on patients with suspected acute heart failure or chronic obstructive pulmonary disease exacerbation in the emergency department: A prospective observational study.
Nakao S, Vaillancourt C, Taljaard M, Nemnom MJ, Woo MY, Stiell IG. | CJEM. 2020 May;22(3):342-349
DOI: https://doi.org/10.1017/cem.2019.499
Keywords: Acute heart failure; emergency medicine; point-of-care ultrasonography; shortness of breath.

Original Research

Introduction : Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD.

Méthode : We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses.

Résultats : There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05-2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events.

Conclusion : In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.

Conclusion (proposition de traduction) : Dans cette étude, l'utilisation de l'échographie pulmonaire au point d'intervention n'a entraîné aucune différence pour la durée du séjour aux urgences et le délai de décision, mais a été associée à une administration plus rapide de traitements spécifiques à la maladie pour les patients âgés suspectés d'insuffisance cardiaque aiguë ou de BPCO.

Efficacy of calcitonin for treating acute pain associated with osteoporotic vertebral compression fracture: an updated systematic review.
Boucher E, Rosgen B, Lang E. | CJEM. 2020 May;22(3):359-367
DOI: https://doi.org/10.1017/cem.2019.490
Keywords: Aucun

Original Research

Introduction : Acutely painful osteoporotic vertebral compression fractures are associated with hospitalization and mortality in older adults. Calcitonin may be an alternative to opioid or nonopioid analgesia for treating acute compression fracture pain in emergency and primary care settings. This review summarizes pain, function, and adverse events associated with calcitonin.

Méthode : We searched MEDLINE, EMBASE, The Cochrane Library, clinical trials registries, and reference lists of included studies. Eligible studies evaluated the effect of synthetic calcitonins (salmon, eel, and human) on pain scores in adults ≥60 years old with a recent atraumatic compression fracture. Two reviewers screened studies, extracted data, and allocated bias in duplicate. A random effects meta-analysis evaluated standard mean difference (SMD) and heterogeneity (I2).

Résultats : Of 1,198 articles screened, 11 were included (9 in the meta-analysis). Treatment lasted from 14 days to 6 months. Pain was lower in the salmon calcitonin group (100-200 IU IM or NAS, daily) than the control group with high certainty of evidence at week 1 (SMD, -1.54; 95% confidence interval [CI], -2.02 - -1.06; I2 = 52%), representing a number needed to treat of two. The analgesic efficacy of salmon calcitonin at 4 weeks was unclear due to substantial heterogeneity. There was low certainty evidence that calcitonin did not increase the overall risk of adverse events, including nausea and vomiting (risk ratio, 2.10; 95% CI, 0.87-5.08; I2 = 47%).

Conclusion : Calcitonin is beneficial and appears safe for treating acute pain associated with compression fractures. Further studies may improve the certainty of evidence.

Conclusion (proposition de traduction) : La calcitonine est bénéfique et semble sûre pour traiter la douleur aiguë associée aux fractures de compression. D'autres études pourraient améliorer la certitude des preuves.

Evaluating the potential impact of an emergency department extracorporeal resuscitation (ECPR) program: a health records review.
McDonald L, Mastoras G, Hickey M, McDonald B, Kwok ESH. | CJEM. 2020 May;22(3):375-378
DOI: https://doi.org/10.1017/cem.2019.472
Keywords: Cardiac arrest; critical care; resuscitation

Original Research

Introduction : Extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program.

Méthode : This retrospective health records review included patients aged 18-75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both "liberal" and "restrictive" ECPR criteria were defined and applied to our cohort.

Résultats : A total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31-53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR.

Conclusion : At our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Conclusion (proposition de traduction) : Dans notre établissement, nous estimons qu'entre 6 % et 40 % des patients en arrêt cardiaque réfractaire aux urgences seraient candidats à l'ECPR. Ces résultats suggèrent que la mise en œuvre d'un programme ECPR devrait être explorée.

Coagulopathy of Coronavirus Disease 2019.
Iba T, Levy JH, Levi M, Connors JM, Thachil J. | Crit Care Med. 2020 May 27:10.1097/CCM.0000000000004458
DOI: https://doi.org/10.1097/ccm.0000000000004458  | Télécharger l'article au format  
Keywords: Aucun

REVIEW ARTICLE: PDF ONLY

Introduction : Recent studies have reported a high prevalence of thrombotic events in coronavirus disease 2019. However, the significance of thromboembolic complications has not been widely appreciated. The purpose of this review is to provide current knowledge of this serious problem.

Méthode : Design: Narrative review.
Data sources: Online search of published medical literature through PubMed using the term "COVID-19," "SARS," "acute respiratory distress syndrome," "coronavirus," "coagulopathy," "thrombus," and "anticoagulants."
Study selection and data extraction: Articles were chosen for inclusion based on their relevance to coagulopathy and thrombosis in coronavirus disease 2019, and anticoagulant therapy. Reference lists were reviewed to identify additional relevant articles.

Résultats : Coronavirus disease 2019 is associated with a strikingly high prevalence of coagulopathy and venous thromboembolism that may contribute to respiratory deterioration. Monitoring coagulation variables is important, as abnormal coagulation tests are related to adverse outcomes and may necessitate adjuvant antithrombotic interventions. In the initial phase of the infection, D-dimer and fibrinogen levels are increased, while activated partial prothrombin time, prothrombin time, and platelet counts are often relatively normal. Increased D-dimer levels three times the upper limit of normal may trigger screening for venous thromboembolism. In all hospitalized patients, thromboprophylaxis using low-molecular-weight heparin is currently recommended. The etiology of the procoagulant responses is complex and thought to be a result of specific interactions between host defense mechanisms and the coagulation system. Although the coagulopathy is reminiscent of disseminated intravascular coagulation and thrombotic microangiopathy, it has features that are markedly distinct from these entities.

Conclusion : Severe acute respiratory syndrome coronavirus 2/coronavirus disease 2019 frequently induces hypercoagulability with both microangiopathy and local thrombus formation, and a systemic coagulation defect that leads to large vessel thrombosis and major thromboembolic complications, including pulmonary embolism in critically ill hospitalized patients. D-dimers and fibrinogen levels should be monitored, and all hospitalized patients should undergo thromboembolism prophylaxis with an increase in therapeutic anticoagulation in certain clinical situations.

Conclusion (proposition de traduction) : Le syndrome respiratoire aigu sévère à coronavirus 2/maladie à coronavirus 2019 induit fréquemment une hypercoagulabilité avec à la fois une microangiopathie et une formation de thrombus local, et un défaut de coagulation systémique qui conduit à une thrombose des gros vaisseaux et à des complications thromboemboliques majeures, y compris une embolie pulmonaire chez des patients hospitalisés en soins critiques. Les D-dimères et les taux de fibrinogène doivent être surveillés, et tous les patients hospitalisés doivent bénéficier d'une prophylaxie thrombo-embolique avec une augmentation de l'anticoagulation thérapeutique dans certaines situations cliniques.

End of life care in the emergency department.
Dawood M | Emerg Med J [Internet]. 2020 May;37(5):273
DOI: http://dx.doi.org/10.1136/emermed-2019-208632
Keywords: Aucun

Practice review

Editorial : The importance of end of life care (EoLC) for patients and their families is well documented, however, the skills and knowledge of emergency clinicians in delivering EoLC is not widely understood but it is clear from the existing literature that we fall short in delivering consistently good EoLC although there is recognition of the need to improve. This paper will acknowledge the challenges of delivering good EoLC in the emergency department (ED) but more importantly consider practical ways of improving EoLC in the ED in line with best practice guidelines on EoLC.

