Metrics of mechanical chest compression device use in out-of-hospital cardiac arrest.
Levy M, Kern KB, Yost D, Chapman FW, Hardig BM. | J Am Coll Emerg Physicians Open. 2020 Jul 4;1(6):1214-1221
DOI: https://doi.org/10.1002/emp2.12184 | Télécharger l'article au format
Keywords: cardiac arrest; cardiopulmonary resuscitation; mechanical CPR; resuscitation.
Introduction : The quality of cardiopulmonary resuscitation (CPR) affects outcomes from cardiac arrest, yet manual CPR is difficult to administer. Although mechanical CPR (mCPR) devices offer high quality CPR, only limited data describe their deployment, their interaction with standard manual CPR (sCPR), and the consequent effects on chest compression continuity and patient outcomes. We sought to describe the interaction between sCPR and mCPR and the impact of the sCPR-mCPR transition upon outcomes in adult out-of-hospital cardiac arrest (OHCA).
Méthode : We analyzed all adult ventricular fibrillation OHCA treated by the Anchorage Fire Department (AFD) during calendar year 2016. AFD protocols include the immediate initiation of sCPR upon rescuer arrival and transition to mCPR, guided by patient status. We compared CPR timing, performance, and outcomes between those receiving sCPR only and those receiving sCPR transitioning to mCPR (sCPR + mCPR).
Résultats : All 19 sCPR-only patients achieved return of spontaneous circulation (ROSC) after a median of 3.3 (interquartile range 2.2-5.1) minutes. Among 30 patients remaining pulseless after sCPR (median 6.9 [5.3-11.0] minutes), transition to mCPR occurred with a median chest compression interruption of 7 (5-13) seconds. Twenty-one of 30 sCPR + mCPR patients achieved ROSC after a median of 11.2 (5.7-23.8) additional minutes of mCPR. Survival differed between groups: sCPR only 14/19 (74%) versus sCPR + mCPR 13/30 (43%), P = 0.045.
Conclusion : In this series, transition to mCPR occurred in patients unresponsive to initial sCPR with only brief interruptions in chest compressions. Assessment of mCPR must consider the interactions with sCPR.
Conclusion (proposition de traduction) : Dans cette série, la transition vers la réanimation cardio-pulmonaire mécanique a été réalisé chez des patients qui ne répondaient pas à la réanimation cardio-pulmonaire manuelle standard initiale avec seulement de brèves interruptions des compressions thoraciques. L'évaluation de la réanimation cardio-pulmonaire mécanique doit tenir compte des interactions avec la réanimation cardio-pulmonaire manuelle standard.
Lung Ultrasound Findings in Patients With Coronavirus Disease (COVID-19).
Zhang Y, Xue H, Wang M, He N, Lv Z, Cui L. | AJR Am J Roentgenol. 2020 Jul 22:1-5
DOI: https://doi.org/10.2214/ajr.20.23513 | Télécharger l'article au format
Keywords: COVID-19; US; coronavirus disease; sonography; ultrasound.
Introduction : Although chest CT is the standard imaging modality in early diagnosis and management of coronavirus disease (COVID-19), the use of lung ultrasound (US) presents some advantages over the use of chest CT and may play a complementary role in the workup of COVID-19. The objective of our study was to investigate US findings in patients with COVID-19 and the relationship of the US findings with the duration of symptoms and disease severity.
Méthode : From March 3, 2020, to March 30, 2020, consecutive patients with a positive reverse transcriptase polymerase chain reaction test result for the virus that causes COVID-19 were enrolled in this study. Lung US was performed, and the imaging features were analyzed. The Fisher exact test was used to compare the percentages of patients with each US finding between groups with different symptom durations and disease severity.
Résultats : Our study population comprised 28 patients (14 men and 14 women; mean age ± SD, 59.8 ± 18.3 years; age range, 21-92 years). All 28 patients (100.0%, 28/28) had positive lung US findings. The most common findings were the following: B-lines (100.0%, 28/28), consolidation (67.9%, 19/28), and a thickened pleural line (60.7%, 17/28). A thickened pleural line was observed in a higher percentage of patients with a longer duration of the disease than in those with a shorter duration of the disease, and pulmonary consolidations were more common in severe and critical cases than in moderate cases.
Conclusion : Typical lung US findings in patients with COVID-19 included B-lines, pulmonary consolidation, and a thickened pleural line. In addition, our results indicate that lung US findings can be be used to reflect both the infection duration and disease severity.
Conclusion (proposition de traduction) : Les résultats typiques de l'échographie pulmonaire chez les patients atteints de COVID-19 comprenaient des lignes B, une consolidation pulmonaire et une ligne pleurale épaissie. De plus, nos résultats indiquent que les résultats de l'échographie pulmonaire peuvent être utilisés pour refléter à la fois la durée de l'infection et la gravité de la maladie.
Commentaire : Voir l'article sur le sujet dans Intensive Care Medicine par :
Zieleskiewicz L, Markarian T, Lopez A, Taguet C, Mohammedi N, Boucekine M, et al. Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia. Intensive Care Med [Internet]. 2020;46(9):1707–13 .
Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study.
Nowak RM, Christenson RH, Jacobsen G, McCord J, Apple FS, Singer AJ, Limkakeng A Jr, Peacock WF, deFilippi CR. | Ann Emerg Med. 2020 Jul;76(1):1-13
Introduction : We determine the accuracy of high-sensitivity cardiac troponin I (hs-cTnI), European-derived, rapid, acute myocardial infarction, rule-out/rule-in algorithms applied to a US emergency department (ED) population.
Méthode : Adults presenting to the ED with suspected acute myocardial infarction were included. Plasma samples collected at baseline and between 40 and 90 minutes and 2 and 3 hours later were analyzed in core laboratories using the Siemens Healthineers hs-cTnI assays. Acute myocardial infarction diagnosis was independently adjudicated. The sensitivity, specificity, and negative and positive predictive values for rapid acute myocardial infarction rule-out/rule-in using European algorithms and 30-day outcomes are reported.
Résultats : From 29 US medical centers, 2,113 subjects had complete data for the 0/1-hour algorithm analyses. With the Siemens Atellica Immunoassay hs-cTnI values, 1,065 patients (50.4%) were ruled out, with a negative predictive value of 99.7% and sensitivity of 98.7% (95% confidence interval 99.2% to 99.9% and 96.3% to 99.6%, respectively), whereas 265 patients (12.6%) were ruled in, having a positive predictive value of 69.4% and specificity of 95.7% (95% confidence interval 63.6% to 74.7% and 94.7% to 96.5%, respectively). The remaining 783 patients (37.1%) were classified as having continued evaluations, with an acute myocardial infarction incidence of 5.6% (95% confidence interval 4.2% to 7.5%). The overall 30-day risk of death or postdischarge acute myocardial infarction was very low in the ruled-out patients but was incrementally increased in the other groups (rule-out 0.2%; continued evaluations 2.1%; rule-in 4.8%). Equivalent results were observed in the 0/2- to 3-hour analyses and when both algorithms were applied to the hs-cTnI ADVIA Centaur measurements.
Conclusion : The European rapid rule-out/rule-in acute myocardial infarction algorithm hs-cTnI cut points can be harmonized with a demographically and risk-factor diverse US ED population.
Conclusion (proposition de traduction) : Les limites de positivité des taux de troponine cardiaque I à haute sensibilité de l'algorithme européen rapide d'identification de l'infarctus aigu du myocarde peuvent être harmonisés dans diverses populations des services d'urgence américains sur le plan démographique et sur les facteurs de risque.
Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis.
deSouza IS, Tadrous M, Sexton T, Benabbas R, Carmelli G, Sinert R. | Ann Emerg Med. 2020 Jul;76(1):14-30
Introduction : We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED).
