Bibliographie de Médecine d'Urgence

Mois de juin 2020


Academic Emergency Medicine

Symptom Criteria for COVID-19 Testing of Heath Care Workers.
Clemency BM, Varughese R, Scheafer DK, Ludwig B, Welch JV, McCormack RF, Ma C, Nan N, Giambra T, Raab T. | Acad Emerg Med. 2020 Jun;27(6):469-474
DOI: https://doi.org/10.1111/acem.14009  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Symptom criteria for COVID-19 testing of heath care workers (HCWs) limitations on testing availability have been challenging during the COVID-19 pandemic. An evidence-based symptom criteria for identifying HCWs for testing, based on the probability of positive COVID-19 test results, would allow for a more appropriate use of testing resources.

Méthode : This was an observational study of outpatient COVID-19 testing of HCWs. Prior to testing, HCWs were asked about the presence of 10 symptoms. Their responses were then compared to their subsequent pharyngeal swab COVID-19 polymerase chain reaction test results. These data were used to derive and evaluate a symptom-based testing criteria.

Résultats : A total of 961 HCWs were included in the analysis, of whom 225 (23%) had positive test results. Loss of taste or smell was the symptom with the largest positive likelihood ratio (3.33). Dry cough, regardless of the presence or absence of other symptoms, was the most sensitive (74%) and the least specific (32%) symptom. The existing testing criteria consisting of any combination of one or more of three symptoms (fever, shortness of breath, dry cough) was 93% sensitive and 9% specific (area unce the curve [AUC] = 0.63, 95% confidence interval [CI] = 0.59 to 0.67). The derived testing criteria consisting of any combination of one or more of two symptoms (fever, loss of taste or smell) was 89% sensitive and 48% specific (AUC = 0.75, 95% CI = 0.71 to 0.78). The hybrid testing criteria consisting of any combination of one or more of four symptoms (fever, shortness of breath, dry cough, loss of taste or smell) was 98% sensitive and 8% specific (AUC = 0.77, 95% CI = 0.73 to 0.80).

Conclusion : An evidence-based approach to COVID-19 testing that at least includes fever and loss of taste or smell should be utilized when determining which HCWs should be tested.

Conclusion (proposition de traduction) : Une approche fondée sur des données probantes pour les critères de réalisation des tests COVID-19, incluant au moins la fièvre et la perte du goût ou de l'odorat, devrait être utilisée pour déterminer quels personnels de santé devraient être testés

Emergency Potassium Normalization Treatment Including Sodium Zirconium Cyclosilicate: A Phase II, Randomized, Double-blind, Placebo-controlled Study (ENERGIZE).
Peacock WF, Rafique Z, Vishnevskiy K, Michelson E, Vishneva E, Zvereva T, Nahra R, Li D, Miller J. | Acad Emerg Med. 2020 Jun;27(6):475-486
DOI: https://doi.org/10.1111/acem.13954  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Sodium zirconium cyclosilicate (SZC) is a novel, highly selective potassium binder currently approved in the United States and European Union for treatment of hyperkalemia. This pilot evaluation explored the efficacy of SZC with insulin and glucose as hyperkalemia treatment in the emergency department (ED).

Méthode : This exploratory, phase II, multicenter, randomized, double-blind, placebo-controlled study (NCT03337477) enrolled adult ED patients with blood potassium ≥ 5.8 mmol/L. Patients were randomized 1:1 to receive SZC 10 g or placebo, up to three times during a 10-hour period, with insulin and glucose. The primary efficacy outcome was the mean change in serum potassium (sK+ ) from baseline until 4 hours after start of dosing.

Résultats : Overall, 70 patients were randomized (SZC n = 33, placebo n = 37), of whom 50.0% were male. Their mean (± standard deviation [±SD]) age was 59.0 (±13.8) years and mean initial sK+ was similar between groups (SZC 6.4 mmol/L, placebo 6.5 mmol/L). The least squares mean (±SD) sK+ change from baseline to 4 hours was -0.41 (±0.11) mmol/L and -0.27 (±0.10) mmol/L with SZC and placebo, respectively (difference = -0.13 mmol/L, 95% confidence interval [CI] = -0.44 to 0.17). A greater reduction in mean (±SD) sK+ from baseline occurred with SZC compared with placebo at 2 hours: -0.72 (±0.12) versus -0.36 (±0.11) mmol/L (LSM difference = -0.35 mmol/L, 95% CI = -0.68 to -0.02), respectively. A numerically lower proportion of patients in the SZC group required additional potassium-lowering therapy due to hyperkalemia at 0 to 4 hours versus placebo (15.6% vs. 30.6%, respectively; odds ratio = 0.40, 95% CI = 0.09 to 1.77). Comparable proportions of patients experienced adverse events in both treatment groups at 0 to 24 hours.

Conclusion : This pilot study suggested that SZC with insulin and glucose may provide an incremental benefit in the emergency treatment of hyperkalemia over insulin and glucose alone.

Conclusion (proposition de traduction) : Cette étude pilote suggére que le SZC associé à l'insuline et au glucose pourrait fournir un avantage supplémentaire dans le traitement d'urgence de l'hyperkaliémie par rapport à l'insuline et au glucose seuls.

Commentaire : Voir sur le sujet :
• Packham DK, Rasmussen HS, Lavin PT, El-Shahawy MA, Roger SD, Block G, Qunibi W, Pergola P, Singh B. Sodium zirconium cyclosilicate in hyperkalemia. N Engl J Med. 2015 Jan 15;372(3):222-31  .
• Hoy SM. Sodium Zirconium Cyclosilicate: A Review in Hyperkalaemia. Drugs. 2018 Oct;78(15):1605-1613  .

Pour information : Le Lokelma® poudre pour suspension buvable de AstraZeneca (produit non disponible en France) est une résine échangeuse de cations qui fixe sélectivement le potassium grâce à des micropores, en échange de protons (H+) et de sodium (Na+), puis l’ensemble est éliminé dans les selles. Il s’agit d’une structure cubique microporeuse composée d’atomes de zirconium (Zr) et de silicium (Si) coordonnés à des atomes d’oxygènes.

Annals of Emergency Medicine

Artificial Intelligence in Emergency Medicine: Surmountable Barriers With Revolutionary Potential.
Grant K, McParland A, Mehta S, Ackery AD. | Ann Emerg Med. 2020 Jun;75(6):721-726
DOI: https://doi.org/10.1016/j.annemergmed.2019.12.024  | Télécharger l'article au format  
Keywords: Aucun

The Practice of Emergency Medicine

Editorial : Artificial intelligence just might be the next major technologic breakthrough to affect health care delivery, with seemingly endless possibilities for the improvement of patient care and optimization of the health care system overall. Simply defined, artificial intelligence is a field of computer science focused on enabling computers to complete tasks or generate knowledge that, in the traditional sense, would typically require human intelligence. Within the topic of artificial intelligence, there are the fields of machine learning and deep learning. Machine learning refers to the ability of computer systems to automatically improve their functioning, or “learn,” in accordance with continued exposure to data, as opposed to being explicitly coded to complete to a specific task. Deep learning similarly works to determine relationships between inputs and outputs, but leverages a more complex network of nodes between the inputs and outputs that enable deep learning algorithms to more accurately solve complex problems. Machine learning and deep learning differ critically from other computerized tools in that they do not simply execute tasks or generate data based on preprogrammed human assumptions, but rather “learn” through the creation and testing of assumptions they generates autonomously through the analysis of large amounts of data.

Conclusion : Implementing these changes in the conceptualization and design of artificial intelligence technologies would help ensure that they address clinically meaningful problems, that they are able to be readily integrated into existing health care information technology systems, and that providers can—and want to—use them.

Conclusion (proposition de traduction) : La mise en œuvre de ces changements dans la conceptualisation et la conception des technologies d'intelligence artificielle aiderait à garantir qu'elles traitent des problèmes cliniquement significatifs, qu'elles peuvent être facilement intégrées dans les systèmes de technologie de l'information sur les soins de santé existants et que les prestataires peuvent - et souhaitent - les utiliser.

Oral Ondansetron to Reduce Vomiting in Children Receiving Intranasal Fentanyl and Inhaled Nitrous Oxide for Procedural Sedation and Analgesia: A Randomized Controlled Trial.
Fauteux-Lamarre E, McCarthy M, Quinn N, Davidson A, Legge D, Lee KJ, Palmer GM, Babl FE, Hopper SM. | Ann Emerg Med. 2020 Jun;75(6):735-743
DOI: https://doi.org/10.1016/j.annemergmed.2019.11.019
Keywords: Aucun

Pediatrics

Introduction : Intranasal fentanyl and inhaled nitrous oxide are increasingly combined to provide procedural sedation and analgesia in the pediatric emergency setting. This regimen is attractive because of its nonparenteral administration, but is associated with a higher incidence of vomiting than nitrous oxide alone. We seek to assess whether prophylactic oral ondansetron use could reduce the incidence of vomiting associated with intranasal fentanyl and nitrous oxide for procedural sedation compared with placebo.

Méthode : This was a double-blind, randomized controlled trial of oral ondansetron versus placebo conducted at a single tertiary care pediatric emergency department. Children aged 3 to 18 years with planned sedation with intranasal fentanyl and nitrous oxide were randomized to receive oral ondansetron or placebo 30 to 60 minutes before nitrous oxide administration. The primary outcome was early vomiting associated with procedural sedation, defined as occurring during or up to 1 hour after nitrous oxide administration. Secondary outcomes included vomiting 1 to 24 hours after procedural sedation, procedural sedation duration, adverse events, and quality of sedation across the 2 groups.

Résultats : We recruited 442 participants and 436 were included for analysis. There was no significant difference in the primary outcome, early vomiting associated with procedural sedation, between the groups: ondansetron 12% versus placebo 16%, with a difference in proportions of -4.6% (95% confidence interval -11% to 2.0%; P=.18). Most sedations were reported as optimal by treating clinicians (91%). Only 2 minor adverse events occurred, both in the placebo group.

Conclusion : Oral ondansetron does not significantly reduce vomiting during or shortly after procedural sedation with combined intranasal fentanyl and inhaled nitrous oxide.

Conclusion (proposition de traduction) : L'ondansétron per os ne réduit pas significativement les vomissements pendant, ou peu de temps après, la sédation procédurale avec du fentanyl intranasal combiné au protoxyde d'azote.

Managing Hypertension in Patients With Acute Stroke.
Cocchi MN, Edlow JA. | Ann Emerg Med. 2020 Jun;75(6):767-771
DOI: https://doi.org/10.1016/j.annemergmed.2019.09.015
Keywords: Aucun

Neurology

Introduction : For patients presenting to the emergency department (ED) with acute stroke, treatments in the minutes to hours after the event can affect outcomes. Patients with acute stroke often present with elevated blood pressure, which can exacerbate the underlying pathology and drive therapeutic interventions. This article focuses on the current evidence-based approach to blood pressure management in the setting of acute stroke, including acute ischemic stroke, aneurysmal subarachnoid hemorrhage, and intraparenchymal hemorrhage. When direct evidence is lacking, we suggest approaches based on what data do exist, pathophysiologic principles, and our own practice provides a concise summary of existing recommendations and targets based on cause.