Conclusion : Delivering good end of life care can be a challenging process in emergency departments as it is often associated with practical, ethical and legal dilemmas. However, as demands for emergency care continue to rise alongside a shortage of inpatient beds, it is essential that emergency department clinicians move towards an acceptance that provision of end of life care is a necessary and appropriate purpose of the emergency department. Making the end of life care a core function for emergency care amounts to a paradigm shift which will not happen overnight. But it is a goal we must work towards to ensure the emergency department is not ‘the wrong place to die’ and the memory for those who live on is the best it can be. It is the greatest privilege for clinicians to have the opportunity to care and comfort a patient in the last hours of their life; we can, with the right mindset and resources do this well.

Conclusion (proposition de traduction) : Fournir des soins palliatifs de qualité peut être un processus difficile dans les services d'urgence car il est souvent associé à des dilemmes pratiques, éthiques et juridiques. Cependant, alors que la demande de soins d'urgence continue d'augmenter parallèlement à une pénurie de lits d'hospitalisation, il est essentiel que les cliniciens des services d'urgence s'orientent vers l'acceptation que la prestation de soins de fin de vie est un objectif nécessaire et approprié du service d'urgence. Faire des soins de fin de vie une fonction essentielle des soins d'urgence équivaut à un changement de paradigme qui ne se fera pas du jour au lendemain. Mais c’est un objectif que nous devons atteindre pour nous assurer que le service d’urgence n’est pas « le mauvais endroit où mourir » et que la mémoire de ceux qui vivent est la meilleure possible. C'est un grand privilège pour les cliniciens d'avoir la possibilité de soigner et de réconforter un patient dans les dernières heures de sa vie; nous pouvons, avec la bonne mentalité et les bonnes ressources, bien faire cela.

Successful endotracheal intubation following a failed first attempt during aeromedical retrieval.
Glasheen J, Hooper J, Donohue A, Finn E, Murray-Smith B, Bolot R,. | Emerg Med J [Internet]. 2020 May 1;37(5):314
DOI: http://dx.doi.org/10.1136/emermed-2019-208425
Keywords: Aucun

Original research

Introduction : First attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt.

Méthode : LifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics.

Résultats : Of the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid.

Conclusion :  Although a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

Conclusion (proposition de traduction) : Bien qu'un taux global élevé de réussite de l'intubation ait été trouvé, un patient sur dix qui a été intubé a eu une première tentative infructueuse. La majorité des tentatives ultérieures réussies ont été précédées d'au moins un changement de technique d'intubation. Les praticiens qui doivent réaliser intubation doivent être en mesure d'identifier et de corriger les problèmes aboutissant à une échec du premier essai.

Continuous Positive Airway Pressure to Avoid Intubation in SARS-CoV-2 Pneumonia: A Two-Period Retrospective Case-Control Study.
Oranger M, Gonzalez-Bermejo J, Dacosta-Noble P, Llontop C, Guerder A, Trosini-Desert V, Faure M, Raux M, Decavele M, Demoule A, Morélot-Panzini C, Similowski T. | Eur Respir J. 2020 May 19:2001692
DOI: https://doi.org/10.1183/13993003.01692-2020  | Télécharger l'article au format  
Keywords: Aucun

Early View

Editorial : COVID-19 pneumonia can be life-threatening. Given the unprecedented burden place on ICU resources by the epidemic, avoiding intubation is a major issue. This study suggests that CPAP can achieve this objective.

Conclusion : Our findings indicate that CPAP is feasible in deteriorating COVID-19 patients managed in a pulmonology unit. They suggest that CPAP can avoid intubation at 7 days and at 14 days, particularly in patients with a previous "do not intubate" decision, which resembles similar observations with NIV in patients having declined intubation.
Regarding safety, none of our patients receiving CPAP had to be intubated under high emergency or cardiac arrest conditions. We acknowledge that may unduly delay intubation in non-expert hands, and insist on the notion that intubation should not be delayed in the absence of a rapid and clear response to treatment. The proportion of caregivers contaminated by SARS-CoV-2 was similar during period #2 (6%)and during period #1 (10%).

Conclusion (proposition de traduction) : Nos résultats indiquent que la CPAP est possible pour l'aggravation des patients COVID-19 pris en charge dans une unité de pneumologie. Ils suggèrent que la CPAP peut éviter l'intubation à 7 jours et à 14 jours, en particulier chez les patients avec une décision précédente de « ne pas intuber », ce qui ressemble à des observations similaires avec la VNI chez les patients ayant refusé l'intubation.
En ce qui concerne la sécurité, aucun de nos patients ayant bénéficier de la CPAP n'a dû être intubé dans des conditions d'urgence élevée ou d'arrêt cardiaque. Nous reconnaissons que cela peut retarder indûment l'intubation entre des mains non expertes et insistons sur l'idée que l'intubation ne devrait pas être retardée en l'absence d'une réponse rapide et claire au traitement. La proportion de soignants contaminés par le SRAS-CoV-2 était similaire pendant la période n° 2 (6 %) et pendant la période n° 1 (10 %).

The use of clinical decision rules for pulmonary embolism in the emergency department: a retrospective study.
Al Dandan O, Hassan A, Alnasr A, Al Gadeeb M, AbuAlola H, Alshahwan S, Al Shammari M, Alzaki A. | Int J Emerg Med. 2020 May 11;13(1):23
DOI: https://doi.org/10.1186/s12245-020-00281-1
Keywords: Computed Tomography; Guidelines; Pulmonary embolism; Wells criteria.

Original Research

Introduction : Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. This study aims to assess the adherence of physicians to the diagnostic algorithms and rules.

Méthode : A retrospective observational study examining the utilization of CT-PA in the Emergency Department of King Fahd Hospital of Imam Abdulrahman Bin Faisal University for patients with suspected PE from May 2016 to December 2019. The electronic health records were used to collect the data, including background demographic data, clinical presentation, triage vital signs, D-dimer level (if ordered), risk factors for PE, and the CT-PA findings. The Wells score and pulmonary embolism rule-out (PERC) criteria were calculated retrospectively without knowledge of the results of D-dimer and the CT-PA.

Résultats : The study involved a total of 353 patients (125 men and 228 women) with a mean age of 46.7 ± 18.4 years. Overall, 200 patients (56.7%) were classified into the "PE unlikely" group and 153 patients (43.3%) in the "PE likely" group as per Wells criteria. Out of all the CT-PA, 119 CT-PA (33.7%) were requested without D-dimer assay (n = 114) or with normal D-dimer level (n = 5) despite being in the "PE unlikely" group. Only 49 patients had negative PERC criteria, of which three patients had PE.

Conclusion : The study revealed that approximately one-third of all CT-PA requests were not adhering to the clinical decision rules with a significant underutilization of D-dimer assay in such patients. To reduce overutilization of imaging, planned interventions to promote the adherence to the current guidelines seem imperative.