Méthode : We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook.
Résultats : The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency.
Conclusion : For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.
Conclusion (proposition de traduction) : Pour la cardioversion pharmacologique de la fibrillation auriculaire d'apparition récente au cours d'une consultation aux urgences de 4 heures, les preuves sont insuffisantes pour déterminer quel traitement est supérieur. Plusieurs agents sont associés à une probabilité accrue de conversion dans les 4 heures par rapport au placebo ou au contrôle. Des données limitées excluent toute recommandation de cardioversion du flutter auriculaire d'apparition récente. Une étude supplémentaire de haute qualité est nécessaire.
Commentaire : Les médicaments cités dans l'article sont :
• L'antazoline, antihistaminique de 1ère génération aux propriétés anticholinergiques
• Le tédisamil, agent antiarythmique de classe III
• Le vernakalant (BRINAVESS®), agent antiarythmique recommandé en 2012 (ESC) pour la cardioversion des FA rapides récentes de moins de 7 jours, mais n’est pas commercialisé en France
• La propafénone (Rythmol), agent anti-arythmique de classe 1C
• Le flécaïnide, agent antiarythmique de classe Ic
• L'ibutilide, agent antiarythmique de classe III
Using volunteers to improve the experience of older patients in the emergency department.
Ellis B, Melady D, Foster N, Sinha S, Lau V, Saraga S, McLeod SL. | CJEM. 2020 Jul;22(4):514-518
DOI: https://doi.org/10.1017/cem.2020.9 | Télécharger l'article au format
Keywords: Emergency department; older patients; patient experience; volunteers.
Introduction : The Maximizing Aging Using Volunteer Engagement in the Emergency Department (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program.
Méthode : Volunteers were trained to identify and approach older patients at risk for adverse outcomes, including poor patient experience, and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form.
Résultats : Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median time (interquartile range [IQR]) a MAUVE volunteer spent with a patient was 10 minutes (IQR = 5, 20), with a range of 1 to 130 minutes. The median number of patients seen per shift was 7 (IQR = 6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%).
Conclusion : Preliminary data suggest the MAUVE + ED volunteers were able to provide additional care to older adults and their families/carers in the ED.
Conclusion (proposition de traduction) : Les données préliminaires suggèrent que le programme « Maximiser le vieillissement grâce à l'engagement des bénévoles dans le service des urgences » a été en mesure de fournir des soins supplémentaires aux personnes âgées et à leurs familles/aidants aux urgences.
Reducing unnecessary testing in the emergency department: The case for INR and aPTT.
Tawadrous D, Detombe S, Thompson D, Columbus M, Van Aarsen K, Skoretz T. | CJEM. 2020 Jul;22(4):534-541
Keywords: Costing; efficiency; emergency medicine; laboratory medicine
Introduction : Routine coagulation testing is rarely indicated in the emergency department. Our goal is to determine the combined effects of uncoupling routine coagulation testing (i.e., international normalized ratio [INR]; activated partial thromboplastin time [aPTT]), disseminating an educational module, and implementing a clinical decision support system (CDSS) on coagulation testing rates in two academic emergency departments.
Méthode : A prospective pre-post study of INR-aPTT uncoupling, educational module distribution, and CDSS implementation in two academic emergency departments. All patients ages 18 years and older undergoing evaluation and treatment during the period of August 1, 2015, to November 30, 2017, were included. Primary outcome was coagulation testing utilization during the emergency department encounter. Secondary outcomes included associated costs, frequency of downstream testing, and frequency of blood transfusions.
Résultats : Uncoupling INR-aPTT testing combined with educational module distribution and CDSS implementation resulted in significantly decreased coupled INR-aPTT testing, with significantly increased selective INR and aPTT testing. Overall, the aggregate rate of coagulation testing declined for both INR and aPTT testing (48 tests/100 patients/day to 26 tests/100 patients/day). There was a significant decrease in associated daily costs (median cost per day: $1048.32 v. $601.68), realizing estimated annual savings of $163,023 Canadian dollars (CAD). There was no signal of increased downstream testing or patient blood product requirements.
Conclusion : Compared to baseline practice patterns, our multimodal initiative significantly decreased coagulation testing, with meaningful cost savings and without evidence of patient harm. Clinicians and administrators now have a growing toolkit to target the plethora of low-value tests and treatments in emergency medicine.
Conclusion (proposition de traduction) : Par rapport aux modèles de pratique de base, notre initiative multimodale a considérablement réduit les tests de coagulation, avec des économies de coûts significatives et sans preuve de préjudice au patient. Les cliniciens et les administrateurs disposent désormais d'une boîte à outils de plus en plus fournie pour cibler la pléthore de tests et de traitements de faible valeur en médecine d'urgence.
Effect of alcohol on blood pressure.
Tasnim S, Tang C, Musini VM, Wright JM. | Cochrane Database Syst Rev. 2020 Jul 1;7:CD012787
Introduction : Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population.
Primary objective: To determine short-term dose-related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short-term dose-related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age.
Méthode : The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions.
Sélection criteria: Randomised controller trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age).
Résultats : Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed-effect model was used to combine effect sizes across studies. MAIN RESULTS: We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low-dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate-certainty evidence). Medium-dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI -8.3 to -3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI -6.0 to -2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate-certainty evidence for all). Medium-dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium-dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High-dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI -6.0 to -1.0), decreased DBP by 1.9 mmHg (95% CI-3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High-dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI -7.0 to -0.5) and DBP by 1.7 mmHg (95% CI -4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High-dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate-certainty evidence for all).
Conclusion : High-dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High-dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials.
Conclusion (proposition de traduction) : L'alcool à forte dose a un effet biphasique sur la pression artérielle ; il la diminue jusqu'à 12 heures après la consommation et l'augmente 13 heures après la consommation. L'alcool à forte dose augmente la fréquence cardiaque pendant 24 heures. Les résultats de cette revue concernent principalement les hommes en bonne santé, car seul un petit nombre de femmes a été inclus dans les essais inclus.
Commentaire : Voir l'analyse de l'article sur :
L'alcool a un effet biphasique sur la pression artérielle et augmente la fréquence cardiaque .
Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department.
Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. | Cochrane Database Syst Rev. 2020 Jul 23;7(7):CD013031
Cochrane Database of Systematic Reviews
Introduction : Chest X‐ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes.
Objectives: To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non‐radiologist physicians versus chest X‐ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED).
To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non‐radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy.
Méthode : We conducted a comprehensive search of the following electronic databases from database inception to 10 April 2020: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection and Clinicaltrials.gov. We handsearched reference lists of included articles and reviews retrieved via electronic searching; and we carried out forward citation searching of relevant articles in Google Scholar and looked at the "Related articles" on PubMed.
Selection criteria: We included prospective, paired comparative accuracy studies comparing CUS performed by frontline non‐radiologist physicians to supine CXR in trauma patients in the emergency department (ED) suspected of having pneumothorax, and with computed tomography (CT) of the chest or tube thoracostomy as the reference standard.
Data collection and analysis: Two review authors independently extracted data from each included study using a data extraction form. We included studies using patients as the unit of analysis in the main analysis and we included those using lung fields in the secondary analysis. We performed meta‐analyses by using a bivariate model to estimate and compare summary sensitivities and specificities.
Résultats : We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was −0.007 (95% CI −0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax.