Conclusion : Optimal blood pressure targets in the setting of acute ischemic stroke, acute subarachnoid hemorrhage, and spontaneous intracerebral hemorrhage remain somewhat controversial, and the evidence is evolving. Guidelines offer a data-driven framework to make decisions, but by necessity, they suggest general approaches to individual patients. Target blood pressure goals should be informed by existing evidence-based guidelines but tailored to individual patients.

Conclusion (proposition de traduction) : Les cibles optimales de pression artérielle dans le cadre d'un AVC ischémique aigu, d'une hémorragie sous-arachnoïdienne aiguë et d'une hémorragie intracérébrale spontanée restent quelque peu controversées et les preuves évoluent. Les lignes directrices offrent un cadre fondé sur les données pour prendre des décisions, mais par nécessité, elles suggèrent des approches générales aux patients individuels. Les objectifs cibles en matière de tension artérielle doivent être fixées par les lignes directrices existantes fondées sur des preuves mais adaptés à chaque patient.

Biology of Sex Differences

Sex differences in pharmacokinetics predict adverse drug reactions in women.
Zucker I, Prendergast BJ. | Biol Sex Differ. 2020 Jun 5;11(1):32
DOI: https://doi.org/10.1186/s13293-020-00308-5  | Télécharger l'article au format  
Keywords: Adverse drug reactions; Drugs; Pharmacokinetics; Sex differences.

Research

Introduction : Women experience adverse drug reactions, ADRs, nearly twice as often as men, yet the role of sex as a biological factor in the generation of ADRs is poorly understood. Most drugs currently in use were approved based on clinical trials conducted on men, so women may be overmedicated. We determined whether sex differences in drug pharmacokinetics, PKs, predict sex differences in ADRs.

Méthode : Searches of the ISI Web of Science and PubMed databases were conducted with combinations of the terms: drugs, sex or gender, pharmacokinetics, pharmacodynamics, drug safety, drug dose, and adverse drug reaction, which yielded over 5000 articles with considerable overlap. We obtained information from each relevant article on significant sex differences in PK measures, predominantly area under the curve, peak/maximum concentrations, and clearance/elimination rates. ADRs were identified from every relevant article and recorded categorically as female-biased, male-biased, or not sex-biased.

Résultats : For most of the FDA-approved drugs examined, elevated blood concentrations and longer elimination times were manifested by women, and these PKs were strongly linked to sex differences in ADRs. Of the 86 drugs evaluated, 76 had higher PK values in women; for 59 drugs with clinically identifiable ADRs, sex-biased PKs predicted the direction of sex-biased ADRs in 88% of cases. Ninety-six percent of drugs with female-biased PK values were associated with a higher incidence of ADRs in women than men, but only 29% of male-biased PKs predicted male-biased ADRs. Accessible PK information is available for only a small fraction of all drugs.

Conclusion : Sex differences in pharmacokinetics strongly predict sex-specific ADRs for women but not men. This sex difference was not explained by sex differences in body weight. The absence of sex-stratified PK information in public records for hundreds of drugs raises the concern that sex differences in PK values are widespread and of clinical significance. The common practice of prescribing equal drug doses to women and men neglects sex differences in pharmacokinetics and dimorphisms in body weight, risks overmedication of women, and contributes to female-biased adverse drug reactions. We recommend evidence-based dose reductions for women to counteract this sex bias.

Conclusion (proposition de traduction) : Les différences de sexe dans la pharmacocinétique prédisent fortement les effets indésirables spécifiques au sexe chez les femmes mais pas chez les hommes. Cette différence de sexe n'était pas expliquée par les différences de poids corporel entre les sexes. L'absence d'informations pharmacocinétiques stratifiées par sexe dans les dossiers publics pour des centaines de médicaments soulève la préoccupation que les différences entre les sexes dans les valeurs pharmacocinétiques soient répandues et d'importance clinique. La pratique courante consistant à prescrire des doses égales de médicaments aux femmes et aux hommes néglige les différences entre les sexes dans la pharmacocinétique et les dimorphismes du poids corporel, risque de surmédication chez les femmes et contribue à des effets indésirables féminins. Nous recommandons des réductions de dose fondées sur des données probantes pour les femmes afin de contrer ce biais sexuel.

Commentaire : Voir l'analyse de l'article sur le site Medscape : Hommes/femmes : doit-on adapter les doses des médicaments ?  . Rédigé par Marine Cygler le 1er septembre 2020.

BMC Emergency Medicine

Evaluation of manual chest compressions according to the updated cardiopulmonary resuscitation guidelines and the impact of feedback devices in an educational resuscitation course.
Urushibata N, Murata K, Endo H, Yoshiyuki A, Otomo Y. | BMC Emerg Med. 2020 Jun 16;20(1):49
DOI: https://doi.org/10.1186/s12873-020-00345-8  | Télécharger l'article au format  
Keywords: Basic life support; Cardiopulmonary resuscitation; Feedback

Research article

Introduction : The cardiopulmonary resuscitation guidelines revised in 2015 recommend target chest compression rate (CCR) and chest compression depth (CCD) of 100-120 compressions per minute (cpm) and 5-6 cm, respectively. We hypothesized that the new guidelines are harder to comply with, even with proper feedback.

Méthode : This prospective observational study using data collected from the participants of an Immediate Cardiac Life Support course included the evaluation of chest compressions using performance data from a feedback device after the completion of the course. Participants completed chest compressions for 1 min and were provided with feedback, after which they performed another cycle of CC. Primary outcome measures were CCR and CCD as well as the correct CCR percentage and CCD percentage for pre and post feedback.

Résultats : The study included a total of 88 participants. The median pre-CCR was 112.5 cpm (interquartile range [IQR] 108-116 cpm), and the median correct pre-CCR percentage was 96% (IQR 82.5-99.5%). After the feedback, there was a slight increase in the correct CCR percentage (99% [IQR 92.5-100%]). Conversely, the median pre-CCD was 5.4 cm (IQR 4.9-5.8 cm), and the median pre-correct CCD percentage was 66% (IQR 18.5-90%). The increase in the median post-correct CCD percentage to 72% (IQR 27-94%) observed after the feedback was not statistically significant (P = 0.361).

Conclusion : Compliance with the new guidelines for chest compressions, especially those regarding the CCD, might be difficult. However, whether the changes in guidelines affect outcomes in actual clinical settings is uncertain and requires further investigation.

Conclusion (proposition de traduction) : Le respect des nouvelles directives pour les compressions thoraciques, en particulier celles concernant la profondeur de compression thoracique, pourrait être difficile. Cependant, la question de savoir si les modifications des lignes directrices affectent les résultats dans les contextes cliniques réels est incertaine et nécessite une enquête plus approfondie.

Use of peripheral vascular access in the prehospital setting: is there room for improvement?.
Gonvers E, Spichiger T, Albrecht E, Dami F. | BMC Emerg Med. 2020 Jun 9;20(1):46
DOI: https://doi.org/10.1186/s12873-020-00340-z  | Télécharger l'article au format  
Keywords: Out-of-hospital; Paramedic; Peripheral vascular access; Prehospital.

Research article

Introduction : Previous studies have shown that prehospital insertion of peripheral vascular access is highly variable. The aim of this study is to establish the proportion of peripheral vascular access placement and its use with regard to both the severity of cases and the main problem suspected by the paramedics involved. Over-triage was considered to have taken place where peripheral vascular access was placed but unused and these cases were specifically analysed in order to evaluate the possibility of improving current practice.

Méthode : This is a one-year (2017) retrospective study conducted throughout one State of Switzerland. Data were extracted from the state's public health service database, collected electronically by paramedics on RescueNet® from Siemens. The following data were collected and analyzed: sex, age, main diagnosis suspected by paramedics and the National Advisory Committee for Aeronautics score (NACA) to classify the severity of cases.

Résultats : A total of 33,055 missions were included, 29,309 (88.7%) with a low severity. A peripheral vascular access was placed in 8603 (26.0%) cases. Among those, 3948 (45.9%) were unused and 2626 (66.5%) of these patients had a low severity score. Opiates represent 48.3% of all medications given. The most frequent diagnosis among unused peripheral vascular access were: respiratory distress (12.7%), neurological deficit without coma or trauma (9.6%), cardiac condition with thoracic pain and without trauma or loss of consciousness (9.6%) and decreased general condition of the patient (8.5%).

Conclusion : Peripheral vascular access was set in 26% of patients, nearly half of which were unused. To reduce over-triage, special attention should be dedicated to cases defined by EMS on site as low severity, as they do not require placement of a peripheral vascular access as a precautionary measure. Alternative routes, such as the intra-nasal route, should be promoted, particularly for analgesia, whose efficiency is well documented. Emergency medical services medical directors may also consider modifying protocols of acute clinical situations when data show that mandatory peripheral vascular access, in stroke cases for example, is almost never used.

Conclusion (proposition de traduction) : L'accès vasculaire périphérique a été posé chez 26 % des patients, dont près de la moitié n'ont pas été utilisés. Afin de réduire le temps supplémentaire, une attention particulière devrait être accordée aux cas définis par les services médicaux d’urgence sur place comme étant de faible gravité, car ils ne nécessitent pas l’installation d’un accès vasculaire périphérique par de mesure de précaution. D’autres voies, telles que la voie intra-nasale, devraient être encouragées, en particulier pour l’analgésie, dont l’efficacité est bien documentée. Les directeurs des services médicaux d’urgence peuvent également envisager de modifier les protocoles des situations cliniques aiguës lorsque les données montrent que l’accès vasculaire périphérique obligatoire, par exemple dans les cas d’AVC, n’est presque jamais utilisé.

Critical Care Medicine

Clinical Features of Coronavirus Disease 2019 Patients With Mechanical Ventilation: A Nationwide Study in China.
Wang T, Tang C, Chen R, Ruan H, Liang W, Guan W, Sang L, Tang R, Zhong N, Li S. | Crit Care Med. 2020 Jun 23:10
DOI: https://doi.org/10.1097/ccm.0000000000004473  | Télécharger l'article au format  
Keywords: Aucun

Online Brief Report: PDF Only

Introduction : The outbreak of coronavirus disease 2019 is becoming a worldwide pandemic. Mechanical ventilation is lifesaving for respiratory distress, this study was designed to delineate the clinical features of the coronavirus disease 2019 patients with mechanical ventilation from a national cohort in China.

Méthode : Design: Prospective observational study.
Setting: The rapid spread of severe acute respiratory syndrome coronavirus 2 has infected more than 7.7 million people and caused more than 423,000 deaths.
Patients: Adult hospitalized coronavirus disease 2019 patients with mechanical ventilation from 557 hospitals from China.
Interventions: None.

Résultats : From a nationwide cohort, 141 coronavirus disease 2019 cases with mechanical ventilation were extracted from 1,590 cases. Cigarette smoke, advanced age, coexisting chronic illness, elevated systolic blood pressure, high body temperature, and abnormal laboratory findings are common in these ventilated cases. Multivariate regression analysis showed that higher odds of in-hospital death was associated with invasive mechanical ventilation requirement (hazard ratio: 2.95; 95% CI, 1.40-6.23; p = 0.005), and coexisting chronic obstructive pulmonary disease (hazard ratio, 4.57; 95% CI, 1.65-12.69; p = 0.004) and chronic renal disease (hazard ratio, 5.45; 95% CI, 1.85-16.12; p = 0.002). Compared with patients with noninvasive mechanical ventilation, patients who needs invasive mechanical ventilation showed higher rate of elevated D-dimer (> 1.5 mg/L) at admission (hazard ratio, 3.28, 95% CI, 1.07-10.10; p = 0.039).