Conclusion (proposition de traduction) : L'étude a révélé qu'environ un tiers de toutes les demandes d'angiographie pulmonaire par tomodensitométrie ne respectaient pas les règles de décision clinique avec une sous-utilisation significative du dosage des D-dimères chez ces patients. Pour réduire la surutilisation de l'imagerie, des interventions planifiées pour favoriser le respect des directives actuelles semblent impératives.

High-Sensitivity Cardiac Troponin I Levels and Prediction of Heart Failure: Results From the BiomarCaRE Consortium.
Yan I, Börschel CS, Neumann JT, Sprünker NA, Makarova N, Kontto J, Kuulasmaa K, Salomaa V, Magnussen C, Iacoviello L, Di Castelnuovo A, Costanzo S, Linneberg A, Söderberg S, Zeller T, Ojeda-Echevarria FM, Blankenberg S, Westermann D. | JACC Heart Fail. 2020 May;8(5):401-411
DOI: https://doi.org/10.1016/j.jchf.2019.12.008
Keywords: BiomarCaRE; N-terminal pro-B-type natriuretic peptide; cardiovascular risk factors; high-sensitivity cardiac troponin I; prediction of heart failure.

CLINICAL RESEARCH

Introduction : The aims of this study were to characterize the association of high-sensitivity cardiac troponin I (hs-cTnI) with heart failure (HF), to determine its predictive value beyond classical cardiovascular risk factors (CVRFs) and N-terminal pro-B-type natriuretic peptide, and to derive a relevant cutoff for potential clinical application.
Background : HF is an important contributor to the overall burden of cardiovascular disease. Early identification of individuals at risk could be beneficial for preventive therapies.

Méthode : Based on the Biomarker for Cardiovascular Risk Assessment in Europe consortium, we analyzed individual-level data from 4 prospective population-based cohort studies including 48,455 individuals. Participants with myocardial infarction, HF, and stroke at baseline were excluded. We investigated the value of adding hs-cTnI to CVRFs and N-terminal pro-B-type natriuretic peptide using Cox proportional hazards survival models and for prediction by calculating C-statistics and Brier score.

Résultats : The median age of the study population was 51 years, and the median follow-up time for occurrence of HF was 6.61 years. Cox regression models adjusted for age, sex, and CVRFs revealed a significant association of hs-cTnI with incident HF (hazard ratio: 1.42 per log [ng/l] unit change [95% confidence interval: 1.31 to 1.53]). The best predictive value was achieved in the model with CVRFs (base model) and both biomarkers (C-index = 0.862; 95% confidence interval: 0.841 to 0.882). Optimal hs-cTnI cutoff values of 2.6 ng/l for women and 4.2 ng/l for men were derived for selecting individuals at risk.

Conclusion : In this large dataset from the general population, hs-cTnI could show its independence for the prognosis of HF.

Conclusion (proposition de traduction) : Dans ce grand ensemble de données de la population générale, la troponine cardiaque I ultrasensible pourrait montrer son indépendance pour le pronostic de l'insuffisance cardiaque.

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality.
Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Léguillier T, Gueye-Ngalgou P, Vivien B. | Prehosp Emerg Care. 2020 May 15:1-8
DOI: https://doi.org/10.1080/10903127.2020.1763532
Keywords: Septic shock; antibiotic therapy; mortality; prehospital setting.

Article

Introduction : Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting.

Méthode : From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality.

Résultats : Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016).

Conclusion : In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, l'antibiothérapie préhospitalière réduit la mortalité à 30 jours des patients en choc septique pris en charge par une unité mobile de réanimation. Des études complémentaires seront nécessaires pour confirmer l'effet bénéfique de l'antibiothérapie préhospitalière en association ou non avec l'optimisation hémodynamique préhospitalière pour améliorer la survie des patients en choc septique.

The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team.
Abid ES, McNamara J, Hall P, Miller KA, Monuteaux M, Kleinman ME, Nagler J. | Prehosp Emerg Care. 2020 May 15:1-8
DOI: https://doi.org/10.1080/10903127.2020.1761492
Keywords: airway; critical care transport; intubation; pediatrics; videolaryngoscopy.

Article

Introduction : Endotracheal intubation may be required for the transport of critically ill neonates and children. Data suggest that first pass success (FPS) is associated with lower rates of complications. Thus, understanding factors associated with FPS can have important implications for clinical outcomes. We aimed to determine the impact of videolaryngoscopy (VL) on FPS by a pediatric critical care transport team (CCTT).

Méthode : We performed a retrospective cross-sectional study on pediatric patients (≤ 18 years of age) requiring endotracheal intubation by a tertiary care-based pediatric CCTT between 2011 and 2019. Patients were categorized as neonatal (≤ 28 days of age, either preterm or term) or pediatric (> 28 days of age). All intubation attempts using VL were performed with the C-MAC videolaryngoscope. Our primary outcome was rate of FPS. Descriptive statistics of patient, provider, and procedure characteristics were calculated. Multivariate regression was used to test the association between FPS and type of laryngoscope (video versus direct) adjusting for significant clinical predictors.

Résultats : Over the study period, 135 patients were intubated by the CCTT. Sixty percent of these patients were neonates, and 40% were pediatric. The overall FPS rate was 61%, with lower rates in neonates (54%) and higher rates in pediatric patients (70%). Use of videolaryngoscopy increased over the study period. First pass success rate using the C-MAC videolaryngoscope was 72% compared to 42% for direct laryngoscopy across the whole study population. In adjusted analyses, FPS using VL was significantly higher in the pediatric patient population (aOR 12.42 [95%CI 3.33, 46.29]), but not in neonates (aOR 1.08 [0.44, 2.63]). Use of VL increased significantly over the study period.

Conclusion : We found use of a C-MAC videolaryngoscope by a critical care transport team was associated with improved FPS during endotracheal intubation of pediatric patients but not neonates, after controlling for other patient and provider characteristics. In addition to the impact on FPS, use of VL may offer additional educational and quality benefits.

Conclusion (proposition de traduction) : Nous avons constaté que l'utilisation d'un vidéolaryngoscope C-MAC par une équipe de transport de soins intensifs était associée à une amélioration du succès d'intubation au premier essai lors de l'intubation endotrachéale des patients pédiatriques mais pas des nouveau-nés, après contrôle des autres caractéristiques des patients et des intervenants. En plus de l'impact sur le succès du premier essai, l'utilisation de la vidéolaryngoscopie peut offrir des avantages éducatifs et de qualité supplémentaires.

Systematic Review of Evidence-Based Guidelines for Prehospital Care.
Turner S, Lang ES, Brown K, Franke J, Workun-Hill M, Jackson C, Roberts L, Leyton C, Bulger EM, Censullo EM, Martin-Gill C. | Care. Prehosp Emerg Care. 2020 May 7:1-14
DOI: https://doi.org/10.1080/10903127.2020.1754978
Keywords: clinical guidelines; emergency medical services; prehospital.

Article

Introduction : Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported.
Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM.

Méthode : We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus.

Résultats : We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing.

Conclusion : EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.

Conclusion (proposition de traduction) : Il existe des lignes directrices fondées sur des données probantes traitant de divers sujets en médecine des services médicaux d'urgence. Cette revue et évaluation systématiques des lignes directrices des services médicaux d'urgence a identifié un large éventail dans la qualité de ces lignes directrices et des rapports variables sur les éléments clés des lignes directrices cliniques. Les futurs concepteurs de lignes directrices devraient tenir compte des recommandations méthodologiques et de rapport établies pour améliorer la qualité des lignes directrices des services médicaux d'urgence.