Conclusion : The diagnostic accuracy of chest ultrasonography performed by frontline non‐radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine Chest X‐ray, independent of the type of trauma, type of chest ultrasonography operator, or type of chest ultrasonography probe used. These findings suggest that chest ultrasonography for the diagnosis of traumatic pneumothorax could be incorporated into trauma protocols and algorithms in future medical training programmes. In addition, chest ultrasonography may beneficially change routine management of trauma
Conclusion (proposition de traduction) : La précision diagnostique de l'échographie thoracique effectuée par des médecins non radiologues de première ligne pour le diagnostic du pneumothorax chez les patients traumatisés à l'urgence est supérieure à la radiographie thoracique en décubitus dorsal, indépendamment du type de traumatisme, du type d'opérateur d'échographie thoracique ou du type de sonde d'échographie thoracique utilisé. Ces résultats suggèrent que l'échographie thoracique pour le diagnostic du pneumothorax traumatique pourrait être intégrée aux protocoles et algorithmes de traumatologie dans les futurs programmes de formation médicale. De plus, l'échographie thoracique peut modifier de manière bénéfique la gestion de routine du traumatisme
Effectiveness and applicability of Non-Invasive Ventilation (NIV) in the Emergency Department in acute respiratory failure due to Sars-CoV-2 pneumonia.
Lari F, Giostra F, Guerrini S. | Emergency Care Journal. 2020 Jul;16(2):55-60
DOI: https://doi.org/10.4081/ecj.2020.9127 | Télécharger l'article au format
Keywords: acute respiratory failure, non-invasive ventilation, Sars- CoV-2
Editorial : Treatment of de novo acute hypoxic respiratory failure is not recommended by current Non-Invasive Ventilation (NIV) guidelines as it does not seem to improve patients outcome. Many cases of acute hypoxic respiratory failure associated with Sars-Cov2 infection (SARI) have been observed during Sars-Cov2 pandemic. So far, data are missing regarding the use of NIV, but a correct identification of subgroups of patients based on different clinical, patho-physiological and radiological features, might be helpful for stratifying patients and choosing the correct respiratory support (invasive versus non-invasive). In case of NIV appliance, risk of environmental virus dispersion is particularly elevated; therefore, extreme attention by operators is required.
Conclusion : Generally, the use of NIV in de novo hypoxaemic patients such SARI, severe pneumonia, other pandemic related to viruses, and ARDS, is not recommended by guidelines as not effective in terms of prognosis (it does not reduce mortality and the need of intubation). In case of Sars-CoV-2, its role needs to be defined. Distinguishing the 2 different phenotypes of Sars-CoV-2 pneumonia may not be easy because in the emergency departments we cannot measure negative intrathoracic swing or lung compliance, but radiological findings (CT, US) and clinical conditions (respiratory distress) may help us. In Sars-CoV-2 SARI with phenotype L without severe respiratory distress HFNC and NIV might improve the breathing pattern and oxygenation when traditional oxygen therapy fails; in these patients, intubation should be avoided to prevent complications and worsening of lung injury. Patients with severe respiratory distress and phenotype H should be treated invasively according to ARDS guidelines, in this case NIV plays a marginal role and intubation must not be delayed (protective ventilation). Ventilate in NIV gently with low pressure (PEEP 8-10 cm H2O), even phenotype L patients. A correct choice of interfaces and the use of filters are highly recommended to limit environmental virus dispersion. NIV and CPAP should be applied by highly trained personnel in negative pressure rooms if it’s possible, based on local resources and organization. Consider weaning from NIV when respiratory distress is missing.
Conclusion (proposition de traduction) : En général, l'utilisation de la VNI chez les patients hypoxémiques de novo dans l'infection à Sars-cov2, la pneumonie sévère, les autres pandémies liées aux virus et le SDRA, n'est pas recommandée par les lignes directrices car non efficace en termes de pronostic (elle ne réduit pas la mortalité et la nécessité d'intubation).
Dans le cas de Sars-CoV-2, son rôle doit être défini. Distinguer les 2 phénotypes de la pneumonie à Sars-CoV-2 peut ne pas être facile car dans les services d'urgence, nous ne pouvons pas mesurer le swing intrathoracique négatif ou la compliance pulmonaire, mais les résultats radiologiques (scanner, échographie) et les conditions cliniques (détresse respiratoire) peuvent nous aider.
Dans l'infection à Sars-CoV-2 avec le phénotype L sans détresse respiratoire sévère, l'oxygénothérapie à haut débit (HFNC) et la VNI pourraient améliorer le modèle de respiration et l'oxygénation lorsque l'oxygénothérapie traditionnelle échoue ; chez ces patients, l'intubation doit être évitée pour éviter les complications et l'aggravation des lésions pulmonaires.
Les patients souffrant de détresse respiratoire sévère et de phénotype H doivent être traités de manière invasive selon les directives du SDRA, dans ce cas la VNI joue un rôle marginal et l'intubation ne doit pas être retardée (ventilation protectrice). Ventiler en VNI doucement à basse pression (PEEP 8-10 cm H2O), même chez les patients de phénotype L.
Un choix correct des interfaces et l'utilisation de filtres sont fortement recommandés pour limiter la dispersion des virus dans l'environnement.
La VNI et la CPAP doivent être appliquées par du personnel hautement qualifié dans des salles à pression négative si possible, en fonction des ressources et de l’organisation locales. Envisager le sevrage de la VNI lorsque la détresse respiratoire n'est pas présente.
Endotracheal intubation with barrier protection.
Jazuli F, Bilic M, Hanel E, Ha M, Hassall K, Trotter BG. | Emerg Med J. 2020 Jul;37(7):398-399
DOI: https://doi.org/10.1136/emermed-2020-209785 | Télécharger l'article au format
Report from the front
Editorial : Given the high risk of healthcare worker (HCW) infection with COVID-19 during aerosol-generating medical procedures, the use of a box barrier during intubation for protection of HCWs has been examined. Previous simulation work has demonstrated its efficacy in protecting HCWs from cough-expelled droplets. Our objective was to assess its ability to protect HCWs against aerosols generated during aerosol-generating medical procedures. We used a battery-powered vapouriser to assess movement of vapour with: (1) no barrier; (2) a box barrier; and (3) a box barrier and a plastic sheet covering the box and patient’s body. We visualised the trajectory of vapour and saw that the vapour remained within the barrier space when the box barrier and plastic sheet were used. This is in contrast to the box barrier alone, where vapour diffused towards the feet of the patient and throughout the room, and to no barrier where the vapour immediately diffused to the laryngoscopist. This demonstrates that the box with the plastic sheet has the potential to limit the spread of aerosols towards the laryngoscopist, and thus may play a role in protecting HCWs during aerosol-generating medical procedures. This is of particular importance in the care of patients with suspected COVID-19.
Conclusion : At this time, our institution is not using the box barrier to limit aerosol diffusion routinely. In light of the infection risk to healthcare workers during this pandemic, the potential efficacy of the box barrier to enhance protection of healthcare workers must be supported with future work demonstrating that it does not compromise intubation success, especially in the context of protected protocols and patient factors common to clinical care in the current climate.
Conclusion (proposition de traduction) : À l'heure actuelle, notre institution n'utilise pas la tente barrière pour limiter la diffusion des aérosols de manière systématique. Compte tenu du risque d'infection pour les travailleurs de la santé durant cette pandémie, l'efficacité potentielle de la tente barrière pour renforcer la protection des travailleurs de la santé doit être confirmée par des travaux futurs démontrant qu'elle ne compromet pas le succès de l'intubation, en particulier dans le contexte des protocoles protégés et des facteurs communs aux soins cliniques dans le climat actuel.
Oral nitroglycerin solution for oesophageal food impaction: a prospective single-arm pilot study.
Willenbring BA, Schnitker CK, Stellpflug SJ. | Emerg Med J. 2020 Jul;37(7):434-436
Keywords: clinical care; effectiveness; gastro-intestinal; management, emergency department management; research, clinical
Introduction : Thirteen episodes of oesophageal food impaction (EFI) per 100 000 people present to a medical setting each year. Several pharmacological interventions meant to relieve such impactions have been explored; none have proven superior.