Conclusion : The potential risk factors of elevated D-dimer level could help clinicians to identify invasive mechanical ventilation requirement at an early stage, and coexisting chronic obstructive pulmonary disease or chronic renal disease are independent risk factors associated with fatal outcome in coronavirus disease 2019 patients with mechanical ventilation.

Conclusion (proposition de traduction) : Les taux élevés de D-dimères comme facteur de risque potentiels pourraient aider les cliniciens à identifier les besoins en ventilation mécanique invasive à un stade précoce, et l'insuffisance respiratoire chronique obstructive ou l'insuffisance rénale chronique coexistante sont des facteurs de risque indépendants associés à une évolution fatale chez les patients atteints de coronavirus 2019 en ventilation mécanique.

Current Pulmonology Reports

Current Management Strategies for Primary Spontaneous Pneumothorax.
Welch H, Walker S, Maskell N. | Curr Pulmonol Rep. 2020 June:9;56–62
DOI: https://doi.org/10.1007/s13665-020-00249-9
Keywords: Pneumothorax; ambulatory; conservative management

Article

Introduction : Primary spontaneous pneumothorax is a distressing condition which affects young healthy patients. In this review, we highlight recent advances in the management of primary spontaneous pneumothorax and look to the future with the advent of studies that will have global impact in the area.

Méthode : Recent research has taken a step back from immediate invasive interventions which can confine a patient to a hospital bed, exploring instead alternative approaches such as ambulatory management or observation.

Conclusion : When managing primary spontaneous pneumothoraces acutely, rather than opting for aggressive chest tube drainage, clinicians are encouraged to consider less invasive management options such as conservative observation, aspiration, or insertion of pleural vents. An assessment of the underlying cause of primary spontaneous pneumothorax is essential. Similarly, the clinician must evaluate the risk of recurrence as this influences onward management. In the next few years, we expect further exciting developments emerge that will illuminate these issues further.

Conclusion (proposition de traduction) : Lors de la prise en charge en urgence des pneumothorax spontanés primitifs, plutôt que d'opter pour un drainage agressif avec un drain thoracique, les cliniciens sont encouragés à envisager des options de gestion moins invasives telles que l'observation conservatrice, l'aspiration ou l'insertion d'évents pleuraux. Une évaluation de la cause sous-jacente du pneumothorax spontané primaire est essentielle. De même, le clinicien doit évaluer le risque de récidive car cela influence la prise en charge ultérieure. Au cours des prochaines années, nous nous attendons à ce que d'autres développements passionnants émergent qui éclaireront davantage ces questions.

Education thérapeutique du patient/Therapeutic patient education

COVID-19: An emergency educational model.
Margat A, Pétré B, d’Ivernois JF, Lombrail P, Cailhol1 J, Gagnayre R. | Educ Ther Patient/Ther Patient Educ. 2020 june;12(1):10402
DOI: https://doi.org/10.1051/tpe/2020003  | Télécharger l'article au format  
Keywords: Aucun

Article original

Editorial : La crise sanitaire actuelle rappelle tout l’enjeu de la communication des messages de prévention et de leur compréhension par la population. Si les messages sur les gestes barrières ont été conçus pour être facilement compris, il n’en reste pas moins que le passage du traitement de l’information à la mise en œuvre d’un comportement de santé représente un véritable défi. Pour obtenir des changements de comportements de santé face à l’épidémie, il est impératif de proposer une « éducation d’urgence », couplée à une stratégie d’information, en particulier pour aider les personnes les plus vulnérables et démunies. Dans ce contexte, le Laboratoire Éducations et Pratiques de Santé (LEPS UR 3412) de l’Université Sorbonne Paris Nord a conçu une intervention éducative brève pour les personnes concernées par le COVID-19. Cette intervention (30 min à 1 h) s’adosse à trois champs de pratiques : l’éducation thérapeutique de sortie d’hôpital dite ETP-SH, la littératie en santé et l’identité-logement. Les différentes phases de cette intervention sont proches de celles de celles de l’ETP-SH : un diagnostic éducatif suivi de la négociation des applications possibles avec la personne, une phase d’échanges interactifs, la vérification permanente de la compréhension par la personne et la planification d’une séance téléphonique planifiée à distance.

Conclusion (proposition de traduction) : Dans cette période d’épidémie, la simple répétition de messages de prévention ne garantit pas qu’ils seront appliqués sur une durée encore difficile à estimer. Cela suppose, au contraire, l’acquisition de compétences au moyen d’une véritable stratégie d’information et d’éducation assurant aux personnes concernées un véritable apprentissage. Dans l’urgence, « l’intervention d’éducation brève COVID-19 » est une réponse qui vise à pallier les insuffisances d’une politique de santé dont les responsables n’ont pas suffisamment misé sur la compétence en santé des personnes et ont sous-estimé l’importance de leur littératie en santé.

Emergency Medicine Journal

Undertriage of the elderly major trauma patient continues in major trauma centre care: a retrospective cohort review.
Hoyle AC, Biant LC, Young M. | Emerg Med J. 2020 Jun 16:emermed-2019-208541
DOI: https://doi.org/10.1136/emermed-2019-208541
Keywords: geriatrics; trauma; triage

Trauma

Introduction : Major trauma (Injury Severity Score (ISS) ≥16) in older people is increasing, but concerns persist that major trauma is not always recognised in older patients on triage. This study compared undertriage of older and younger adult major trauma patients in the major trauma centre (MTC) setting to investigate this concern.

Méthode : A retrospective review of Trauma Audit and Research Network data was conducted for three MTCs in the UK for 3 months in 2014. Age, ISS, injury mechanism and injured areas were examined for all severely injured patients (ISS ≥16) and appropriate major trauma triage rates measured via the surrogate markers of trauma team activation and the presence of a consultant first attender, as per standards for major trauma care set by National Confidential Enquiry into Patient Outcomes and Deaths, Royal College of Surgeons of England and the British Orthopaedic Association. Trends in older (age ≥65) and younger (ages 18-64) adult major trauma presentation, triage and reception were reviewed.

Résultats : Of 153 severely injured patients, 46 were aged ≥65. Older patients were significantly less likely to receive the attention of a consultant first attender or trauma team. Similar trends were also seen on subgroup analysis by mechanism of injury or number of injured body areas. Older major trauma patients exhibit a higher mortality, despite a lower median ISS (older patient ISS=20 (IQR 16-25), younger patient ISS=25 (IQR 18-29)).

Conclusion : Older major trauma patients are at greater risk of undertriage, even in the MTC environment. Existing hospital trauma triage practices should be further investigated to explain and reduce undertriage of elderly trauma patients.

Conclusion (proposition de traduction) : Les personnes âgées souffrant de traumatismes majeurs sont plus exposées au risque de voir leurs lésions sous-estimées, même dans l'environnement des centres de traitement médical. Les pratiques existantes de triage des traumatismes dans les hôpitaux devraient être étudiées plus avant afin d'expliquer et tenter de réduire la sous-estimation des lésions des patients âgés souffrant de traumatismes.

BET 2: Video laryngoscopy for patients requiring endotracheal intubation in the emergency department.
Howson A, Goodliff A, Horner D. | Emerg Med J. 2020 Jun;37(6):381-383
DOI: https://doi.org/10.1136/emermed-2020-209962.3
Keywords: Aucun

BEST EVIDENCE TOPIC REPORTS

Editorial : A short-cut review of the literature was carried out to examine whether video laryngoscopy (VL) could improve first-pass success and reduce complication rates in ED patients requiring endotracheal intubation, when compared with direct laryngoscopy. Four papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that current evidence suggests VL is likely to improve first-pass success and reduce oesophageal intubation rates, but there is no evidence at present that it improves clinically relevant outcomes. In addition, no difference was found between first-pass success rates in senior/experienced operators, who should use techniques with which they are familiar.

Conclusion : Finally, several studies report little difference in first-pass success or oesophageal intubation rates when video laryngoscopy is compared with direct laryngoscopy use in experienced operators. It is highly likely that senior staff who have extensive experience and familiarity with direct laryngoscopy are so proficient with this technique that video laryngoscopy adds little benefit.

Conclusion (proposition de traduction) : Enfin, plusieurs études rapportent peu de différence dans le succès du premier essai ou les taux d'intubation œsophagienne lorsque la vidéo-laryngoscopie est comparée à l'utilisation de la laryngoscopie directe chez des opérateurs expérimentés. Il est fort probable que les personnels séniors qui possèdent une vaste expérience et une connaissance approfondie de la laryngoscopie directe soient si compétents avec cette technique que la vidéo-laryngoscopie ajoute peu d'avantages.

The CRASH3 study: prehospital TXA for every injured patient?.
Coats TJ, Lecky FE. | Emerg Med J. 2020 Jun;37(6):392-394
DOI: http://dx.doi.org/10.1136/emermed-2019-209264  | Télécharger l'article au format  
Keywords: Aucun

In perspective

Editorial : The CRASH3 results are out, but do we know what to do? The study enrolled 9202 head- injured patients within 3 hours of injury with a Glasgow Coma Scale (GCS) of ≤12, or any intracranial bleeding on CT scan and randomised them to tranexamic acid (TXA) or placebo. The relative risks (RR) of all- cause mortality (RR: 0.96, 95% CI: 0.89 to 1.04) and head injury death (RR: 0.94, 95% CI: 086 to 1.02) among those receiving TXA were not signif- icant. However, there were significant differences in subgroups who were less severely injured (RR: 0.89, 95% CI: 0.80 to 1.00 if those with GCS=3 or bilateral fixed pupils were excluded, and RR: 0.78, 95% CI: 0.64 to 0.95, in the GCS 9–15 subgroup) or treated earlier (p=0.005 for time effect).
The results need to be considered in the context of earlier CRASH2 results, which showed a reduc- tion in all- cause mortality (RR: 0.91, 95% CI: 0.85 to 0.97) and death due to bleeding (RR: 0.85, 95% CI: 0.76 to 0.96) if trauma patients who were bleeding or at risk of bleeding were given TXA. In both CRASH2 and CRASH3, the TXA was given in the emergency department.

Conclusion : Decisions about the implementation of the CRASH3 results are complex and it seems as if we should think about stratifying patients. The key implementation choices for the GCS <13 group (who probably have an NNT in the hundreds) are whether to move treatment into the prehospital phase and whether the patients with the most severe injuries should be treated. Overall, in high-income settings, it seems reasonable to suggest that prehospital intravenous TXA should be given for all injured patients with a prehospital GCS of ≤12.
The situation for the GCS 13–15 patients (who may have an NNT in the thousands) is more complex, particularly as the current CRASH3 publication does not give all the data needed to estimate an NNT for this group. The three approaches in GCS 13–15 patients are either to only give TXA in the emergency department after a positive CT showing an intracranial bleed; or to give early (prehospital) treatment to all those at risk according to the local CT head scan criteria; or to develop a new method of prehospital risk stratification that emphasises specificity over sensitivity. In the GCS 13–15 group, the current best recommendation seems to be to treat patients in the ED after a bleed is found on CT scan, but the future is likely to be the development of a clinical decision rule for TXA use with higher specificity for cerebral bleeding than the current CT scanning rules.