Time to Return of Spontaneous Circulation and Survival: When to Transport in out-of-Hospital Cardiac Arrest?.
de Graaf C, Donders DNV, Beesems SG, Henriques JPS, Koster RW. | Prehosp Emerg Care. 2020 May 7:1-11
DOI: https://doi.org/10.1080/10903127.2020.1752868
Keywords: In OHCA patients with prehospital ROSC survival significantly decreases with increasing time-to-ROSC. Of all patients, 90% of survivors had achieved ROSC within the first 15 min of EMS resuscitation. The optimal time for the decision to transport is between 8 and 15 min after EMS arrival.

Article

Introduction : In out-of-hospital cardiac arrest (OHCA), 10-50% of patients have return of spontaneous circulation (ROSC) before hospital arrival. It is important to investigate the relation between time-to-ROSC and survival to determine the optimal timing of transport to the hospital in patients without ROSC.

Méthode : We analyzed data of OHCA patients with a presumed cardiac cause (excluding traumatic and other obvious non-cardiac causes) and ROSC before hospital arrival from the Amsterdam Resuscitation Study (ARREST) database. ROSC included those patients whose ROSC was persistent or transient before or during transport, lasting ≥1 min. Of these data, we analyzed the association between the time of emergency medical services (EMS) arrival until ROSC (time-to-ROSC) and 30-day survival.

Résultats : Of 3632 OHCA patients with attempted resuscitation, 810 patients with prehospital ROSC were included. Of these, 332 (41%) survived 30 days. Survivors had a significant shorter time-to-ROSC compared to non-survivors of median 5 min (IQR 2,10) vs. median 12 min (IQR 9,17) (p < 0.001). Of the survivors, 90% achieved ROSC within 15 min compared to 22 min of non-survivors. In a multivariable model adjusted for known system determinants time-to-ROSC per minute was significantly associated with 30-day survival (OR 0.89; 95%CI 0.86-0.91). A ROC curve showed 8 min as the time-to-ROSC with the best test performance (sensitivity of 0.72 and specificity of 0.77).

Conclusion : In OHCA patients with prehospital ROSC survival significantly decreases with increasing time-to-ROSC. Of all patients, 90% of survivors had achieved ROSC within the first 15 min of EMS resuscitation. The optimal time for the decision to transport is between 8 and 15 min after EMS arrival.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque extra-hospitaliers avec récupération d'activité cardiaque spontanée préhospitalier, la survie diminue de manière significative avec l'augmentation du temps de retour à la récupération d'activité cardiaque spontanée. De tous les patients, 90 % des survivants avaient obtenu une récupération d'activité cardiaque spontanée dans les 15 premières minutes de réanimation des services médicaux d'urgence. Le moment optimal pour la décision de transport se situe entre 8 et 15 min après l'arrivée des services médicaux d'urgence.

Oxygen and carbon dioxide levels in patients after cardiac arrest.
Peluso L, Belloni I, Calabró L, Dell'Anna AM, Nobile L, Creteur J, Vincent JL, Taccone FS. | Resuscitation. 2020 May;150:1-7
DOI: https://doi.org/10.1016/j.resuscitation.2020.02.030
Keywords: Carbon dioxide; Cardiac arrest; Outcome; Oxygen.

Clinical Paper

Introduction : The relationship of PaO2 and PaCO2 levels with outcome after cardiac arrest (CA) is controversial. Few studies have analysed both PaO2 and PaCO2 in this setting and the overall exposure to different PaO2 and PaCO2 levels has not been taken into account.

Méthode : We reviewed blood gas data obtained within the first 24 h from all comatose adult patients who were admitted to the intensive care unit after successful resuscitation from CA. Exposure times to different PaO2 and PaCO2 thresholds were reported as areas under the curve (AUC) and the time above these thresholds was then calculated. The primary outcome measure was neurological outcome assessed using the Cerebral Performance Category (CPC) score at 3 months. An unfavourable outcome was defined as a CPC of 3-5 and a favourable outcome as a CPC of 1-2.

Résultats : A total of 356 patients were studied, with a median number of 9 [6-11] blood gas measurements within the first 24 h after admission. The highest and lowest PaO2 and PaCO2 were similar in patients with unfavourable and favourable neurological outcomes. There were no differences in the AUCs or times over different thresholds of PaO2 and PaCO2 in the two groups. In a multivariable analysis, high blood lactate concentrations on admission, presence of shock and a non-shockable initial rhythm were significantly associated with unfavourable outcome.

Conclusion : There was no association between exposure to various levels of PaO2 and PaCO2 and neurological outcome after cardiac arrest.

Conclusion (proposition de traduction) : Il n'y avait pas d'association entre les différents taux de PaO₂ et PaCO₂ et le résultat neurologique après un arrêt cardiaque (Les PaO₂ et les PaCO₂ les plus élevées et les plus basses étaient similaires chez les patients présentant des résultats neurologiques défavorables et favorables).

Commentaire : En revanche, sur l'analyse multivariée, des concentrations sanguines élevées de lactate à l'admission, la présence d'un état de choc et un rythme initial non choquable étaient significativement associés à une issue défavorable.

Out-of-hospital cardiac arrest: Causes according to autopsy and electrocardiography - Analysis of 781 patients with neither hospital care nor prescribed medication during the preceding two years.
Holmgren C, Abdon NJ, Bergfeldt L, Edvardsson N, Herlitz J, Karlsson T, Nyström B, Åstrand B. | Resuscitation. 2020 May;150:65-71
DOI: https://doi.org/10.1016/j.resuscitation.2020.02.040
Keywords: Aetiology; Healthy; Medication; Out-of-hospital cardiac arrest.

Clinical paper

Introduction : There is a knowledge gap regarding aetiology of and potential for predicting out-of-hospital cardiac arrest (OHCA) among individuals who are healthy before the event.
Aim: To describe causes of OHCA and the potential for predicting OHCA in apparently healthy patients.

Méthode : Patients were recruited from the Swedish Register of Cardiopulmonary Resuscitation from November 2007 to January 2011. Inclusion criteria were: OHCA with attempted CPR but neither dispensed prescription medication nor hospital care two years before the event The register includes the majority of patients suffering OHCA in Sweden where cardiopulmonary resuscitation (CPR) was attempted. Medication status was defined by linkage to the Swedish Prescribed Drug Register. Cause of death was assessed based on autopsy and the Swedish Cause of Death Register. Prediction of OHCA was attempted based on available electrocardiograms (ECG) before the OHCA event.

Résultats : Altogether 781 individuals (16% women) fulfilled the inclusion criteria. Survival to 30 days was 16%. Autopsy rate was 72%. Based on autopsy, 70% had a cardiovascular aetiology and 59% a cardiac aetiology. An ECG recording before the event was found in 23% of cases. The ECG was abnormal in 22% of them.

Conclusion : Among OHCA victims who appeared to be healthy prior to the event, the cause was cardiovascular in the great majority according to autopsy findings. A minority had a preceding abnormal ECG that could have been helpful in avoiding the event.

Conclusion (proposition de traduction) : Parmi les victimes d'arrêts cardiaques extra-hospitaliers qui semblaient en bonne santé avant l'événement, la cause était cardiovasculaire dans la grande majorité selon les résultats de l'autopsie. Une minorité avait un ECG anormal précédent qui aurait pu être utile pour éviter l'événement.