Objectives: Perform a single-arm feasibility study of oral nitroglycerin solution for EFI.
Méthode : Twenty adult patients presenting to a single urban tertiary medical centre thought to have EFI were given up to three doses of 0.4 mg nitroglycerin solution orally and evaluated for resolution of symptoms, new symptoms and vital signs. Patients with intractable vomiting, haemodynamic instability, airway compromise, oesophageal perforation, coronary ischaemia or presentation delayed greater than 12 hours were excluded.
Résultats : 17 of 20 enrolled subjects received the intervention. The average duration of symptoms prior to intervention was 285 min (SD=187). Four subjects did not tolerate the intervention (inability to swallow or headache). Two of 17 (11.8%) subjects obtained temporally proximal symptom resolution: 11 min after the second dose, and 7 min after the third dose. Seven also received glucagon during their visit, with 0% temporally proximal symptom resolution. Fifteen underwent endoscopy, with food bolus identified in 12. One subject had brief and mild hypotension with spontaneous resolution. Two subjects developed a headache after nitroglycerin administration. The median length of stay for those who found relief without endoscopy was 195 min (range 129-261) vs 374 min (range 122-525) among those with endoscopy.
Conclusion : The observed rate of relief after oral nitroglycerin solution for EFI is disappointing but comparable to previous glucagon, benzodiazepines and effervescent beverage studies, and that of placebo. Oral nitroglycerin solution appears to be well tolerated among those able to swallow, although in our sample several subjects were unable to tolerate swallowing entirely.
Conclusion (proposition de traduction) : Le taux de soulagement observé après une administration orale de nitroglycérine pour impactation de corps étranger alimentaire oesophagien est décevant mais comparable aux études précédentes sur le glucagon, les benzodiazépines et les boissons effervescentes, et à celui du placebo. L'administration orale de nitroglycérine semble bien tolérée chez les personnes capables d'avaler, bien que dans notre échantillon, plusieurs sujets étaient incapables de déglutir complètement.
Comparison of various risk scores for the prognosis of hemorrhagic upper gastrointestinal mucosal disorder.
Kita S, Shirai Y, Yoshida T, Shiraishi K, Nakamura A, Kawano M, Kinoshita Y, Noguchi T, Ito S. | Int J Emerg Med. 2020 Jul 29;13(1):41
DOI: https://doi.org/10.1186/s12245-020-00293-x | Télécharger l'article au format
Keywords: AIMS65 score; Charlson Comorbidity Index; Prognosis; Upper gastrointestinal bleeding; Upper gastrointestinal mucosal disorder.
Introduction : Various risk scores have been proposed that are useful for the management of upper gastrointestinal bleeding (UGIB), which is an important disease in emergency medicine. Few studies have examined the usefulness of Charlson Comorbidity index (CCI) in this disease, which evaluates the patient's general condition by scoring the patient's underlying disease. There have been no studies investigating the efficacy of CCI compared to other risk scores in the management of UGIB requiring endoscopic hemostasis.
Méthode : In addition to the Glasgow-Blatchford score, AIMS65 score, and Rockall score, we investigated the efficacy of the outcome prediction obtained by the original CCI and the updated CCI, scored only with respect to the underlying disease. We also examined the cutoff value when using the risk score. This retrospective study included 265 patients with hemorrhagic upper gastrointestinal mucosal lesions who underwent emergency endoscopic hemostasis during a 6-year period between 2011 and 2016 in our hospital.
Résultats : The updated CCI and AIMS65 score correlated with prognosis in multivariate analysis (p = 0.002 and p = 0.003, respectively). In clinical practice, the prognosis might be worse if both updated CCI and AIMS65 score were 3 point or more.
Conclusion : In addition to the AIMS65 score, the updated CCI can be a useful tool for managing upper gastrointestinal mucosal disorder bleeding that requires endoscopic hemostasis.
Conclusion (proposition de traduction) : En plus du score AIMS65, l'index Charlson Comorbidity mis à jour peut être un outil utile pour gérer le saignement des troubles de la muqueuse gastro-intestinale supérieure qui nécessite une hémostase endoscopique.
Commentaire : Voir le calculateur en ligne MDCalc :
Charlson Comorbidity Index (CCI)
A randomised crossover comparison of two endotracheal tube introducers: the FROVA and the Flexible Tip Bougie for GlideScope intubation of a difficult airway manikin by infrequent intubators.
Cormack J, Langley B, Bhanabhai LR, Kluger R. | Int J Emerg Med. 2020 Jul 17;13(1):38
DOI: https://doi.org/10.1186/s12245-020-00298-6 | Télécharger l'article au format
Keywords: Airway management; Intratracheal intubation; Manikin; Teaching materials.
Introduction : This unblinded randomised crossover study compares two endotracheal tube introducers (ETIs): the FROVA and the "Flexible Tip Bougie" (FTB), in an airway manikin mimicking difficult intubation with a percentage of glottic opening view of 30%. Participants were Emergency Medicine and Anaesthesia trainees with recent experience of less than twenty patient intubations. The primary outcome was time to intubation, further divided into time taken to pass the ETI and time to railroad the endotracheal tube (ETT) over the ETI. The secondary outcome was the difficulty of intubation.
Résultats : The median total time to ETT placement was significantly shorter with the FTB (37.5 s) compared with the FROVA ETI (63.0 s), P = 0.0006. The median difficulty reported (scores 0-10 with 0 being no difficulty) with the FTB was 2 compared with 5 for the FROVA, P < 0.0001.
Conclusion : The FTB enabled significantly faster and easier placement of the endotracheal tube compared with the FROVA in inexperienced hands intubating a difficult intubation manikin.
Conclusion (proposition de traduction) : Le mandrin Flexible tip a permis une intubation beaucoup plus rapide et plus facile de la sonde endotrachéale par rapport au FROVA dans des mains inexpérimentées intubant un mannequin d'intubation difficile.
Smartphone Activation of Citizen Responders to Facilitate Defibrillation in Out-of-Hospital Cardiac Arrest.
Andelius L, Malta Hansen C, Lippert FK, Karlsson L, Torp-Pedersen C, Kjær Ersbøll A, Køber L, Collatz Christensen H, Blomberg SN, Gislason GH, Folke F. | J Am Coll Cardiol. 2020 Jul 7;76(1):43-53
Keywords: AED; OHCA; cardiopulmonary resuscitation; citizen responder; smartphone app; volunteer.
Introduction : Dispatching citizen responders through a smartphone application (app) holds the potential to increase bystander cardiopulmonary resuscitation (CPR) and defibrillation in out-of-hospital cardiac arrest (OHCA).
Objectives: This study investigated arrival at the OHCA location of app-dispatched citizen responders before the Emergency Medical Services (EMS) and the association with bystander CPR and bystander defibrillation.
Méthode : Suspected OHCAs with alerted citizen responders from September 1, 2017, to August 31, 2018, were included. Citizen responders located 1.8 km (1.1 miles) from the OHCA were dispatched to start CPR or retrieve an automated external defibrillator. OHCAs where at least 1 citizen responder arrived before EMS were compared with OHCAs where EMS arrived first. In both groups, random bystanders could be present before the arrival of citizen responders and the EMS. Primary outcomes were bystander CPR and bystander defibrillation, which included CPR and defibrillation by citizen responders and random bystanders.
Résultats : Citizen responders were alerted in 819 suspected OHCAs, of which 438 (53.5%) were confirmed cardiac arrests eligible for inclusion. At least 1 citizen responder arrived before EMS in 42.0% (n = 184) of all included OHCAs. When citizen responders arrived before EMS, the odds for bystander CPR increased (odds ratio: 1.76; 95% confidence interval: 1.07 to 2.91; p = 0.027) and the odds for bystander defibrillation more than tripled (odds ratio: 3.73; 95% confidence interval: 2.04 to 6.84; p < 0.001) compared with OHCAs in which citizen responders arrived after EMS.