Conclusion (proposition de traduction) : Les décisions concernant la mise en œuvre des résultats de CRASH3 sont complexes et il semble qu'il faille penser à stratifier les patients. Les principaux choix de mise en œuvre pour le groupe Glasgow Coma Scale <13 (dont le nombre de sujets à traiter (NST) se compte probablement en centaines) sont de savoir s'il faut administrer le traitement à la phase préhospitalière et si les patients présentant les blessures les plus graves doivent être traités. Dans l'ensemble, dans les dans les pays à revenu élevé, il semble raisonnable de suggérer que l'acide tranexamique intraveineux en préhospitalier devrait être administré à tous les patients blessés avec un Glasgow Coma score préhospitalier ≤ 12.
La situation des patients ayant un Glasgow Coma score entre 13-15 (qui peuvent avoir un nombre de sujets à traiter (NST) de plusieurs milliers) est plus complexe, d'autant plus que la publication actuelle de CRASH3 ne donne pas toutes les données nécessaires pour estimer le nombre de patient à traiter pour ce groupe. Les trois approches chez les patients présentant un Glasgow Coma score 13-15 sont soit de ne donner de l'acide tranexamique que dans le service d'urgence après un scanner positif montrant un saignement intracrânien, soit d'administrer le traitement (préhospitalier) précoce à toutes les personnes à risque selon les critères de tomodensitométrie locale, soit de développer une nouvelle méthode de stratification du risque en préhospitalier qui privilégie la spécificité à la sensibilité. Dans le groupe Glasgow Coma Scale 13-15, la meilleure recommandation actuelle semble être de traiter les patients dans le service d'urgence après qu'un saignement ait été détecté par tomodensitométrie, mais l'avenir sera vraisemblablement le développement d'une règle de décision clinique pour l'utilisation de l'acide tranexamique avec une spécificité plus élevée pour les saignements cérébraux que les règles actuelles de la tomodensitométrie.

European Journal of Emergency Medicine

The seven Ts of capillary refill time: more than a clinical sign for septic shock patients.
Vera M, Kattan E, Castro R, Hernández G. | Eur J Emerg Med.  2020 Jun;27(3):169-171
DOI: https://doi.org/10.1097/mej.0000000000000705
Keywords: Aucun

Viewpoint Articles

Editorial : Several scores have been proposed to aid in early identi- fication or prognostic stratification of sepsis at the emer- gency department (ED). Early recognition of septic shock may lead to timely resuscitation with impact on major outcomes. Additionally, scoring systems may have prognostic value and serve for triage decisions. However, despite being useful for rapid decision-making, these scores constitute static risk-assessment methods, and thus are not suitable for monitoring dynamic response to early interventions. Moreover, some scores depend on non-universally available laboratory tests.

Conclusion : CRT is much more than just a clinical sign for septic shock monitoring. Robust physiological background, obser- vational data, and the results of the ANDROMEDA- SHOCK trial position CRT as a fundamental clinical test. Indeed, it appears as superior to proposed scoring systems for typification or triage purposes. Moreover, it has the advantage of serving as a dynamic test that interrogates key cardiovascular functions. Finally, it could be used as a resuscitation target with benefits on major outcomes.

Conclusion (proposition de traduction) : Le temps de recoloration cutanée (TRC) est bien plus qu'un simple signe clinique pour la surveillance du choc septique. Un contexte physiologique solide, des données d'observation et les résultats de l'essai ANDROMEDA-SHOCK positionnent le TRC comme test clinique fondamental. En effet, il semble supérieur aux systèmes de notation proposés à des fins de typage ou de triage. De plus, il présente l'avantage de servir de test dynamique qui interroge les fonctions cardiovasculaires clés. Enfin, il pourrait être utilisé comme objectif de réanimation avec des avantages sur les principaux résultats.

Commentaire : Le TRC (capillary refill time CRT, en anglais) est mesurée en appliquant une pression ferme sur la pulpe de la phalange distale de l'index droit (ou le majeur ou l’annulaire) avec une lame de microscope en verre. La pression a été augmentée jusqu'à ce que la peau soit livide, puis maintenue pendant 10 secondes. Le temps nécessaire à la pulpe pour retrouver sa couleur initiale est enregistré avec un chronomètre et un temps supérieur à 3 secondes est défini comme anormal (trois mesures devant être moyennées). Il se mesure en décubitus dorsal, le membre supérieur au niveau du cœur.
Pour plus d'information sur le TRC, lire : Lakhala K, Ehrmannb S, Boulainc T. Couleur et température de la peau dans l’insuffisance circulatoire aiguë. Réanimation 2009 April;18(3):261—266  

Les sept T pour le temps de recoloration cutanée (TRC) sont affichés dans un ordre logique séquentiel. Voir le texte pour l'explication.

European Society For Emergency Medicine position paper on emergency medical systems' response to COVID-19.
Garcia-Castrillo L, Petrino R, Leach R, Dodt C, Behringer W, Khoury A, Sabbe M. | Eur J Emerg Med. 2020 Jun;27(3):174-177
DOI: https://doi.org/10.1097/mej.0000000000000701  | Télécharger l'article au format  
Keywords: Aucun

Review Articles

Editorial : The 2019 novel coronavirus acute respiratory epidemic is creating a stressed situation in all the health systems of the affected countries. Emergency medical systems and specifically the emergency departments as the front line of the health systems are suffering from overload and severe working conditions, the risk of contagion and transmission of the health professionals adds a substantial burden to their daily work. Under the perspective of European Society For Emergency Medicine, the recommendations provided by the health authorities are reviewed focus on the emergency department's activity.

Conclusion (proposition de traduction) : L'épidémie d'infection respiratoire aiguë du nouveau coronavirus de 2019 crée une situation de stress dans tous les systèmes de santé des pays touchés. Les services médicaux d'urgence et plus particulièrement les urgences en tant que première ligne des systèmes de santé souffrent de surcharge et de conditions de travail difficiles, le risque de contagion et de transmission des professionnels de santé alourdit leur travail quotidien. Dans la perspective de la Société Européenne de Médecine d'Urgence, les recommandations émises par les autorités sanitaires sont revues centrées sur l'activité du service des urgences.

Comparing thoracoabdominal injuries of manual versus load-distributing band cardiopulmonary resuscitation.
Sonnemans LJP, Bayat AR, Bruinen ARC, van Wely MH, Brouwer MA, Bosboom D, van der Hoeven JG, Prokop M, Klein WM. | Eur J Emerg Med. 2020 Jun;27(3):197-201
DOI: https://doi.org/10.1097/mej.0000000000000642
Keywords: Aucun

Original Articles

Introduction : To identify and compare manual and load- distributing band (LDB) cardiopulmonary resuscitation (CPR)-related injuries.

Méthode : Retrospective observational cohort study. Adult, nontraumatic deaths with a postmortem computed tomography scan (PMCT) performed were classified into two groups: deceased after LDB CPR or after manual CPR. PMCT scans were reviewed for thoracoabdominal injuries such as fractures, pneumothorax and hemorrhage. The injuries between groups were compared.

Résultats : LDB CPR (n = 43) showed increased incidences of posterior rib fractures (53 vs 18%, P = 0.006), pneumothorax (23 vs 4%, P = 0.04) and more pericardial fluid (median 12 vs 6 mm, P = 0.002) compared with manual CPR (n = 29). Multivariable regression analysis revealed that LDB CPR was significantly associated with posterior rib fractures [odds ratio (OR) 5.37, 95% confidence interval (CI): 1.44–20.09, P = 0.01). Pneumothorax (OR 6.80, 95% CI: 0.73–62.99, P = 0.09) and the amount of pericardial fluid (OR 3.40, 95% CI: 0.20–56.32) were not significantly associated with LDB CPR. No significant difference was found for anterolateral rib fractures, sternal fractures, vertebral fractures, pleural fluid, hemothorax, hemopericardium, pneumoperitoneum, perihepatic, perisplenic and perirenal hemorrhage.

Conclusion : Rib fractures, sternal fractures, hemothorax and hemopericardium are common CPR-related injuries. LDB CPR is significantly associated with more posterior rib fractures and a trend toward more pneumothoraces is observed when compared with manual CPR. This knowledge is important for caretakers in the case of ongoing CPR, as a pneumothorax may attribute to not achieving persistent return of spontaneous circulation, and to improve postresuscitation care of survivors.

Conclusion (proposition de traduction) : Les fractures des côtes, les fractures sternales, un hémothorax et un hémopéricarde sont des blessures courantes liées à la RCP. La par planche à masser à bande de massage est significativement associée à davantage de fractures des côtes postérieures et une tendance vers plus de pneumothoraces est observée par rapport à la RCP manuelle. Cette connaissance est importante pour les soignants en cas de RCP en cours, car un pneumothorax peut conduire à ne pas obtenir un retour à une activité cardiaque spontanée (RACS), et pour améliorer les soins post-réanimation des survivants.

Predictive factors for secondary intensive care unit admission within 48 hours after hospitalization in a medical ward from the emergency room.
Cancella de Abreu M, Rousseau A, Ehrminger S, Rufat P, Hausfater P. | Eur J Emerg Med. 2020 Jun;27(3):186-192
DOI: https://doi.org/10.1097/mej.0000000000000628
Keywords: Aucun

Original Article

Introduction : Unplanned transfer to an ICU within 48 hours of admission from the emergency department (ED) can be considered an adverse event. Screening at risk for such an event is a challenge for ED staff. Our purpose was to identify the clinical and biological variables which may be identified in the ED setting and can predict short-term unplanned secondary transfer to the intensive care setting.

Méthode : This was a three-year retrospective case controlled monocentric study. The cases were patients transferred to a medical ICU within 48 hours of admission to the general wards from the ED. Each case was matched to two controls (patients not transferred to the ICU) based on age, gender, year of admission, and hospital unit. A conditional logistic regression was performed.

Résultats : Three hundred nineteen patients, including 107 cases and 212 controls, were studied. Community-acquired pneumonia (CAP) was the most frequent diagnosis (23% of cases) followed by sepsis (16%). We identified six predictive factors of an unplanned short-term transfer to the ICU. Former smoking status, fever between 38°C and 40°C, dyspnea as the chief complaint in the ED, a lower MEDS score, an elevated acute physiology age chronic health evaluation score, and the ordering of an arterial blood gas each correlate with secondary transfer to an intensive care setting.

Conclusion : We report a higher risk of short-term unscheduled ICU transfer in patients meeting these criteria. These patients should be closely monitored and frequently re-evaluated before being transferred to a general ward.

Conclusion (proposition de traduction) : Nous trouvons un risque plus élevé de transfert imprévu à court terme en USI chez les patients répondant à ces critères (ndlr : tabagisme ancien, fièvre entre 38° C et 40° C, dyspnée comme plainte principale aux urgences, un score MEDS plus bas, un score d'évaluation de la santé chronique de l'âge physiologique aigu élevé et une prescription de gaz du sanguin). Ces patients doivent être étroitement surveillés et fréquemment réévalués avant d'être transférés en service de soins général.

Parental involvement in the manual reduction of pulled elbow in children.
Cho W, Lee SC, Lee JH, Seo JS, Do HH, Kim YW, Lee S. | Eur J Emerg Med. 2020 Jun;27(3):193-196
DOI: https://doi.org/10.1097/mej.0000000000000636
Keywords: Aucun

Original Article

Introduction : To investigate the effect of parental involvement in the manual reduction of pulled elbow in children.