Comparison between new modified external rotation method and external rotation method for reduction of ASD.
Akcimen M, Bedel C. | Am J Emerg Med. 2020 May;38(5):874-878
DOI: https://doi.org/10.1016/j.ajem.2019.07.001
Keywords: External reduction method; Modified external rotation reduction method; Shoulder dislocation.

Original contribution

Introduction : Dislocation of the shoulder joint is common and is mainly anterior. Several reduction methods have been described and the external reduction method (ERM) is one of the newest. We modified the ERM by making some additions in hopes to develop a less painful, quick and simple method. The aim of this study was to compare the new modified external rotation reduction method (MERM) with ERM in acute anterior shoulder dislocations (ASD).

Méthode : A total of 62 patients with ASD were classified randomly into 2 groups. The reduction was performed with MERM in one group and with ERM in the other group and the results were compared. Patients' pain scores, reduction time, success rate of the reduction methods, age, sex, dislocation side, dislocation time, previous dislocations history, injury mechanism, any complications, reduction time and neurovascular examination were collected. Parametric and nonparametric analyses were used to compare MERM and ERM.

Résultats : The study cohort consisted of 62 patients (52 males, 10 females; mean age, 35 years; age range, 18-73 years) who were randomly assigned to treatment with the MERM (n = 32) or the ERM (n = 30). There was a statistically significant difference between the two methods in terms of time, and the MERM can be applied much faster than ERM (1.34 ± 1.41 min vs 3.05 ± 1.93 min; p < 0.001). The intra-reduction VAS pain score was not significantly in patients who were treated with MERM (85.31 ± 10.39 vs. 78.33 ± 16.54; p = 0.122).

Conclusion : MERM can be an alternate method compared to the ERM for the reduction of ASD.

Conclusion (proposition de traduction) : La méthode modifiée de réduction parrotation externe peut être une méthode alternative par rapport à la méthode de réduction externe pour la réduction des luxations antérieures de l'épaule.

Commentaire :  a – d) L'avant-bras du côté de la luxation est fléchi à 90° par rapport au coude. Le bras est relevé à 20° vers l'avant. On place un objet rigide d'environ 5 à 10 cm de diamètre dans la région axillaire. Pendant que le bras est tourné lentement vers l'extérieur à l'aide de l'avant-bras, une force verticale est appliquée à partir du coude. La force continue d'être appliquée jusqu'à ce que l'épaule soit remise en place.

Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness.
Baumann BM, Greenwood JC, Lewis K, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Kilgannon JH, Rodriguez RM. | Am J Emerg Med. 2020 May;38(5):883-889
DOI: https://doi.org/10.1016/j.ajem.2019.07.003
Keywords: Sepsis, lactic acid, mortality, intensive care units, mass screening

Original contribution

Introduction : To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness.

Méthode : This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these.

Résultats : Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3–95.9).

Conclusion : The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.

Conclusion (proposition de traduction) : La combinaison du qSOFA ≥ 1 OU du Lactate ≥ 2 permet une amélioration considérable de la sensibilité pour le dépistage des maladies graves par rapport aux seuils isolés de lactate et de qSOFA.

Age shock index, shock index, and modified shock index for predicting postintubation hypotension in the emergency department.
Lee K, Jang JS, Kim J, Suh YJ. | Am J Emerg Med. 2020 May;38(5):911-915
DOI: https://doi.org/10.1016/j.ajem.2019.07.011
Keywords: Aucun

Original contribution

Introduction : Hypotension after emergent ETI is a relatively common complication during and after emergency airway management. We aimed to evaluate SI, MSI, and age SI to predict PIH in patients who presented to the emergency department. Moreover, which factors would be better for predicting the event or similar to the others.

Méthode : A retrospective, standardized chart review of consecutive ED patients requiring intubation at an urban, tertiary-care teaching hospital, from January 2011 to December 2016. PIH was defined as any recorded SBP <90 mmHg or MAP <65 mmHg within the 60-minute period after intubation.

Résultats : Hypotension after emergent ETI was observed in 130 (29.7%) patients. The ROC-AUC of age SI, MSI, and SI before intubation for prediction of PIH were 0.676 (95% CI 0.63-0.72), 0.614 (95% CI 0.567-0.66), and 0.611 (95% CI 0.564-0.657). The prognostic performance of age SI for prediction of PIH was better than MSI and SI (p = 0.006 for age SI versus MSI, p = 0.005 for age SI versus SI).

Conclusion : Preintubation age SI, MSI, and SI are all independent predictors of PIH in patients who need emergent intubation. Aong these parameters, age SI is the best marker to predict the outcome. Calculation of these indexes are simple and could be an guide of implement to prevent hypotension after ETI.

Conclusion (proposition de traduction) : Age shock index, shock index, et modified shock index préintubation sont tous des prédicteurs indépendants de survenue de l'hypotension post-intubation chez les patients nécessitant une intubation urgente. Parmi ces paramètres, l'Age shock index est le meilleur marqueur pour prédire le résultat. Le calcul de ces indices est simple et pourrait être un guide de conduite à tenir pour éviter une hypotension après intubation endotrachéale.

Commentaire : Calculateurs en ligne (MDCalc) :
• Shock Index  .
• Shock Index, Pediatric Age-Adjusted (SIPA)  .

The utility of iPhone oximetry apps: A comparison with standard pulse oximetry measurement in the emergency department.
Jordan TB, Meyers CL, Schrading WA, Donnelly JP. | Am J Emerg Med. 2020 May;38(5):925-928
DOI: https://doi.org/10.1016/j.ajem.2019.07.020
Keywords: Applications; Oximetry; Pulse ox; Smart phone; iPhone apps.

Original contribution

Introduction : To determine if a correlation exists between 3 iphone pulse ox applications' measurements and the standard pulse oximetry (SpO2) and whether these applications can accurately determine hypoxia.

Méthode : Three applications reportedly measuring SpO2 were downloaded onto an iPhone 5s. Two of these applications used the onboard light and camera lens "Pulse Oximeter" (Pox) and "Heart Rate and Pulse Oximeter" (Ox) and one used an external device that plugged into the iphone (iOx). Patients in the ED were enrolled with chief complaints of cardiac/pulmonary origin or a SpO2 ≤ 94%. All measurements were compared to controls. Concordance correlation coefficients, sensitivity, and specificity were calculated.

Résultats : A total of 191 patients were enrolled. The concordance correlation of iOx with control was 0.55 (CI 0.46, 0.63), POx was 0.01 (CI -0.09, 0.11), and Ox was 0.07 (CI -0.02, 0.15). 68/191 patients (35%) were found to have hypoxemia. Sensitivities for detecting hypoxia were 69%, 0%, and 7% for iOx, POx, and Ox, respectively. Specificities were 89%, 100%, and 89%. Even iOx (the most accurate) 21 (11%) were incorrectly classified nonhypoxic, and 22 (12%) were incorrectly classified hypoxic.

Conclusion : While iOx has modest concordance with control, Ox and POx showed almost none. The iOx device was best in correctly identifying hypoxia patients, but almost 1/4 of patients were incorrectly classified. The three apps provided inaccurate SpO2 measurements and had limited to no ability to accurately detect hypoxia. These apps should not be relied upon to provide accurate SpO2 measurements in emergent, even austere conditions.