Conclusion : Arrival of app-dispatched citizen responders before EMS was associated with increased odds for bystander CPR and a more than 3-fold increase in odds for bystander defibrillation.
Conclusion (proposition de traduction) : L’arrivée d’intervenants citoyens envoyés par l'application avant les Services médicaux d’urgence a été associée à une augmentation des chances pour la réalisation d'une RCP par les témoins et à une augmentation de plus de trois fois des chances pour la réalisation d'une défibrillation par les témoins.
Commentaire : Voir l'analyse de l'article sur le site JIM : L’appli qui pourrait sauver des vies . Rédigé par le Dr Robert Haïat le 06/07/2020.
The role of lung ultrasonography in COVID-19 disease management.
Boero E, Schreiber A, Rovida S, Vetrugno L, Blaivas M. | J Am Coll Emerg Physicians Open. 2020 Jul 21;1(6):1357–63
DOI: https://doi.org/10.1002/emp2.12194 | Télécharger l'article au format
Editorial : Coronavirus disease 2019 (COVID-19) has created unprecedented disruption for global healthcare systems. Offices and emergency departments (EDs) were the first responders to the pandemic, followed by medical wards and intensive care unit (ICUs). Worldwide efforts sprouted to coordinate proper response by increasing surge capacity and optimizing diagnosis and containment. Within the complex scenario of the outbreak, the medical community shared scientific research and implemented best-guess imaging strategies in order to save time and additional staff exposures. Early publications showed agreement between chest computed tomography (CT) and lung sonography: widespread ground-glass findings resembling acute respiratory distress syndrome (ARDS) on CT of COVID-19 patients matched lung ultrasound signs and patterns. Well-established accuracy of bedside sonography for lung conditions and its advantages (such as no ionizing radiation; low-cost, real-time bedside imaging; and easier disinfection steps) prompted a wider adoption of lung ultrasound for daily assessment and monitoring of COVID-19 patients. Growing literature, webinars, online materials, and international networks are promoting lung ultrasound for the same purpose. We propose 11 lung ultrasound roles for different medical settings during the pandemic, starting from the out-of-hospital setting, where lung ultrasound has ergonomic and infection control advantages. Then we describe how medical wards and ICUs can safely integrate lung ultrasound into COVID-19 care pathways. Finally, we present outpatient use of lung ultrasound to aid follow-up of positive case contacts and of those discharged from the hospital.
Conclusion : Growing evidence supports the utility of lung ultrasound in COVID-19 patients, but data from multicenter observational studies are stilllacking. Lung ultrasound may play strategic roles in the management ofCOVID-19 patients from their initial presentation to ED, during theirhospitalization and after discharge in the community. Hence, a rapid,multidisciplinary, and comprehensive effort to find out the more accu-rate lung ultrasound protocol and its usefulness when adopted alone orintegrated to other clinical parameters is urgently needed to improvepatient care as well as healthcare workers’ safety.
Conclusion (proposition de traduction) : De plus en plus de preuves soutiennent l'utilité de l'échographie pulmonaire chez les patients COVID-19, mais les données d'études d'observation multicentriques manquent encore. L'échographie pulmonaire peut jouer un rôle stratégique dans la prise en charge des patients COVID-19 depuis leur présentation initiale aux urgences, pendant leur hospitalisation et après leur sortie. Par conséquent, un effort rapide, multidisciplinaire et complet pour découvrir le protocole d'échographie pulmonaire plus précis et son utilité lorsqu'il est adopté seul ou intégré à d'autres paramètres cliniques est nécessaire de toute urgence pour améliorer les soins des patients ainsi que la sécurité des travailleurs de la santé.
Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial.
Hallifax RJ, McKeown E, Sivakumar P, Fairbairn I, Peter C, Leitch A, Knight M, Stanton A, Ijaz A, Marciniak S, Cameron J, Bhatta A, Blyth KG, Reddy R, Harris MC, Maddekar N, Walker S, West A, Laskawiec-Szkonter M, Corcoran JP, Gerry S, Roberts C, Harvey JE, Maskell N, Miller RF, Rahman NM. | Lancet. 2020 Jul 4;396(10243):39-49
DOI: https://doi.org/10.1016/s0140-6736(20)31043-6 | Télécharger l'article au format
Introduction : Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care.
Méthode : In this open-label, randomised controlled trial, adults (aged 16-55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis.
Résultats : Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0-3]) than in the 113 with available data who received standard care (4 days [IQR 0-8]; p<0·0001; median difference 2 days [95% CI 1-3]). 110 (47%) of 236 patients had adverse events, including 64 (55%) of 117 patients in the ambulatory care arm and 46 (39%) of 119 in the standard care arm. All 14 serious adverse events occurred in patients who received ambulatory care, eight (57%) of which were related to the intervention, including an enlarging pneumothorax, asymptomatic pulmonary oedema, and the device malfunctioning, leaking, or dislodging.
Conclusion : Ambulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention.
Conclusion (proposition de traduction) : La prise en charge ambulatoire du pneumothorax spontané primitif a considérablement réduit la durée de l'hospitalisation, y compris les réadmissions dans les 30 premiers jours, mais au détriment d'une augmentation des événements indésirables.
Ces données suggèrent que le pneumothorax spontané primitif peut être géré pour les patients ambulatoires, en utilisant des dispositifs ambulatoires chez ceux qui nécessitent une intervention.
Bagate F, Boissier F, Mekontso Dessap A. | Méd Intensive Réa. 29(3):183-190
DOI: https://doi.org/10.37051/mir-00031 | Télécharger l'article au format
Keywords: circulatory insufficiency, PCO2 gradients, tissue perfusion, micro and macrocirculation
Editorial : Le dioxyde de carbone (CO2) constitue le produit de dégradation final du métabolisme cellulaire. Plusieurs gradients de CO2, obtenus grâce à la mesure de la pression partielle de CO2 (PCO2) dans différents compartiments, sont utilisés afin d’évaluer l’état circulatoire des patients de réanimation. Au cours d’un état de choc, l’augmentation de la PCO2 veineuse et tissulaire est principalement la conséquence d’une hypoperfusion tissulaire et non d’une hypoxémie, reflétant ainsi une anomalie macro et/ou microcirculatoire. Un gradient veino-artériel de PCO2 (Pv-aCO2) ≥ 6 mmHg peut suggérer une inadéquation du débit cardiaque. À l’échelle locale, un gradient tissu-artériel en PCO2 (Pt-aCO2) élevé malgré un Pv-aCO2 normal (< 6 mmHg) peut faire évoquer une atteinte de la microcirculation locale. Enfin, un indice combiné des paramètres dérivés du CO2 et de l’O2, comme le rapport entre le Pv-aCO2 et la différence des contenus artériel et veineux en oxygène (Pv-aCO2 / CaO2 – CvO2), suggère une hypoxie tissulaire lorsqu’il dépasse 1,4. Chez les patients de réanimation en insuffisance circulatoire, les paramètres dérivés du CO2 doivent toutefois s’intégrer dans une approche multiparamétrique (examen clinique, marqueurs biologiques, échocardiographie et autres outils hémodynamiques). Mots-clés : insuffisance circulatoire, gradients de PCO2, perfusion tissulaire, atteinte micro et macrocirculatoire
Conclusion (proposition de traduction) : Les paramètres dérivés du CO2 peuvent aider le clinicien dans la prise en charge hémodynamique des patients en insuffisance circulatoire afin d’apprécier la macro- circulation, la perfusion tissulaire, et le métabolisme cellulaire. Ces paramètres, notamment le Pv-aCO2, doivent toutefois s’intégrer dans une prise en charge globale avec une approche multiparamétrique (examen clinique, marqueurs biologiques, échocardiographie et autres outils hémodynamiques).