Méthode : We conducted a prospective case-control study from January to December 2018. The patients were under 6 years old with suspected radial head subluxation and were randomly assigned to two groups (an intervention group with a physician's and a parent's finger placed on the patient's radial head and a control group with the physician's finger only placed on the patient's radial head) according to the method of reduction. The results of a questionnaire given to the parent and physician were analyzed.

Résultats : A total of 150 patients were included in the study: 75 in the intervention group and 75 in the control group. There were no significant differences between the groups. The average number of attempts at manual reduction was 1.29 ± 0.73 in the intervention group and 1.31 ± 0.72 in the control group (P = 0.91) and the success rate of manual reduction was 96.0 and 94.7% (P = 0.70), respectively. The ease of conducting the procedure by the doctors did not show a significant difference between the two groups. However, the parents' understanding and satisfaction was significantly higher in the intervention group.

Conclusion : Parental involvement did not affect the procedure of physician, but it improved the understanding and satisfaction of the parents.

Conclusion (proposition de traduction) : L'implication des parents n'a pas affecté la procédure du médecin, mais elle a amélioré la compréhension et la satisfaction des parents.

Commentaire :  Manual reduction of pulled elbow in the intervention group.

Diagnostic performance of prehospital ultrasound diagnosis for traumatic pneumothorax by a UK Helicopter Emergency Medical Service.
Oliver P, Bannister P, Bootland D, Lyon RM. | Eur J Emerg Med. 2020 Jun;27(3):202-206
DOI: https://doi.org/10.1097/mej.0000000000000641
Keywords: Aucun

Original Article

Introduction : Up to 20% of major trauma patients may sustain a pneumothorax. Traumatic pneumothoraces can be difficult to diagnose on scene. Although the use of handheld ultrasound (HHUS) is becoming increasingly widespread, there remains uncertainty about its efficacy as a diagnostic tool in the prehospital setting. The aim of this study was to determine the diagnostic performance of prehospital chest HHUS in trauma patients.

Méthode : Retrospective review of trauma patients who received a prehospital chest HHUS and subsequently conveyed to the Royal Sussex County Hospital (RSCH) between 1 July 2013 and 24 September 2018. Data including patient age, sex, mechanism of injury and clinical interventions were obtained. Prehospital ultrasound findings were compared with the computer tomography (CT) scan performed on arrival at the hospital.

Résultats : Four hundred eleven patients were conveyed to RSCH, the single largest group being following road traffic collisions. The majority of HHUS (66%) were performed by doctors. Three hundred sixty-one patients (88%) subsequently had a CT scan. Of these, 98 patients (27%) were found to have pneumothoraces. For pneumothorax diagnosis, prehospital HHUS had a sensitivity of 28% [95% confidence interval (CI): 19-37%] and specificity of 98% [95% CI: 97-99%].

Conclusion : In this retrospective study, sensitivity of prehospital HHUS for diagnosing a pneumothorax was lower than is often reported in in-hospital studies. This suggests that caution should be exercised in using HHUS for the exclusion of pneumothorax in the prehospital setting.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, la sensibilité de l'échographie portative préhospitalière pour diagnostiquer un pneumothorax était plus faible que ce qui est souvent rapporté dans les études en milieu hospitalier. Cela suggère qu'il faut être prudent lors de l'utilisation de l'échographie portative pour l'exclusion du pneumothorax en milieu préhospitalier.

The efficiency of continuous positive airway pressure therapy in carbon monoxide poisoining in the emergency department.
Bal U, Sönmez BM, Inan S, Işcanli MD, Yilmaz F. | Eur J Emerg Med. 2020 Jun;27(3):217-222
DOI: https://doi.org/10.1097/mej.0000000000000647
Keywords: Aucun

Original article

Introduction : To determine whether oxygen therapy with continuous positive airway pressure (CPAP) is superior to normobaric oxygen therapy in carbon monoxide poisoning.

Méthode : The study participants were 43 patients diagnosed with carbon monoxide poisoning between the dates 15 March and 30 June 2016 at the emergency department of an urban teaching hospital. The control group comprised patients who received normobaric oxygen therapy. The case group consisted of patients who underwent one-hour CPAP therapy. The primary outcome was the determination of the half-life of carboxyhemoglobin (COHb) with CPAP treatment. The CPAP and control groups were compared in terms of the reduction in COHb levels after 60 minutes of therapy.

Résultats : The COHb level among patients in the CPAP group was lower in the 30th and 60th minutes. The half-life of COHb was apparently decreased in the CPAP group compared with the control group (control and case groups mean plasma half-life of COHb were 80.26 ± 12.70 and 36.20 ± 4.58 minutes, respectively).

Conclusion : The results of the present study demonstrate that CPAP therapy may be an effective option for oxygen therapy among patients with carbon monoxide intoxication; this is achieved by decreasing the half-life of COHb.

Conclusion (proposition de traduction) : Les résultats de l'étude démontrent que la CPAP peut être une option efficace pour l'oxygénothérapie chez les patients présentant une intoxication au monoxyde de carbone ; ceci est obtenu en diminuant la demi-vie de HbCO.

Internal and Emergency Medicine

Prospective evaluation of the quickSOFA score as a screening for sepsis in the emergency department.
Loritz M, Busch HJ, Helbing T, Fink K. | Intern Emerg Med. 2020 Jun;15(4):685-693
DOI: https://doi.org/10.1007/s11739-019-02258-2
Keywords: Emergency department; SIRS; Screening; Sepsis; qSOFA

EM - ORIGINAL

Introduction : In 2016, the new bedside tool quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) was presented to identify patients at high risk of developing sepsis or adverse outcome. The aim of this study was to investigate the diagnostic performance of the qSOFA scoring system as a screening in patients presenting at an emergency department (ED) of any cause. Therefore, we compared qSOFA with the systemic inflammatory response syndrome (SIRS) criteria and two modifications of qSOFA score.

Méthode : This is a prospective single-center study including patients presenting to the ED of any non-traumatic cause. Primary outcome was development of sepsis within 48 h, secondary outcomes were 30-day mortality and ICU stay for > 3 days. Data were collected within one hour after arrival to indicate an impression of initial medical contact.

Résultats : Among 1,668 patients, 105 sepsis cases were identified. 8.4% presented with qSOFA ≥ 2, 27.2% with SIRS ≥ 2 within one hour. Sensitivity of qSOFA in predicting sepsis was lower compared to the SIRS criteria. qSOFA showed better prognostic accuracy for 30-day mortality compared to SIRS (p < 0.05), but not for prolonged ICU stay (p = 0.56).

Conclusion : Modification of qSOFA in replacing GCS by other scoring systems recording altered mental status did not improve its sensitivity. The qSOFA score has poor sensitivity to identify patients at risk of developing sepsis and can therefore not be considered as an adequate screening for sepsis in patients presenting to the ED. Furthermore, a positive qSOFA at arrival at the ED showed no sufficient reliability in detecting patients with adverse clinical course.

Conclusion (proposition de traduction) : Modifier le qSOFA, en remplaçant l'échelle de Glasgow par d'autres systèmes de notation en ce qui concerne l'état mental altéré, n'a pas amélioré sa sensibilité. Le score qSOFA a une faible sensibilité pour identifier les patients à risque de développer un septis et ne peut donc pas être considéré comme un dépistage adéquat du septis chez les patients se présentant aux urgences. En outre, un qSOFA positif à l'arrivée aux urgences n'a pas montré de fiabilité suffisante pour détecter les patients présentant une évolution clinique défavorable.

Pediatric Emergency Care

Sugammadex: A Limited But Important Role in Emergency Medicine.
Chen B | Pediatr Emerg Care. 2020 Jun;36(6):296-301
DOI: https://doi.org/10.1097/pec.0000000000002126
Keywords: Aucun

CME Review Article

Editorial : Sugammadex reverses neuromuscular blockade by the steroidal nondepolarizing neuromuscular blocking agents rocuronium and vecuronium. In 2015, it was approved in the United States by the Food and Drug Administration for adult use. However, there are ongoing clinical trials investigating its use in the pediatric population. Before approval in adult use in the United States, several adverse effects were noted to occur in patients receiving sugammadex in clinical trials including prolonged QT interval, bradycardia, hypersensitivity reactions, and prolongation of coagulation parameters. Additional investigations further elucidated the risks of these adverse events. Sugammadex is approved for use in children older than 2 years in other countries in Europe and Asia. Investigations suggest that the efficacy, safety, and pharmacokinetic profile is similar in children when compared with adults. Published pediatric data favor the use of sugammadex in children older than 2 years, but there are some data in young children younger than 2 years. Case reports discuss the use of sugammadex in pediatric patients with neuromuscular diseases. Although sugammadex is typically used in the operating room for reversing neuromuscular blockade for surgical procedures, there is a small but important role for sugammadex use in the emergency department. In cases where rapid neurological examination is required after neuromuscular blockage with rocuronium or vecuronium, sugammadex can assist in facilitating a timely comprehensive neurological examination where pharmacologic or surgical management may depend on examination findings such as in the case of cerebral vascular accident, status epilepticus, or traumatic brain injury. Some clinicians have advocated for the use of sugammadex in the cannot intubate, cannot ventilate scenario. However, caution should be exercised in this situation as reversal of paralysis can take up to 22 minutes to occur.

Conclusion : Sugammadex is traditionally used in operating rooms to reverse the effects of the steroidal nondepolarizing NMBAs rocuronium and vecuronium. Sugammadex is currently ap- proved for use only in adult patients, although there are many ongoing clinical trials in pediatric patients. The safety profile for sugammadex is generally favorable, although there remains a small risk of hypersensitivity reaction and transient rise in co- agulation parameters after administration. In the emergency department, extubation after neuromuscular blockade is typi- cally deferred to inpatient services. However, rapid reversal of neuromuscular blockade and paralysis may be facilitated with sugammadex use in some patients for timely comprehen- sive neurological examination. Clinicians should exercise cau- tion in using sugammadex to remedy a “cannot intubate, cannot ventilate” scenario because timely reversal of neuromuscular blockade is not reliable in all patients.

Conclusion (proposition de traduction) : Le sugammadex (Bridion®) est traditionnellement utilisé au bloc opératoire pour réverser les effets des curares stéroïdiens non dépolarisants, le rocuronium (Esméron®) et le vécuronium (Norcuron®). Le sugammadex a actuellement l'indication pour une utilisation uniquement chez les patients adultes, bien que de nombreux essais cliniques soient en cours en pédiatrie. Le profil de tolérance du sugammadex est généralement favorable, bien qu'il subsiste un faible risque de réaction d'hypersensibilité et d'augmentation transitoire des paramètres de coagulation après administration. Au service des urgences, l'extubation après une curarisation est généralement confiée aux services hospitaliers. Cependant, une inversion rapide du blocage et de la paralysie neuromusculaires peut être facilitée par l'utilisation de sugammadex chez certains patients pour permettre l'examen neurologique complet en temps opportun. Les cliniciens doivent faire preuve de prudence dans l'utilisation du sugammadex pour résoudre la situation « impossible à intuber, impossible à ventiler » car la réversion rapide du blocage neuromusculaire n'est pas fiable chez tous les patients.

Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department.
Pokrajac N, Sbiroli E, Hollenbach KA, Kohn MA, Contreras E, Murray M. | Pediatr Emerg Care. 2020 Jun 22
DOI: https://doi.org/10.1097/pec.0000000000002171
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED.

Méthode : We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment.

Résultats : In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97).