Conclusion (proposition de traduction) : Alors que l'"iOx" présente une concordance modeste avec le contrôle, le "Heart Rate and Pulse Oximeter" et le "Pulse Oximeter" n'en montrent pratiquement aucune. Le dispositif "iOx" était le meilleur pour identifier correctement les patients hypoxiques mais près d'un quart des patients ont été mal classés. Les trois applications ont fourni des mesures de SpO₂ imprécises et n'ont pas permis de détecter l'hypoxie avec précision. Il ne faut pas se fier à ces applications pour fournir des mesures précises de SpO₂ dans des conditions émergentes, même austères.

Commentaire : Retrouvez les application sur iTunes :
iOx  
Heart Rate and Pulse Oximeter   (non disponible en France).
Pulse Oximeter  .

Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections.
Tran QK, Rehan MA, Haase DJ, Matta A, Pourmand A. | Am J Emerg Med. 2020 May;38(5):983-989
DOI: https://doi.org/10.1016/j.ajem.2019.11.037
Keywords: Anterior epistaxis; Anterior nasal packing; Prophylactic antibiotics.

Reviews

Introduction : Patients presenting to emergency departments with spontaneous anterior epistaxis may undergo anterior nasal packing and sometimes receive systemic prophylactic antibiotics. There has not been sufficient evidence to support or refute this practice. The main objective of this study was to compare the likelihood of clinically significant infection (CSI) between patients with or without prophylactic antibiotics for anterior nasal packing due to spontaneous epistaxis.

Méthode : We performed a meta-analysis of the literature to assess whether prophylactic antibiotics prevented CSI among patients with anterior nasal packing by searching PubMed, Embase, and Scopus databases for original articles. We also looked at the secondary outcome of non-infectious complications. We reported the outcomes using random effect models. Human studies in English, randomized control trials, quasi-randomized trials, clinical trials, retrospective studies, and case series were included. We excluded studies involving patients undergoing otolaryngologic surgeries. Statistical heterogeneity was examined using the DerSimonian and Laird Q test and I² statistic.

Résultats : A total of 281 articles were identified. Of these, 5 articles met inclusion criteria, with 383 patients receiving anterior nasal packing. One hundred sixty (42%) patients did not receive prophylactic antibiotics while 223 (58%) received antibiotics. The proportion of CSI in the pooled cohort was 0.8% (95% CI 0.2-1.9), resulting in a number needed to treat (NNT) to prevent one infection of 571. The rate of non-infectious complications associated with epistaxis was 20% (95% CI 10-32).

Conclusion : This meta-analysis suggests that prescribing prophylactic antibiotics for anterior nasal packing may not be necessary due to the low proportion of CSIs across heterogenous patient populations. Further high-quality randomized trials are needed to support this finding.

Conclusion (proposition de traduction) : Cette méta-analyse suggère que l'antibioprophylaxie pour le méchage antérieur pourrait ne pas être nécessaire en raison de la faible proportion d'infections cliniquement significatives dans les populations de patients hétérogènes. D'autres essais randomisés de haute qualité sont nécessaires pour étayer cette conclusion.

Ultrasound for airway management: An evidence-based review for the emergency clinician.
Gottlieb M, Holladay D, Burns KM, Nakitende D, Bailitz J. | Am J Emerg Med. 2020 May;38(5):1007-1013
DOI: https://doi.org/10.1016/j.ajem.2019.12.019
Keywords: Airway, intubation; Cricothyroidotomy; Endotracheal; Ultrasound.

Reviews

Introduction : Airway management is a common procedure performed in the Emergency Department with significant potential for complications. Many of the traditional physical examination maneuvers have limitations in the assessment and management of difficult airways. Point-of-care ultrasound (POCUS) has been increasingly studied for the evaluation and management of the airway in a variety of settings.

Méthode : This article summarizes the current literature on POCUS for airway assessment, intubation confirmation, endotracheal tube (ETT) depth assessment, and performing cricothyroidotomy with an emphasis on those components most relevant for the Emergency Medicine clinician.

Discussion : POCUS can be a useful tool for identifying difficult airways by measuring the distance from the skin to the thyrohyoid membrane, hyoid bone, or epiglottis. It can also predict ETT size better than age-based formulae. POCUS is highly accurate for confirming ETT placement in adult and pediatric patients. The typical approach involves transtracheal visualization but can also include lung sliding and diaphragmatic elevation. ETT depth can be assessed by visualizing the ETT cuff in the trachea, as well as using lung sliding and the lung pulse sign. Finally, POCUS can identify the cricothyroid membrane more quickly and accurately than the landmark-based approach.

Conclusion : Airway management is a core skill in the Emergency Department. POCUS can be a valuable tool with applications ranging from airway assessment to dynamic cricothyroidotomy. This paper summarizes the key literature on POCUS for airway management.

Conclusion (proposition de traduction) : La gestion des voies respiratoires est une compétence essentielle au service des urgences. L'échographie au point d'intervention peut être un outil précieux avec des applications allant de l'évaluation des voies respiratoires à la cricothyroïdotomie dynamique. Cet article résume la littérature clé sur l'échographie au point d'intervention pour la gestion des voies respiratoires.

Presentation Times of Myocardial Infarctions to the Emergency Department: Disappearance of the Morning Predominance.
Masiewicz S, Gutovitz S, Hart L, Leaman SM, Jehle D. | J Emerg Med. 2020 May;58(5):741-748
DOI: https://doi.org/10.1016/j.jemermed.2020.01.002
Keywords: Emergency Department; NSTEMI; STEMI; acute myocardial infarction; circadian; daily; diurnal; seasonal.

Research article

Introduction : Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning.
Objectives: We hypothesized that there no longer is a morning predominance of MI, and that the timing of ST-elevation myocardial infarction (STEMI) vs. non-ST-elevation myocardial infarction (NSTEMI) presentation differs.

Méthode : We reviewed MI, STEMI, and NSTEMI patients (2013-2017) from a multiple-hospital system, identified by diagnostic codes. Daily emergency department arrival times were categorized into variable time intervals for count and proportional analysis, then examined for differences.

Résultats : There were 18,663 MI patients from 12 hospitals included in the analysis. Most MIs occurred between 12:00 pm and 5:59 pm (35.7%), and least between 12:00 am-5:59 am (16.3%). After subdividing all MIs into STEMIs and NSTEMIs, both groups continued to have the greatest presentation between 12:00 pm and 5:59 pm (33.1% and 36.0%, respectively). STEMIs (17.2%) and NSTEMIs (16.2%) were least frequent between 12:00 am and 5:59 am. We found the second most common presentation time for MIs was in the 6 pm-11:59 pm time period, which held true for both subtypes (MI 26.7%, STEMI 26.4%, NSTEMI 26.7%).

Conclusion : These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.

Conclusion (proposition de traduction) : Ces données suggèrent un changement potentiel dans le schéma circadien des infarctus du myocarde, révélant une prédominance dans l'après-midi pour les sous-types STEMI et NSTEMI.