Prehospital opioid dose and myocardial injury in patients with ST elevation myocardial infarction .
Fernando H, Nehme Z, Peter K, Bernard S, Stephenson M, Bray J, Cameron P, Ellims A, Taylor A, Kaye DM, Smith K, Stub D; AVOID investigators. | Open Heart. 2020 Jul;7(2):e001307
DOI: https://doi.org/10.1136/openhrt-2020-001307 | Télécharger l'article au format
Keywords: STEMI; antiplatelet treatment; coronary intervention (PCI); myocardial ischaemia and infarction (IHD); platelet activation.
Introduction : To characterise the relationship between opioid dose and myocardial infarct size in patients with ST elevation myocardial infarction (STEMI).
Méthode : Patients given opioid treatment by emergency medical services with confirmed STEMI were included in this secondary, retrospective cohort analysis of the Air versus Oxygen in Myocardial Infarction (AVOID) study. Patients with cardiogenic shock were excluded. The primary endpoint was comparison of cardiac biomarkers as a measure of infarct size based on opioid dose (low ≤8.75 mg, intermediate 8.76-15 mg and high >15 mg of intravenous morphine equivalent dose).
Résultats : 422 patients were included in the analysis. There was a significantly higher proportion of patients with Thrombolysis in Myocardial Infarction (TIMI) 0 or 1 flow pre-percutaneous coronary intervention (PCI) (94% vs 81%, p=0.005) and greater use of thrombus aspiration catheters (59% vs 30%, p<0.001) in the high compared with low-dose opioid group. After adjustment for potential confounders, every 1 mg of intravenous morphine equivalent dose was associated with a 1.4% (95% CI 0.2%, 2.7%, p=0.028) increase in peak creatine kinase; however, this was no longer significant after adjustment for TIMI flow pre-PCI.
Conclusion : Our study suggests no benefit of higher opioid dose and a dose-dependent signal between opioid dose and increased myocardial infarct size. Prospective randomised controlled trials are required to establish causality given that this may also be explained by patients with a greater ischaemic burden requiring higher opioid doses due to more severe pain. Future research also needs to focus on strategies to mitigate the opioid-P2Y12 inhibitor interaction and non-opioid analgesia to treat ischaemic chest pain.
Conclusion (proposition de traduction) : Notre étude ne retrouve aucun bénéfice pour des doses plus élevées de morphinomimétiques et en faveur d’un signal dose-dépendant entre la dose de morphinomimétiques et l’augmentation de la taille de l’infarctus du myocarde. Des études prospectives randomisées et contrôlées sont nécessaires pour établir un lien étant donné que cela peut également être expliqué par des patients présentant une taille de la zone ischémique plus importante qui nécessiterait des doses plus élevées de morphinomimétiques en raison d’une douleur plus sévère. Les recherches futures doivent également porter sur les stratégies visant à atténuer l’interaction des morphinomimétiques et des inhibiteurs P2Y12 et l’analgésie non-morphiniquee pour traiter les douleurs thoraciques ischémiques.
Evaluation of the C-MAC Miller Video Laryngoscope Sizes 0 and 1 During Tracheal Intubation of Infants Less Than 10 kg.
Raimann FJ, Cuca CE, Kern D, Zacharowski K, Rolle U, Meininger D, Weber CF, Byhahn C, Mutlak H. | Pediatr Emerg Care. 2020 Jul;36(7):312-316
Introduction : Video laryngoscopy has primarily been developed to assist in difficult airways. Using video laryngoscopy in pediatric airway management is an up-and-coming topic. The aim of the presented study was to compare the intubation conditions obtained when using the C-MAC video laryngoscope with Miller blades sizes 0 and 1 for standard direct laryngoscopy and indirect laryngoscopy in children weighing less than 10 kg.
Méthode : This was a prospective study.
Setting: The study was performed in a university hospital.
Patients: Following ethical approval, 86 infants weighing less than 10 kg and undergoing surgery under general anesthesia were studied prospectively.
Intervention: Indirect and direct laryngoscopy either with C-MAC Miller blade size 0 or size 1.
Measurements: First, direct laryngoscopy was performed, and the best obtained view was graded without looking at the video monitor. A second investigator blinded to the view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Time to intubation, intubation conditions, and intubation attempts were recorded.
Résultats : n infants less than 10 kg, intubation conditions were excellent. There were no significant differences between the use of Miller blade 0 or 1 in reference to Cormack-Lehane grade, time to intubation, time to best view, or intubation attempts. Comparing direct and indirect intubation conditions using either Miller blade 0 or 1 revealed that the use of indirect laryngoscopy provided a significantly better view (P < 0.05) of the vocal cords. In 3 infants weighing more than 8 kg, the Miller blade 0 was described as too short and narrow for intubation.
Conclusion : Both devices allowed for an excellent visualization of the vocal cords.
Conclusion (proposition de traduction) : Les deux appareils ont permis une excellente visualisation des cordes vocales.
Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers.
Wiitala EL, Parker JL, Jones JS, Benner CA. | Pediatr Emerg Care. 2020 Jul 9
Introduction : Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers.
Méthode : We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale.
Résultats : There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198).
Conclusion : Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.
Conclusion (proposition de traduction) : Parmi les enfants présentant un traumatisme contondant sévère, les patients traités dans les centres de traumatologie pédiatrique de niveau 1 étaient moins susceptibles de recevoir des scanners thoraciques et abdominale que ceux traités dans les centres de traumatologie pédiatrique de niveau 2 ou adultes de niveau 1/2, sans différence significative de la mortalité. Ces résultats plaident pour une utilisation de l'imagerie sélective dans les traumatismes pédiatriques contondants graves.
Commentaire : Il s'agit d'une étude qui montre que le body scanner pour bilantes les traumatismes dans une population pédiatrique n'est probablement pas nécessaire.
Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport.
Patrick C, Ward B, Anderson J, Fioretti J, Rogers Keene K, Oubre C, Cash RE, Panchal AR, Dickson R. | Prehosp Disaster Med. 2020 Jul 23:1-6
Keywords: Emergency Medical Services; epinephrine; hypotension; prehospital; shock
Online ahead of print
Introduction : The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.
Méthode : This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record.
Résultats : Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.
Conclusion : These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.
Conclusion (proposition de traduction) : Ces données préliminaires suggèrent que l'administration d'épinéphrine en bolus peut être efficace pour améliorer rapidement une hypotension en milieu préhospitalier avec une incidence minimale d'événements indésirables. L'utilisation par des ambulanciers paramédicaux d'épinéphrine en bolus a augmenté avec succès la pression artériel systolique et la pression artérielle moyenne sans effets secondaires cliniquement significatifs. Des études prospectives avec des échantillons de plus grande taille sont nécessaires pour étudier plus en détail les effets de l'épinéphrine en bolus préhospitalier sur la morbidité et la mortalité des patients.
Brief Research Report: Prehospital Rapid Sequence Airway.
Braude D, Dixon D, Torres M, Martinez JP, O'Brien S, Bajema T. | Prehosp Emerg Care. 2020 Jul 22:1-5
Keywords: LMA; airway; extraglottic; rapid sequence
Introduction : Rapid Sequence Airway (RSA) describes the administration of an induction agent and paralytic followed by the intended primary placement of an extraglottic airway device rather than an endotracheal tube. The purpose of this study was to determine the success rates for prehospital RSA. The secondary goal was to determine aspiration rates among patients managed with RSA.