Conclusion : Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

Conclusion (proposition de traduction) : L'hypoxie (ou une valeur d'oxymétrie de pouls impossible à obtenir) était le meilleur prédicteur de survenue d'un arrêt cardiaque associé à la procédure d'intubation chez les enfants après une intubation endotrachéale en urgence dans notre échantillon. Un modèle de risque simple combinant l'hypoxie au cours de la procédure d'intubation endotrachéale et un âge inférieur à un an a montré une excellente discrimination dans cet échantillon. Nos résultats nécessitent une validation indépendante.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Preventing Death by Intubation in Kids  . Rédigé par lay Smith, le 27 août 2020.

Prehospital and Disaster Medicine

Prehospital Vital Signs Accurately Predict Initial Emergency Department Vital Signs.
Trust MD, Schellenberg M, Biswas S, Inaba K, Cheng V, Warriner Z, Love BE, Demetriades D. | Prehosp Disaster Med. 2020 Jun;35(3):254-259
DOI: https://doi.org/10.1017/s1049023x2000028x
Keywords: ED vital signs; prehospital vital signs; trauma; vital signs

Original Research

Introduction : Prehospital vital signs are used to triage trauma patients to mobilize appropriate resources and personnel prior to patient arrival in the emergency department (ED). Due to inherent challenges in obtaining prehospital vital signs, concerns exist regarding their accuracy and ability to predict first ED vitals.
The objective of this study was to determine the correlation between prehospital and initial ED vitals among patients meeting criteria for highest levels of trauma team activation (TTA). The hypothesis was that in a medical system with short transport times, prehospital and first ED vital signs would correlate well.

Méthode : After exclusions, 15,320 patients were included. Mean age was 39 years (range 0-105) and 11,622 patients (76%) were male. Mechanism of injury was blunt in 79% (n = 12,041) and mortality was three percent (n = 513). Mean transport time was 21 minutes (range 0-1,439). Prehospital and first ED vital signs demonstrated good agreement for Glasgow Coma Scale (GCS) score (ICC 0.79; 95% CI, 0.77-0.79); fair agreement for heart rate (HR; ICC 0.59; 95% CI, 0.56-0.61) and systolic blood pressure (SBP; ICC 0.48; 95% CI, 0.46-0.49); and poor agreement for pulse pressure (PP; ICC 0.32; 95% CI, 0.30-0.33) and respiratory rate (RR; ICC 0.13; 95% CI, 0.11-0.15).

Conclusion : Despite challenges in prehospital assessments, field GCS, SBP, and HR correlate well with first ED vital signs. The data show that these prehospital measurements accurately predict initial ED vitals in an urban setting with short transport times. The generalizability of these data to settings with longer transport times is unknown.

Conclusion (proposition de traduction) : Malgré les défis des évaluations préhospitalières, le Glasgow, la pression artérielle systolique et le rythme cardiaque sur le terrain sont bien corrélées aux premiers signes vitaux aux urgences. Les données montrent que ces mesures préhospitalières prédisent avec précision les signes vitaux initiaux aux urgences en milieu urbain avec des temps de transport courts. La généralisabilité de ces données à des paramètres avec des temps de transport plus longs est inconnue.

The Principles of Triage in Emergencies and Disasters: A Systematic Review.
Bazyar J, Farrokhi M, Salari A, Khankeh HR. | Prehosp Disaster Med. 2020 Jun;35(3):305-313
DOI: https://doi.org/10.1017/s1049023x20000291
Keywords: disasters; emergencies; mass-casualty incidents; triage.

Systematic Review

Introduction : The use of triage systems is one of the most important measures in response to mass-casualty incidents (MCIs) caused by emergencies and disasters. In these systems, certain principles and criteria must be considered that can be achieved with a lack of resources. Accordingly, the present study was conducted as a systematic review to explore the principles of triage systems in emergencies and disasters world-wide.

Méthode : The present study was conducted as a systematic review of the principles of triage in emergencies and disasters. All papers published from 2000 through 2019 were extracted from the Web of Science, PubMed, Scopus, Cochrane Library, and Google Scholar databases. The search for the articles was conducted by two trained researchers independently.

Résultats : The classification and prioritization of the injured people, the speed, and the accuracy of the performance were considered as the main principles of triage. In certain circumstances, including chemical, biological, radiation, and nuclear (CBRN) incidents, certain principles must be considered in addition to the principles of the triage based on traumatic events. Usually in triage systems, the classification of the injured people is done using color labeling. The short duration of the triage and its accuracy are important for the survival of the injured individuals. The optimal use of available resources to protect the lives of more casualties is one of the important principles of triage systems and does not conflict with equity in health.

Conclusion : The design of the principles of triage in triage systems is based on scientific studies and theories in which attempts have been made to correctly classify the injured people with the maximum correctness and in the least amount of time to maintain the survival of the injured people and to achieve the most desirable level of health. It is suggested that all countries adopt a suitable and context-bond model of triage in accordance with all these principles, or to propose a new model for the triage of injured patients, particularly for hospitals in emergencies and disasters.

Conclusion (proposition de traduction) : La conception des principes du triage dans les systèmes de triage est basée sur des études scientifiques et des théories dans lesquelles on a tenté de classer correctement les personnes blessées avec le maximum d'exactitude et dans le minimum de temps pour maintenir la survie des personnes blessées et atteindre le niveau de santé optimal. Il est suggéré que tous les pays adoptent un modèle de triage adapté et lié au contexte, conformément à tous ces principes, ou proposent un nouveau modèle de triage des patients blessés, en particulier pour les hôpitaux en cas d'urgence et de catastrophe.

Ketamine as a Prehospital Analgesic: A Systematic Review.
Bansal A, Miller M, Ferguson I, Burns B. | Prehosp Disaster Med. 2020 Jun;35(3):314-321
DOI: https://doi.org/10.1017/s1049023x20000448
Keywords: analgesia; ketamine; prehospital.

Systematic Review

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

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

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

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

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

The American Journal of Emergency Medicine

Point-of-care blood analysis of hypotensive patients in the emergency department.
Shin H, Lee I, Kim C, Choi HJ. | Am J Emerg Med. 2020 Jun;38(6):1049-1057
DOI: https://doi.org/10.1016/j.ajem.2019.158363
Keywords: Capillary blood; Emergency medical services; Hypotension; Point-of-care systems.

Original Contribution

Introduction : The aim of this study is to compare a point-of-care (POC) analysis, Enterprise POC (epoc), using the capillary blood obtained from skin puncture with conventional laboratory tests using arterial and venous blood in hypotensive patients.

Méthode : This study was conducted at the emergency department of a tertiary care hospital between June and November 2018. 231 hypotensive patients were enrolled. Three types of blood samples (capillary blood from skin puncture and arterial and venous blood from blood vessel puncture) were collected and analyzed. We compared a total of 13 parameters (pH, pCO2, pO2, HCO3-, Ca2+, lactate, Na+, K+, Cl-, glucose, Hb, Hct, and creatinine) between the POC analysis and reference analyzers by performing the equivalence test and Bland-Altman plot analysis.

Résultats : In hypotensive patients, with the exception of two parameters (pCO2, pO2), the pH, HCO3-, Ca2+, lactate, Na+, K+, Cl-, glucose, Hb, Hct, and creatinine parameters measured by the POC analysis were equivalent to or correlated with the reference values. In the patients with cardiac arrest group, nine parameters (pH, HCO3-, Ca2+, Na+, K+, glucose, Hb, Hct, and creatinine) analyzed by the epoc system were equivalent to the reference values.

Conclusion : Most parameters, except pO2, measured by the epoc system using the capillary blood in hypotensive patients were equivalent to or correlated with those measured by the reference analyzers.

Conclusion (proposition de traduction) : La plupart des paramètres, à l'exception de la pO2, mesurés par le système epoc (Enterprise POC) utilisant le sang capillaire chez les patients hypotendus étaient équivalents ou corrélés à ceux mesurés par les analyseurs de référence.

Emergency department monitor alarms rarely change clinical management: An observational study.
Fleischman W, Ciliberto B, Rozanski N, Parwani V, Bernstein SL. | Am J Emerg Med. 2020 Jun;38(6):1072-1076
DOI: https://doi.org/10.1016/j.ajem.2019.158370
Keywords: Alarm fatigue; Emergency department alarms; Monitor alarms; Monitoring; Telemetry.

Original contribution

Introduction : Monitor alarms are prevalent in the ED. Continuous electronic monitoring of patients' vital signs may alert staff to physiologic decompensation. However, repeated false alarms may lead to desensitization of staff to alarms. Mitigating this could involve prioritizing the most clinically-important alarms. There are, however, little data on which ED monitor alarms are clinical meaningful. We evaluated whether and which ED monitor alarms led to observable changes in patients' ED care.

Méthode : This prospective, observational study was conducted in an urban, academic ED. An ED physician completed 53 h of observation, recording patient characteristics, alarm type, staff response, whether the alarm was likely real or false, and whether it changed clinical management. The primary outcome was whether the alarm led to an observable change in patient management. Secondary outcomes included the type of alarms and staff responses to alarms.

Résultats : There were 1049 alarms associated with 146 patients, for a median of 18 alarms per hour of observation. The median number of alarms per patient was 4 (interquartile range 2-8). Alarms changed clinical management in 8 out of 1049 observed alarms (0.8%, 95% CI, 0.3%, 1.3%) in 5 out of the 146 patients (3%, 95% CI, 0.2%, 5.8%). Staff did not observably respond to most alarms (63%).

Conclusion : Most ED monitor alarms did not observably affect patient care. Efforts at improving the clinical significance of alarms could focus on widening alarm thresholds, customizing alarms parameters for patients' clinical status, and on utilizing monitoring more selectively.

Conclusion (proposition de traduction) : La plupart des alarmes de surveillance au services des urgences n'ont pas eu d'incidence sur les soins aux patients. Les efforts visant à améliorer la signification clinique des alarmes pourraient se concentrer sur l'élargissement des seuils d'alarme, la personnalisation des paramètres des alarmes en fonction de l'état clinique des patients et une utilisation plus sélective de la surveillance.

A multicenter randomized controlled trial of a modified Valsalva maneuver for cardioversion of supraventricular tachycardias.
Chen C, Tam TK, Sun S, Guo Y, Teng P, Jin D, Xu L, Liu X. | Am J Emerg Med. 2020 Jun;38(6):1077-1081
DOI: https://doi.org/10.1016/j.ajem.2019.158371
Keywords: Supraventricular tachycardia, Modified Valsalva, Cardioversion

Original contribution

Editorial : Valsalva maneuver is a recognized treatment for supraventricular tachycardia, but in clinical setting it has a low chance to achieve successful cardioversion. Studies suggested that the postural modification of valsalva maneuver may improve the rate of cardioversion. We further modified the maneuver and conduct a multicenter randomized controlled trial to test its efficacy. To verify the efficacy of the modified Valsalva maneuver in SVT in Chinese population and simplify the operation process further.

Conclusion : With this simple modified Valsalva maneuver, the conversion rate of SVT to sinus rhythm was higher than the standard Valsalva maneuver, especially in subgroup with short RP tachycardia.

Conclusion (proposition de traduction) : Avec cette simple manœuvre de Valsalva modifiée, le taux de conversion des tachycardies supraventriculaires en rythme sinusal était plus élevé que la manœuvre de Valsalva standard, en particulier dans le sous-groupe avec tachycardie à PR court.