The Gut Microbiome Distinguishes Mortality in Trauma Patients Upon Admission to the Emergency Department.
Burmeister DM, Johnson TR, Lai Z, Scroggins SR, DeRosa M, Jonas RB, Zhu C, Scherer E, Stewart RM, Schwacha MG, Jenkins DH, Eastridge BJ, Nicholson SE. | J Trauma Acute Care Surg. 2020 May;88(5):579-587
DOI: https://doi.org/10.1097/ta.0000000000002612
Keywords: Aucun

AAST 2019 PODIUM PAPERS

Introduction : Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients.

Méthode : We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses.

Résultats : Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05).

Conclusion : Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients.

Conclusion (proposition de traduction) : La diversité des microbiomes intestinaux à l'admission chez les patients gravement blessés est prédictive d'une variété de résultats cliniquement importants. Bien que notre étude n'aborde pas la question de la causalité, le microbiome intestinal des patients traumatisés peut fournir des cibles diagnostiques et thérapeutiques précieuses pour les soins des patients blessés.

Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock.
Moore HB, Tessmer MT, Moore EE, Sperry JL, Cohen MJ, Chapman MP, Pusateri AE, Guyette FX, Brown JB, Neal MD, Zuckerbraun B, Sauaia A. | J Trauma Acute Care Surg. 2020 May;88(5):588-596
DOI: https://doi.org/10.1097/ta.0000000000002614
Keywords: Aucun

AAST 2019 PODIUM PAPERS

Introduction : Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival.

Méthode : We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less.

Résultats : Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index).

Conclusion : Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy.

Conclusion (proposition de traduction) : Le plasma préhospitalier dans les traumatismes civils est associé à une hypocalcémie, qui à son tour prédit une survie plus faible et une transfusion massive. Ces données soulignent la nécessité de directives explicites de supplémentation en calcium en hémothérapie préhospitalière.

Commentaire : Les lignes directrices européennes publiées en 2019 (Crit Care. 2019;23(1):98  ) préconisaient 10 % de chlorure de calcium (270 mg de calcium élémentaire/10 ml) plutôt que 10 % de gluconate de calcium (90 mg de calcium élémentaire/10 ml), en particulier en présence d'une fonction hépatique anormale, car la diminution du métabolisme des citrates entraîne une libération plus lente de l'i-Ca. Il est important de noter que les deux sels de calcium doivent être administrés lentement pour éviter les effets cardiaques, et que l'extravasation dans les tissus mous peut provoquer de graves lésions (Cutis. 2000;65(4):193–194  ). En raison du faible risque d'effets iatrogènes du gluconate de calcium, nous préconisons d'administrer 1 g (10 ml) pour chaque 1 à 2 U de produits sanguins (plasma compris) et de surveiller les niveaux d'i-Ca à l'admission de manière précoce et souvent chez les patients en état de choc hémorragique.

Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis.
Mehra MR, Desai SS, Ruschitzka F, Patel AN. | Lancet. 2020 May 22:S0140-6736(20)31180-6
DOI: https://doi.org/10.1016/S0140-6736(20)31180-6  | Télécharger l'article au format  
Keywords: Aucun

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Introduction : Hydroxychloroquine or chloroquine, often in combination with a second-generation macrolide, are being widely used for treatment of COVID-19, despite no conclusive evidence of their benefit. Although generally safe when used for approved indications such as autoimmune disease or malaria, the safety and benefit of these treatment regimens are poorly evaluated in COVID-19.

Méthode : We did a multinational registry analysis of the use of hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19. The registry comprised data from 671 hospitals in six continents. We included patients hospitalised between Dec 20, 2019, and April 14, 2020, with a positive laboratory finding for SARS-CoV-2. Patients who received one of the treatments of interest within 48 h of diagnosis were included in one of four treatment groups (chloroquine alone, chloroquine with a macrolide, hydroxychloroquine alone, or hydroxychloroquine with a macrolide), and patients who received none of these treatments formed the control group. Patients for whom one of the treatments of interest was initiated more than 48 h after diagnosis or while they were on mechanical ventilation, as well as patients who received remdesivir, were excluded. The main outcomes of interest were in-hospital mortality and the occurrence of de-novo ventricular arrhythmias (non-sustained or sustained ventricular tachycardia or ventricular fibrillation).

Résultats : 96 032 patients (mean age 53·8 years, 46·3% women) with COVID-19 were hospitalised during the study period and met the inclusion criteria. Of these, 14 888 patients were in the treatment groups (1868 received chloroquine, 3783 received chloroquine with a macrolide, 3016 received hydroxychloroquine, and 6221 received hydroxychloroquine with a macrolide) and 81 144 patients were in the control group. 10 698 (11·1%) patients died in hospital. After controlling for multiple confounding factors (age, sex, race or ethnicity, body-mass index, underlying cardiovascular disease and its risk factors, diabetes, underlying lung disease, smoking, immunosuppressed condition, and baseline disease severity), when compared with mortality in the control group (9·3%), hydroxychloroquine (18·0%; hazard ratio 1·335, 95% CI 1·223–1·457), hydroxychloroquine with a macrolide (23·8%; 1·447, 1·368–1·531), chloroquine (16·4%; 1·365, 1·218–1·531), and chloroquine with a macrolide (22·2%; 1·368, 1·273–1·469) were each independently associated with an increased risk of in-hospital mortality. Compared with the control group (0·3%), hydroxychloroquine (6·1%; 2·369, 1·935–2·900), hydroxychloroquine with a macrolide (8·1%; 5·106, 4·106–5·983), chloroquine (4·3%; 3·561, 2·760–4·596), and chloroquine with a macrolide (6·5%; 4·011, 3·344–4·812) were independently associated with an increased risk of de-novo ventricular arrhythmia during hospitalisation.

Conclusion : We were unable to confirm a benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on in-hospital outcomes for COVID-19. Each of these drug regimens was associated with decreased in-hospital survival and an increased frequency of ventricular arrhythmias when used for treatment of COVID-19.

Conclusion (proposition de traduction) : Nous n'avons pas été en mesure de confirmer un avantage de l'hydroxychloroquine ou de la chloroquine, lorsqu'ils sont utilisés seuls ou avec un macrolide, sur les résultats à l'hôpital pour le COVID-19. Chacun de ces schémas thérapeutiques était associé à une diminution de la survie à l'hôpital et à une fréquence accrue des arythmies ventriculaires lorsqu'il était utilisé pour le traitement du COVID-19.

Out-of-hospital Cardiac Arrest During the COVID-19 Pandemic in Paris, France: A Population-Based, Observational Study.
Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C, Sharifzadehgan A, Waldmann V, Beganton F, Narayanan K, Lafont A, Bougouin W, Jouven X. | Lancet Public Health. 2020 May 27:S2468-2667(20)30117-1
DOI: https://doi.org/10.1016/s2468-2667(20)30117-1  | Télécharger l'article au format  
Keywords: Aucun

Article

Introduction : Although mortality due to COVID-19 is, for the most part, robustly tracked, its indirect effect at the population level through lockdown, lifestyle changes, and reorganisation of health-care systems has not been evaluated. We aimed to assess the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in an urban region during the pandemic, compared with non-pandemic periods.

Méthode : We did a population-based, observational study using data for non-traumatic OHCA (N=30 768), systematically collected since May 15, 2011, in Paris and its suburbs, France, using the Paris Fire Brigade database, together with in-hospital data. We evaluated OHCA incidence and outcomes over a 6-week period during the pandemic in adult inhabitants of the study area.