Méthode : Adult and pediatric prehospital RSA cases between 2005 and 2017 reported to an airway quality assurance registry from one ground and one air agency were reviewed. Success was defined as the ability to adequately ventilate patients after extraglottic device placement. Aspiration was defined as radiologic evidence (chest x-ray or CT scan) within 48 hours of hospital presentation.
Résultats : 68 patients underwent RSA with a King LTS-D (n = 24), LMA-Supreme (n = 28), Combitube (n = 2), LMA-Unique (n = 8) and iGel (n = 6). Age ranged from 1 year to 73 years with 10 patients less than 18. RSA was successful in 64 (94%) cases; 56 (88%) were successful on first pass and 63 (98%) within 2 attempts. The RSA procedure occurred in an aircraft in 14 (21%) of cases and 71% of patients were in cervical precautions. Duration of EGD insertion prior to hospital arrival ranged from 5 to 102 minutes with an average of 34.5 minutes. Aspiration data was available for 46 patients of whom 4 (8.7%) were found to have evidence of aspiration.
Conclusion : Overall and first pass RSA success rates were high and aspiration rates were low in this quality assurance registry despite predictors of airway difficulty. RSA may be a reasonable alternative to RSI for prehospital airway management that merits further research.
Conclusion (proposition de traduction) : Dans l'ensemble et au premier essai, les taux de succès de gestion des voies aériennes en séquence rapide étaient élevés et les taux d'inhalation étaient faibles dans ce registre d'assurance qualité malgré les critères prédictifs d'intubation difficile. La gestion des voies aériennes en séquence rapide pourrait être une alternative raisonnable à l'intubation à séquence rapide pour la gestion préhospitalière des voies respiratoires qui mérite des recherches supplémentaires.
Multicenter Evaluation of Prehospital Seizure Management in Children.
Shah MI, Ostermayer DG, Browne LR, Studnek JR, Carey JM, Stanford C, Fumo N, Lerner EB. | Prehosp Emerg Care. 2020 Jul 17:1-12
Keywords: paramedics; pediatrics; seizures.
Introduction : Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.
Objective: We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.
Méthode : Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.
Résultats : We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients.
Conclusion : Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.
Conclusion (proposition de traduction) : La mise en œuvre d'un protocole de saisie factuel pour les services médicaux d'urgence a augmenté l'administration du midazolam. Les patients recevaient fréquemment une dose incorrecte par rapport à leur poids. Les recherches futures devraient se concentrer sur l'optimisation de l'administration de la dose correcte de midazolam pour améliorer l'arrêt des crises.
Medication Dosing Safety for Pediatric Patients: Recognizing Gaps, Safety Threats, and Best Practices in the Emergency Medical Services Setting. A Position Statement and Resource Document from NAEMSP.
Cicero MX, Adelgais K, Hoyle JD Jr, Lyng JW, Harris M, Moore B, Gausche-Hill M; pediatric committee of NAEMSP adopted by NAEMSP Board of Directors. | Prehosp Emerg Care. 2020 Jul 9:1-22
Introduction : Millions of patients receive medications in the Emergency Medical Services (EMS) setting annually, and dosing safety is critically important. The need for weight-based dosing in pediatric patients and variability in medication concentrations available in the EMS setting may require EMS providers to perform complex calculations to derive the appropriate dose to deliver. These factors can significantly increase the risk for harm when dose calculations are inaccurate or incorrect.We conducted a scoping review of the EMS, interfacility transport and emergency medicine literature regarding pediatric medication dosing safety. A priori, the authors identified four research topics: 1) what are the greatest safety threats that result in significant dosing errors that potentially result in harm to patients, 2) what practices or technologies are known to enhance dosing safety, 3) can data from other settings be extrapolated to the EMS environment to inform dosing safety, and 4) what impact could standardization of medication formularies have on enhancing dosing safety.To address these topics, 17 PICO (Patient, Intervention, Comparison, Outcome) questions were developed and a literature search was performed. After applying exclusion criteria, 70 articles were reviewed. The methods for the investigation, findings from these articles and how they inform EMS medication dosing safety are summarized here. This review yielded 11 recommendations to improve safety of medication delivery in the EMS setting. These recommendations are summarized in the National Association of EMS Physicians® position statement: Medication Dosing Safety for Pediatric Patients in Emergency Medical Services.
Conclusion : Although many interventions found in our study trended towards successfully reducing ED visits or hospitalizations, most studies were observational and evaluations of patient safety were lacking. Our study found several types of interventions that target the reduction of ED visits in long-term care patients. Despite efforts to reduce ED visits by providing better primary care, residents will always be at risk of acute issues. Further investigation into interventions that respond to acute issues, such as community paramedics, may be beneficial. Ideally, more research is needed to evaluate the safety of interventions and should also consider outcomes such as patient preferences and quality of life indicators.
Conclusion (proposition de traduction) : Bien que de nombreuses interventions trouvées dans notre étude aient eu tendance à réduire avec succès les consultations aux urgences ou les hospitalisations, la plupart des études étaient observationnelles et les évaluations de la sécurité des patients faisaient défaut. Notre étude a révélé plusieurs types d'interventions qui visent la réduction des consultations aux urgences chez les patients en soins de longue durée. Malgré les efforts déployés pour réduire les consultations aux urgences en offrant de meilleurs soins primaires, les résidents seront toujours exposés à des problèmes aigus. Une enquête plus approfondie sur les interventions qui répondent à des problèmes aigus, comme les ambulanciers paramédicaux communautaires, peut être bénéfique. Idéalement, des recherches supplémentaires sont nécessaires pour évaluer la sécurité des interventions et devraient également tenir compte des résultats tels que les préférences des patients et les indicateurs de qualité de vie.
Inferior Vena Cava Diameter is an Early Marker of Central Hypovolemia during Simulated Blood Loss.
Johnson BD, Schlader ZJ, Schaake MW, O'Leary MC, Hostler D, Lin H, St James E, Lema PC, Bola A, Clemency BM. | Prehosp Emerg Care. 2020 Jul 7:1-6
Keywords: POCUS; hemorrhage; lower body negative pressure; shock; ultrasound
Introduction : Inferior vena cava (IVC) diameter decreases under conditions of hypovolemia. Point-of-care ultrasound (POCUS) may be useful to emergently assess IVC diameter. This study tested the hypothesis that ultrasound measurements of IVC diameter decreases during severe simulated blood loss.
Méthode : Blood loss was simulated in 14 healthy men (22 ± 2 years) using lower body negative pressure (LBNP). Pressure within the LBNP chamber was reduced 10 mmHg of LBNP every four minutes until participants experienced pre-syncopal symptoms or until 80 mmHg of LBNP was completed. IVC diameter was imaged with POCUS using B-mode in the long and short axis views between minutes two and four of each stage.
Résultats : Maximum IVC diameter in the long axis view was lower than baseline (1.5 ± 0.4 cm) starting at -20 mmHg of LBNP (1.0 ± 0.3 cm; p < 0.01) and throughout LBNP (p < 0.01). The minimum IVC diameter in the long axis view was lower than baseline (0.9 ± 0.3 cm) at -20 mmHg of LBNP (0.5 ± 0.3 cm; p < 0.01) and throughout LBNP (p < 0.01). Maximum IVC diameter in the short axis view was lower than baseline (0.9 ± 0.2 cm) at 40 mmHg of LBNP (0.6 ± 0.2; p = 0.01) and the final LBNP stage (0.6 ± 0.2 cm; p < 0.01). IVC minimum diameter in the short axis view was lower than baseline (0.5 ± 0.2 cm) at the final LBNP stage (0.3 ± 0.2 cm; p = 0.01).