Commentaire : 

Assessment of intravenous insulin dosing strategies for the treatment of acute hyperkalemia in the emergency department.
Keeney KP, Calhoun C, Jennings L, Weeda ER, Weant KA. | Am J Emerg Med. 2020 Jun;38(6):1082-1085
DOI: https://doi.org/10.1016/j.ajem.2019.158374
Keywords: Hyperkalemia, Insulin, Renal insufficiency, Hypoglycemia, Emergency medicine, Pharmacy

Original contribution

Editorial : Hyperkalemia, defined as a serum potassium above 5 milliequivalents per liter (mEq/L), is commonly encountered in emergency departments (ED) across the nation. This accumulation is the result of either an increase in potassium uptake, decrease in excretion, or excessive potassium release from the intracellular space. Serum potassium is commonly used as a marker for electrolyte imbalances but does not account for total body potassium as the majority of concentration (30:1) exists within the intracellular space

Conclusion : Compared to an IV dose of 10 units, a bolus IV dose of 5 units of insulin for the treatment of acute hyperkalemia resulted in a significantly lower occurrence of hypoglycemia, with no difference in serum potassium reduction. Patients with an eGFR ≤45 mL/min/1,732 were significantly more likely to develop hypoglycemia when administered high versus low dose insulin. These findings suggest that for patients with reduced renal function, as indicated by an eGFR ≤45 mL/min/1,732, the utilization of a low dose IV insulin regimen is equally efficacious and less likely to cause iatrogenic hypoglycemia when treating acute hyperkalemia.

Conclusion (proposition de traduction) : Par rapport à une dose IV de 10 unités, une dose IV bolus de 5 unités d'insuline pour le traitement de l'hyperkaliémie aiguë a entraîné une survenue d'hypoglycémie significativement plus faible, sans différence dans la réduction de la kaliémie. Les patients avec un débit de filtration glomérulaire estimé ≤ 45 mL/min/1,732 étaient significativement plus susceptibles de développer une hypoglycémie lorsqu'ils étaient administrés à une dose élevée par rapport à une insuline à faible dose. Ces résultats suggèrent que pour les patients ayant une fonction rénale réduite, comme indiqué par un débit de filtration glomérulaire estimé ≤ 45 mL/min/1,732, l'utilisation d'un débit d'insuline IV à faible dose est tout aussi efficace et moins susceptible de provoquer une hypoglycémie iatrogène lors du traitement de l'hyperkaliémie aiguë.

Utility of plain abdominal radiography in adult ED patients with suspected constipation.
Driver BE, Chittineni C, Kartha G, Cole JB, Klein LR, Rischall M. | Am J Emerg Med. 2020 Jun;38(6):1092-1096
DOI: https://doi.org/10.1016/j.ajem.2019.158377
Keywords: Constipation; General emergency medicine; Radiography; Small bowel obstruction.

Original contribution

Introduction : Abdominal radiographs are often obtained in ED patients with suspected constipation, although their utility in adults is not well understood. We sought to compare ED management when an abdominal radiograph is and is not obtained.

Méthode : We performed a retrospective chart review study of adult ED patients with a chief complaint of constipation from 2010 through 2016. Trained abstractors recorded radiologic tests ordered, treatments received, and final diagnosis. We determined the physician interpretation of the abdominal radiograph and its use in clinical decision making.

Résultats : Of 1142 eligible patients, 481 (42%) patients underwent abdominal radiography. Stool burden rated moderate or large was observed in 271 patients (46%). Sixteen patients (3%) were diagnosed with small bowel obstruction; 15/16 of these patients had high risk features such as old age, complex surgical history, history of small bowel obstruction, abdominal malignancy, or presented with vomiting or inability to pass flatus. Of the 197 patients with no or mild stool burden or normal radiograph, 109 (55%) were diagnosed with constipation and 89 (45%) received constipation treatment in the ED. Conversely, of the 271 patients with moderate or greater stool burden, 114 (42%) received no treatment for constipation in the ED and 104 (38%) were prescribed no discharge medications for constipation; 77 of these 271 patients (28%) were diagnosed with something other than constipation.

Conclusion : Plain abdominal radiography did not appear to significantly affect the ED management of patients presenting with constipation; it was common for patients to receive treatment that was in direct opposition to radiographic findings. Though a small number of patients had concerning diagnoses identified on plain radiography, the history and physical examination should have sufficiently excluded simple constipation, prompting an alternate diagnostic approach. Fecal loading on radiography does not preclude a more serious diagnosis. In conclusion, abdominal radiography appears to have low value in patients with constipation.

Conclusion (proposition de traduction) : La simple radiographie de l'abdomen n'a pas semblé affecter de manière significative la prise en charge au service des urgences des patients souffrant de constipation ; il était courant pour les patients de recevoir un traitement en opposition directe avec les résultats de la radiographie. Bien qu’un petit nombre de patients aient eu l'identification de diagnostics préoccupants sur la simple radiographie, les antécédents et l’examen physique auraient été suffisant pour exclure une simple constipation, incitant une autre approche diagnostique. Un fécalome sur la radiographie n'exclut pas un diagnostic plus sérieux. En conclusion, la radiographie abdominale semble avoir une faible valeur chez les patients souffrant de constipation.

Gentle facemask ventilation during induction of anesthesia.
Zhang Q, Zhou Q, Zhang J, Zhao D. | Am J Emerg Med. 2020 Jun;38(6):1137-1140
DOI: https://doi.org/10.1016/j.ajem.2019.158399
Keywords: Anesthesia induction; Gastric insufflation; Gentle facemask ventilation; Lung ventilation; Surgery.

Original contribution

Introduction : To determine the level of inspiratory pressure minimizing the risk of gastric insufflation while providing adequate pulmonary ventilation.

Méthode : In this prospective, randomized, double-blind study, patients were allocated to one of the two groups (P10, P15) defined by the inspiratory pressure applied during controlled-pressure ventilation: 10 and 15 cm H2O. Anesthesia was induced using propofol and sufentanil; no neuromuscular-blocking agent was administered. Once loss of eyelash reflex occurred, facemask ventilation was started for a 2-min period. The cross-sectional antral area was measured using ultrasonography before and after facemask ventilation. Respiratory parameters were recorded.

Résultats : Forty patients were analyzed. Mean tidal volume was about 7 ml/kg in group P10, and was >11 ml/kg in group P15 in the same period. As indicated by ultrasonography test, the antral area in P15 group was markedly incresed compared with P10 group.

Conclusion : Inspiratory pressure of 10 cm H2O allowed for reduced occurrence of gastric insufflation with proper lung ventilation during induction of anesthesia with sufentanil and propofol in nonparalyzed and nonobese patients.

Conclusion (proposition de traduction) : Une pression inspiratoire de 10 cm H2O a permis de réduire la survenue d'une insufflation gastrique avec une ventilation pulmonaire adaptée pendant l'induction de l'anesthésie avec le sufentanil et le propofol chez les patients non curarisés et non obèses.

The safety and efficacy of hands-on defibrillation in the management of adult cardiac arrest: A systematic review.
Kwak J, Brady WJ. | Am J Emerg Med. 2020 Jun;38(6):1233-1236
DOI: https://doi.org/10.1016/j.ajem.2020.02.020
Keywords: Cardiac arrest; Defibrillation; Safety; Systematic review; “Hands-on”.

Reviews

Introduction : Hands-on defibrillation (HOD) is a technique that has great potential to positively impact outcomes from cardiopulmonary resuscitation (CPR) with the removal of an interruption in chest compressions. The safety and efficacy of HOD, however, have yet to be proven. This review aims to examine the safety of HOD, and secondarily, its efficacy.

Méthode : A systematic literature search was performed through PubMed, MEDLINE, Google Scholar, and the Cochrane Database. Additional articles were selected from the reference lists of this search result.

Résultats : From 52 results, 26 articles were reviewed and from the references of these articles, 9 more were included, leaving 35 articles for analysis. 14 of the analyzed articles were excluded.

Conclusion : HOD generally appears safe, though significant uncertainty still remains for each protective barrier type. HOD appears to be efficacious in improving CPR with no strong evidence to suggest otherwise.

Conclusion (proposition de traduction) : La défibrillation tout en gardant les mains sur la poitrine semble généralement sûre, bien qu'une incertitude significative subsiste pour chaque type de barrière de protection. La défibrillation en gardant les mains sur la poitrine semble être efficace pour améliorer la RCP sans aucune preuve solide suggérant le contraire.

Commentaire : La technique « Hands-on defibrillation (HOD) » est proposée pour poursuivre le MCE pendant la défibrillation pour réduire les pauses pendant la réanimation cardio-pulmonaire.
Les secouristes portent des gants en vinyle. Le choc électrique (100-360 J) est délivré au moyen d’électrodes adhésives par un défibrillateur biphasique. Aucun des chocs n’est perceptible par le secouriste, ce qui est confirmé par les mesures objectives des tensions, intensités et impédances sur le secouriste.

Evaluation and management of pulmonary hypertension in the emergency department setting.
Simon E, Bridwell RE, Montrief T, Koyfman A, Long B. | Am J Emerg Med. 2020 Jun;38(6):1237-1244
DOI: https://doi.org/10.1016/j.ajem.2020.02.041
Keywords: Idiopathic pulmonary hypertension; Pulmonary arterial hypertension; Pulmonary hypertension; Pulmonary hypertension management.

Reviews

Introduction : Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance and pulmonary arterial pressure and is associated with significant morbidity and mortality.

Méthode : This narrative review evaluates PH, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population.

Discussion : Approximately 10-20% of individuals in the United States suffer from PH. Each year nearly 12,000 PH patients seek care in the ED for a variety of symptoms which may or may not be related to PH. There are 5 classes of PH, some of which respond to particular therapies outlined in this review. As presenting complaints are frequently vague and non-specific, emergency physicians must recognize manifestations of PH and complications related to PH to deliver appropriate care. Early imaging with chest radiograph, bedside echocardiogram, and computed tomography can assist in determining the underlying etiology of PH exacerbation. Restarting oral or intravenous PH medications that may have been discontinued is crucial in initial management. Immense care should be taken to avoid hypoxia and hypercarbia as well as maintaining right ventricular preload support. In addition to correction of underlying precipitants, judicious vasopressor and inotrope use can help to correct pathophysiology and avoid further airway intervention.

Conclusion : An understanding of the pathophysiology of PH and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease. Restarting maintenance PH medications and proper selection of vasopressors and inotropes will benefit decompensating patients with PH.

Conclusion (proposition de traduction) : Une compréhension de la physiopathologie de l'hypertension pulmonaire et des traitements d'urgence disponibles peut aider les urgentistes à réduire la morbidité et la mortalité immédiates associées à cette maladie. La reprise des traitements d'entretien contre l'hypertension pulmonaire et une sélection appropriée des vasopresseurs et d'inotropes bénéficieront aux patients décompensés souffrant d'hypertension pulmonaire.

The Journal of Emergency Medicine

Reducing Pain During Emergency Arterial Sampling Using Three Anesthetic Methods: A Randomized Controlled Clinical Trial.
Pagnucci N, Pagliaro S, Maccheroni C, Sichi M, Scateni M, Tolotti A. | J Emerg Med. 2020 Jun;58(6):857-863
DOI: https://doi.org/10.1016/j.jemermed.2020.03.027
Keywords: acute pain; anesthesia; arterial blood gas analysis; emergency department.