Résultats : Comparing the 521 OHCAs of the pandemic period (March 16 to April 26, 2020) to the mean of the 3052 total of the same weeks in the non-pandemic period (weeks 12-17, 2012-19), the maximum weekly OHCA incidence increased from 13·42 (95% CI 12·77-14·07) to 26·64 (25·72-27·53) per million inhabitants (p<0·0001), before returning to normal in the final weeks of the pandemic period. Although patient demographics did not change substantially during the pandemic compared with the non-pandemic period (mean age 69·7 years [SD 17] vs 68·5 [18], 334 males [64·4%] vs 1826 [59·9%]), there was a higher rate of OHCA at home (460 [90·2%] vs 2336 [76·8%]; p<0·0001), less bystander cardiopulmonary resuscitation (239 [47·8%] vs 1165 [63·9%]; p<0·0001) and shockable rhythm (46 [9·2%] vs 472 [19·1%]; p<0·0001), and longer delays to intervention (median 10·4 min [IQR 8·4-13·8] vs 9·4 min [7·9-12·6]; p<0·0001). The proportion of patients who had an OHCA and were admitted alive decreased from 22·8% to 12·8% (p<0·0001) in the pandemic period. After adjustment for potential confounders, the pandemic period remained significantly associated with lower survival rate at hospital admission (odds ratio 0·36, 95% CI 0·24-0·52; p<0·0001). COVID-19 infection, confirmed or suspected, accounted for approximately a third of the increase in OHCA incidence during the pandemic.

Conclusion : A transient two-times increase in OHCA incidence, coupled with a reduction in survival, was observed during the specified time period of the pandemic when compared with the equivalent time period in previous years with no pandemic. Although this result might be partly related to COVID-19 infections, indirect effects associated with lockdown and adjustment of health-care services to the pandemic are probable. Therefore, these factors should be taken into account when considering mortality data and public health strategies.

Conclusion (proposition de traduction) : Une augmentation transitoire de deux fois l'incidence des arrêts cardiaques extra-hospitaliers, associée à une réduction de la survie, a été observée pendant la période de la pandémie par rapport à la période équivalente des années précédentes sans pandémie. Bien que ce résultat puisse être en partie lié aux infections par COVID-19, des effets indirects liés au verrouillage et à l'adaptation des services de santé à la pandémie sont probables. Ces facteurs doivent donc être pris en compte lors de l'examen des données de mortalité et des stratégies de santé publique.

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.

Coronavirus Infections in Children Including COVID-19: An Overview of the Epidemiology, Clinical Features, Diagnosis, Treatment and Prevention Options in Children.
Zimmermann P, Curtis N. | Pediatr Infect Dis J. 2020 May;39(5):355-368
DOI: https://doi.org/10.1097/inf.0000000000002660
Keywords: Aucun

Special Article

Editorial : Coronaviruses (CoVs) are a large family of enveloped, single-stranded, zoonotic RNA viruses. Four CoVs commonly circulate among humans: HCoV2-229E, -HKU1, -NL63 and -OC43. However, CoVs can rapidly mutate and recombine leading to novel CoVs that can spread from animals to humans. The novel CoVs severe acute respiratory syndrome coronavirus (SARS-CoV) emerged in 2002 and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012. The 2019 novel coronavirus (SARS-CoV-2) is currently causing a severe outbreak of disease (termed COVID-19) in China and multiple other countries, threatening to cause a global pandemic. In humans, CoVs mostly cause respiratory and gastrointestinal symptoms. Clinical manifestations range from a common cold to more severe disease such as bronchitis, pneumonia, severe acute respiratory distress syndrome, multi-organ failure and even death. SARS-CoV, MERS-CoV and SARS-CoV-2 seem to less commonly affect children and to cause fewer symptoms and less severe disease in this age group compared with adults, and are associated with much lower case-fatality rates. Preliminary evidence suggests children are just as likely as adults to become infected with SARS-CoV-2 but are less likely to be symptomatic or develop severe symptoms. However, the importance of children in transmitting the virus remains uncertain. Children more often have gastrointestinal symptoms compared with adults. Most children with SARS-CoV present with fever, but this is not the case for the other novel CoVs. Many children affected by MERS-CoV are asymptomatic. The majority of children infected by novel CoVs have a documented household contact, often showing symptoms before them. In contrast, adults more often have a nosocomial exposure. In this review, we summarize epidemiologic, clinical and diagnostic findings, as well as treatment and prevention options for common circulating and novel CoVs infections in humans with a focus on infections in children.

Conclusion : SARS-CoV, MERS-CoV and SARS-CoV-2 infections seem to affect children less commonly and less severely as compared with adults. This might be because children are less frequently exposed to the main sources of transmission (which until now has been disproportionally nosocomial) or because they are less exposed to animals. However, it could also be that children are less frequently symptomatic or have less severe symptoms and are therefore less often tested, leading to an underestimate of the true numbers infected. In relation to SARS-CoV-2, a study prepublished in early March 2020 suggests that children are just as likely as adults to become infected with this virus but are less likely to be symptomatic or develop severe symptoms. However, the importance of children in transmitting the virus remains uncertain. The majority of children infected by a novel CoVs reported thus far have a documented household contact, often showing symptoms before them, suggesting the possibility that children are not an important reservoir for novel CoVs. The clinical, laboratory and radiologic features in children are similar for all novel CoVs, except more children infected with SARS-CoV presented with fever compared with SARS-CoV-2 or MERS-CoV. To date, no deaths in children have been reported for SARS-CoV or SARS-CoV-2, except (in the case of the former) for infants of mothers who were infected during pregnancy.

Conclusion (proposition de traduction) : Les infections par le SRAS-CoV, le MERS-CoV et le SRAS-CoV-2 semblent toucher les enfants moins fréquemment et moins gravement que les adultes. Cela peut être dû au fait que les enfants sont moins fréquemment exposés aux principales sources de transmission (qui jusqu'à présent étaient disproportionnellement nosocomiales) ou parce qu'ils sont moins exposés aux animaux. Cependant, il se pourrait également que les enfants présentent moins fréquemment des symptômes ou présentent des symptômes moins graves et soient donc moins souvent testés, ce qui conduit à une sous-estimation du nombre réel de personnes infectées. En ce qui concerne le SRAS-CoV-2, une étude prépubliée au début de mars 2020 suggère que les enfants sont tout aussi susceptibles que les adultes d'être infectés par ce virus, mais sont moins susceptibles d'être symptomatiques ou de développer des symptômes graves. Cependant, l'importance des enfants dans la transmission du virus reste incertaine. La majorité des enfants infectés par un nouveau CoV rapporté jusqu'à présent ont un contact domestique documenté, montrant souvent des symptômes devant eux, suggérant la possibilité que les enfants ne soient pas un réservoir important pour de nouveaux CoV. Les caractéristiques cliniques, de laboratoire et radiologiques chez les enfants sont similaires pour tous les nouveaux CoV, à l'exception de plus d'enfants infectés par le SRAS-CoV présentant de la fièvre par rapport au SARS-CoV-2 ou MERS-CoV. À ce jour, aucun décès n'a été signalé chez les enfants pour le SRAS-CoV ou le SRAS-CoV-2, sauf (dans le cas du premier) pour les nourrissons de mères infectées pendant la grossesse.

Commentaire : La très grande majorité des enfants sont contaminés dans la cellule familiale, dans le sens adulte vers enfants (82 %).