Research article

Introduction : Taking a sample of arterial blood is widely reported as a cause of significant pain.
Objectives: To compare three anesthetic methods with standard practice (no anesthesia) to establish which was the most effective in reducing pain caused by radial artery puncture in patients requiring an arterial blood gas test in the emergency department (ED).

Méthode : A randomized controlled trial was conducted to compare the effectiveness between anesthetic cream, cryoanalgesia, and subcutaneous mepivacaine in reducing pain caused by radial artery puncture in ED patients.

Résultats : After comparing perceived pain during arterial puncture, the lowest median score was obtained in the mepivacaine group (1 interquartile range 0.6-1.3) and the highest median score in the control group (5 interquartile range 4.0-7.0). When comparing the control group with the three intervention groups, the Kruskal-Wallis test showed that mepivacaine (p = 0.023) and cryoanalgesia (p = 0.012) were associated with significantly lower pain scores. The anesthetic cream (p = 0.861) intervention group did not produce a statistically significant median difference compared with the control group.

Conclusion : The results of this study encourage the use of anesthetic methods like cryoanalgesia or mepivacaine for their proven effectiveness in reducing or eliminating pain during arterial puncture.

Conclusion (proposition de traduction) : Les résultats de cette étude encouragent l'utilisation de méthodes anesthésiques comme la cryoanalgésie ou la mépivacaïne pour leur efficacité prouvée dans la réduction ou l'élimination de la douleur lors d'une ponction artérielle.

Emergency Department Chest Pain Patients With or Without Ongoing Pain: Characteristics, Outcome, and Diagnostic Value of the Electrocardiogram.
Nilsson T, Lundberg G, Larsson D, Mokhtari A, Ekelund U. | J Emerg Med. 2020 Jun;58(6):874-881
DOI: https://doi.org/10.1016/j.jemermed.2020.03.010
Keywords: ECG; abated; acute coronary syndrome; chest pain; diagnostic value; emergency department; group characteristics; myocardial infarction; ongoing; outcome.

Research article

Introduction : In emergency department (ED) chest pain patients, it is believed that the diagnostic accuracy of the electrocardiogram (ECG) for acute coronary syndrome (ACS) is higher during ongoing than abated chest pain.
Objectives: We compared patient characteristics and the diagnostic performance of the ECG in ED patients presenting with ongoing, vs. abated, chest pain.

Méthode : In total, 1132 unselected ED chest pain patients were analyzed. The patient characteristics and diagnostic accuracy for index visit ACS of the emergency physicians' interpretation of the ECG was compared in patients with and without ongoing chest pain. Logistic regression analysis was performed to control for possible confounders.

Résultats : Patients with abated chest pain (n = 508) were older, had more comorbidities, and had double the risk of index visit ACS (15%) and major adverse cardiac events (MACE) at 30 days (15.6%) compared with patients with ongoing pain (n = 631; ACS 7.3%, 30-day MACE 7.4%). Sensitivity of the ECG for ACS was 24% in patients with ongoing pain and 35% in those without, specificity was 97% in both groups, negative predictive value was 94% and 89%, respectively, and positive likelihood ratio 10.6 and 7.8, respectively. When the diagnostic performance was controlled for confounders, there was no significant difference between the groups.

Conclusion : Our results indicate that ED chest pain patients with ongoing pain at arrival are younger, healthier, and have less ACS and 30-day MACE than patients with abated pain, but that there is no difference in the diagnostic accuracy of the ECG for ACS between the two groups.

Conclusion (proposition de traduction) : Nos résultats indiquent que les patients souffrant de douleur thoracique au service des urgences avec une douleur persistante à l'arrivée sont plus jeunes, en meilleure santé et ont moins de syndrome coronarien aigu et d'événements cardiaques indésirables majeurs à 30 jours que les patients avec douleur atténuée, mais qu'il n'y a aucune différence dans la précision du diagnostic de l'ECG pour le syndrome coronarien aigu entre les deux groupes.

Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis: Gottlieb M, Dyer S, Peksa GD, Resuscitation. 2020;146:118-125.
Gottlieb M, Dyer S, Peksa GD. | J Emerg Med. 2020 Jun;58(6):984
DOI: https://doi.org/10.1016/j.jemermed.2020.05.031
Keywords: Beta-blockade; Beta-blocker; Cardiac arrest; Esmolol; Propranolol; Ventricular fibrillation; Ventricular tachycardia.

Conference abstract

Introduction : Refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) refers to cases that do not respond to traditional Advanced Cardiac Life Support measures and are associated with significantly lower survival rates. Beta-blockade may improve outcomes by protecting against the deleterious effects associated with epinephrine's beta-receptor effect.
Objective : This systematic review and meta-analysis aimed to evaluate whether beta-blockade compared with control improved outcomes among patients in cardiac arrest due to refractory VF/VT.

Méthode : PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles were assessed on September 2nd, 2019 for all studies evaluating beta-blockade versus control groups in patients with cardiac arrest due to refractory VF/VT. PRISMA guidelines were followed. Data were dual extracted into a predefined worksheet and quality analysis was performed with the Cochrane Risk of Bias in Non-randomised Studies of Interventions tool. Data were summarized and a meta-analysis was performed assessing temporary and sustained return of spontaneous circulation (ROSC), survival-to-admission, survival-to-discharge, and survival with a favorable neurologic outcome.

Résultats : Three studies (n = 115 patients) were selected for final inclusion. Beta-blockade was associated with an increased rate of temporary ROSC (OR 14.46; 95% CI 3.63-57.57), sustained ROSC (OR 5.76; 95% CI 1.79-18.52), survival-to-admission (OR 5.76; 95% CI 1.79-18.52), survival-to-discharge (OR 7.92; 95% CI 1.85-33.89), and survival with a favorable neurologic outcome (OR 4.42; 95% CI 1.05-18.56). Overall risk of bias ranged from moderate-to-severe, which was primarily influenced by selection of participants and potential confounding. This study was registered with PROSPERO (CRD42019126902).

Conclusion : The data suggest that beta-blockade may be associated with improved outcomes ranging from ROSC to survival with a favorable neurologic outcome. Future randomized controlled trials are needed to further evaluate this intervention in refractory VF/VT.

Conclusion (proposition de traduction) : Les données suggèrent que les bêta-bloquants peuvent être associé à de meilleurs résultats allant de la RACS à la survie avec un résultat neurologique favorable. De futurs essais contrôlés randomisés sont nécessaires pour évaluer davantage cette intervention dans la FV/TV réfractaire.

The Journal of Trauma and Acute Care Surgery

Comparison of Direct Oral Anticoagulant (DOAC) and Vitamin K Antagonists (VKA) on outcomes among elderly and non-elderly trauma patients.
Nishimura T, Guyette FX, Naito H, Nakao A, Brown JB, Callaway CW. | J Trauma Acute Care Surg. 2020 Jun 10
DOI: https://doi.org/10.1097/ta.0000000000002823
Keywords: Aucun

Original article

Introduction : Direct Oral Anticoagulants (DOACs) are widely used among patients requiring anticoagulant therapy. These drugs are associated with a lower risk of bleeding than vitamin K antagonists (VKA). However, the outcomes of elderly trauma patients receiving DOACs are not well known.

Méthode : We reviewed data from trauma patients at our Level I trauma center (University of Pittsburgh Medical Center, Presbyterian Hospital) seen from January 2011 to July 2018. We identified trauma patients taking DOACs or VKA and compared these cohorts using 1:1 propensity score matching based on patient characteristics, antiplatelet use, comorbidities, and laboratory values. The primary outcome was in-hospital mortality. Secondary outcomes included the proportion of patients discharged to SNF (Skilled nursing facility)/ rehabilitation facility discharge or to home, and transfusion volume.

Résultats : Of 32,272 trauma patients screened, 530 were taking DOACs and 1702 were taking VKA. We matched 668 patients in a 1:1 ratio (DOACs group: 334 vs. VKA group: 334). The DOACs group had similar mortality (4.8% vs. 1.6%, odds ratio (OR) 3.0, 95% confidence interval (CI) 0.31-28.8, p=0.31) among patients less than 65 years-old, but mortality differed (3.0% vs. 6.6%, OR 0.41, 95%CI 0.17-0.99, p=0.048) among patients over 65 years-old. The proportion of patients discharged to SNF/rehabilitation facility (50.0% vs. 50.6%, OR 0.98, 95%CI 0.72-1.32, p=0.88) and to home (40.4% vs. 38.6%, OR 1.08, 95%CI 0.79-1.47, p=0.64) were similar. Patients in the DOACs group received fewer fresh frozen plasma (p=0.032) but packed red blood cells (p=0.86) and prothrombin complex concentrate (p=0.48) were similar.

Conclusion : In this matched cohort of anticoagulated trauma patients, DOACs were associated with the decreased in-hospital mortality and decreased administration of fresh frozen plasma compared to VKA among trauma patients 65 years of age or greater taking anticoagulant therapy.

Conclusion (proposition de traduction) : Dans cette cohorte appariée de patients traumatisés anticoagulés, les AOD ont été associés à une diminution de la mortalité hospitalière et à une diminution de l'administration de plasma frais congelé par rapport aux AVK chez les patients traumatisés âgés de 65 ans ou plus prenant un traitement anticoagulant.

The Lancet

Effects of a High-Dose 24-h Infusion of Tranexamic Acid on Death and Thromboembolic Events in Patients With Acute Gastrointestinal Bleeding (HALT-IT): An International Randomised, Double-Blind, Placebo-Controlled Trial.
HALT-IT Trial Collaborators | Lancet. 2020 Jun 20;395(10241):1927-1936
DOI: https://doi.org/10.1016/S0140-6736(20)30848-5  | Télécharger l'article au format  
Keywords: Aucun

Articles

Introduction : Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding.

Méthode : We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable.

Résultats : Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82-1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98).

Conclusion : We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial.

Conclusion (proposition de traduction) : Nous avons constaté que l'acide tranexamique ne réduisait pas la mortalité par saignement gastro-intestinal. Sur la base de nos résultats, l'acide tranexamique ne doit pas être utilisé pour le traitement des saignements gastro-intestinaux en dehors du contexte d'un essai randomisé.

Commentaire : Dans l'essai, l'acide tranexamique n'a pas réduit la mortalité par hémorragie gastro-intestinale et a été associé à un risque accru d'événements thromboemboliques veineux et de convulsions.
La proportion de patients présentant une nouvelle hémorragie digestive était similaire dans les groupes acide tranexamique et placebo.
L'étude ne mets en évidence aucune preuve que l'acide tranexamique diminue le risque de décès chez les patients présentant des saignements gastro-intestinaux.
Étant donné que les saignements gastro-intestinaux sont une indication de l'AMM pour l'acide tranexamique, ces résultats pourraient avoir des implications réglementaires.
Les doses élevées d'acide tranexanique administrées pourraient expliquer les effets secondaires. Bien que les effets secondaires pourraient être moins importants avec des doses moins élevées, il est peu probable que des doses plus faibles aient des effets bénéfiques sur les saignements, y compris les saignements et la nécessité de procédures invasives supplémentaires.

Voir les commentaires de l'article dans la même revue : Perner A, Møller MH. Tranexamic acid for severe gastrointestinal bleeding. Lancet. 2020 Jun 20;395(10241):1885-1886  .


Mois de juin 2020