Conclusion : These data demonstrate that IVC diameter decreases prior to changes in traditional vital signs during simulated blood loss. Further study is needed to determine the view and diameter threshold that most accurate for identifying hemorrhage requiring emergent intervention.
Conclusion (proposition de traduction) : Ces données démontrent que le diamètre de la VCI diminue avant la modification des signes vitaux traditionnels lors d'une perte de sang simulée. Une étude plus approfondie est nécessaire pour déterminer la fenêtre et le seuil de diamètre les plus précis pour identifier les hémorragies nécessitant une intervention urgente.
Sustained inflation with 21% versus 100% oxygen during cardiopulmonary resuscitation of asphyxiated newborn piglets - A randomized controlled animal study..
Hidalgo CG, Solevag AL, Kim SY, Shim GH, Cheung P-Y, Lee T-F, O’Reilly M, Schmölzer GM. | Resuscitation. 2020 Jul 26;
Keywords: Infants; Newborn; Neonatal Resuscitation; Chest Compressions; Asphyxia; Oxygen; Sustained Inflation
Introduction : Current neonatal resuscitation guidelines recommend using 100% oxygen during chest compressions (CC), however the most effective oxygen concentration during cardiopulmonary resuscitation remains controversial.
Méthode : In term newborn piglets with asphyxia-induced cardiac arrest does 21% oxygen compared to 100% oxygen during resuscitation using CC during sustained inflation (SI; CC + SI) will have a reduced time to return of spontaneous circulation (ROSC).
Intervention and measurements:
Twenty-two mixed breed piglets (1-3 days old, 1.7-2.4 kg), were obtained on the day of the experiment and anesthetized, intubated, instrumented, and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were resuscitated using CC + SI and randomized to 21% oxygen (n = 8) or 100% oxygen (n = 8). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.
Résultats : Baseline parameters were similar between 21% and 100% oxygen groups. There was no difference in asphyxiation (duration and degree) between groups. Time to ROSC was similar between 21% and 100% oxygen groups: median (interquartile range - IQR) 80 (70-190)sec vs. 90 (70-324)sec, (p = 0.56). There was no significant difference in the rate of ROSC between 21% and 100% oxygen groups: 7/8 (88%) vs. 5/8 (63%), (p = 0.569). All piglets that achieved ROSC survived to four hours post-resuscitation. Hemodynamics and regional perfusion were not significantly different between groups.
Conclusion : In term newborn piglets resuscitated by CC + SI, the use of 21% oxygen resulted in a similar time to ROSC, short-term survival, and hemodynamic recovery compared to 100% oxygen.
Conclusion (proposition de traduction) : Chez les porcelets nouveau-nés à terme, réanimés par des compressions thoraciques et des inflations prolongées, l'utilisation d'oxygène à FiO2 = 21 % a entraîné des temps de récupération d'activité cardiaque spontanée, de survie à court terme et de récupération hémodynamique similaire par rapport à de l'oxygène à FiO2 = 100 %.
Enhancing citizens response to out-of-hospital cardiac arrest: A systematic review of mobile-phone systems to alert citizens as first responders.
Scquizzato T, Pallanch O, Belletti A, Frontera A, Cabrini L, Zangrillo A, Landoni G. | Resuscitation. 2020 Jul;152:16-25
DOI: https://doi.org/10.1016/j.resuscitation.2020.05.006 | Télécharger l'article au format
Keywords: Cardiopulmonary resuscitation; First responders; Mobile-phone technology; Out-of-hospital cardiac arrest.
Introduction : Involving laypersons in response to out-of-hospital cardiac arrest through mobile-phone technology is becoming widespread in numerous countries, and different solutions were developed. We performed a systematic review on the impact of alerting citizens as first responders and to provide an overview of different strategies and technologies used.
Méthode : We searched electronic databases up to October 2019. Eligible studies described systems to alert citizens first responders to out-of-hospital cardiac arrest through text messages or apps. We analyzed the implementation and performance of these systems and their impact on patients' outcomes.
Résultats : We included 28 manuscripts describing 12 different systems. The first text message system was implemented in 2006 and the first app in 2010. First responders accepted to intervene in median (interquartile) 28.7% (27-29%) of alerts and reached the scene after 4.6 (4.4-5.5) minutes for performing CPR. First responders arrived before ambulance, started CPR and attached a defibrillator in 47% (34-58%), 24% (23-27%) and 9% (6-14%) of cases, respectively. Pooled analysis showed that first responders activation increased layperson-CPR rates (1463/2292 [63.8%] in the intervention group vs. 1094/1989 [55.0%] in the control group; OR = 1.70; 95% CI, 1.11-2.60; p = 0.01) and survival to hospital discharge or at 30 days (327/2273 [14.4%] vs. 184/1955 [9.4%]; OR = 1.51; 95% CI, 1.24-1.84; p < 0.001).
Conclusion : Alerting citizens as first responders in case of out-of-hospital cardiac arrest may reduce the intervention-free time and improve patients' outcomes.
Conclusion (proposition de traduction) : Alerter les citoyens en tant que premiers intervenants en cas d'arrêt cardiaque extra-hospitalier peut réduire le temps sans intervention et améliorer le devenir des patients.
Prognostication with point-of-care echocardiography during cardiac arrest: A systematic review.
Reynolds JC, Issa MS, C Nicholson T, Drennan IR, Berg KM, O'Neil BJ, Welsford M; Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. | Resuscitation. 2020 Jul;152:56-68
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Echocardiography; Point-of-care ultrasound; Prognostication; Systematic review.
Introduction : To conduct a prognostic factor systematic review on point-of-care echocardiography during cardiac arrest to predict clinical outcomes in adults with non-traumatic cardiac arrest in any setting.
Méthode : We conducted this review per PRISMA guidelines and registered with PROSPERO (ID pending). We searched Medline, EMBASE, Web of Science, CINAHL, and the Cochrane Library on September 6, 2019. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality in Prognosis Studies (QUIPS) template. We estimated prognostic test performance (sensitivity and specificity) and measures of association (odds ratio). Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology evaluated the certainty of evidence.
Résultats : In total, 15 studies were included. We found wide variation across studies in the definition of 'cardiac motion' and timing of sonographic assessment. Most studies were hindered by high risks of bias from prognostic factor measurement, outcome measurement, and lack of adjustment for other prognostic factors. Ultimately, heterogeneity and risk of bias precluded meta-analyses. We tabulated ranges of prognostic test performance and measures of association for 5 different combinations of definitions of 'cardiac motion' and sonographic timing, as well as other miscellaneous sonographic findings. Overall certainty of this evidence is very low.
Conclusion : The evidence for using point-of-care echocardiography as a prognostic tool for clinical outcomes during cardiac arrest is of very low certainty and is hampered by multiple risks of bias. No sonographic finding had sufficient and/or consistent sensitivity for any clinical outcome to be used as sole criterion to terminate resuscitation.
Conclusion (proposition de traduction) : Les preuves de l'utilisation de l'échocardiographie au point d'intervention comme outil de pronostic des résultats cliniques lors d'un arrêt cardiaque sont d'une très faible certitude et sont entravées par de multiples risques de biais. Aucun résultat échographique n'avait une sensibilité suffisante et/ou constante pour qu'un résultat clinique soit utilisé comme seul critère pour mettre fin à la réanimation.
Oxygenation and ventilation targets after cardiac arrest: A systematic review and meta-analysis.
Holmberg MJ, Nicholson T, Nolan JP, Schexnayder S, Reynolds J, Nation K, Welsford M, Morley P, Soar J, Berg KM; Adult Pediatric Advanced Life Support Task Forces at the International Liaison Committee on Resuscitation (ILCOR). | Resuscitation. 2020 Jul;152:107-115
Keywords: Carbon dioxide; Cardiac arrest; Cardiopulmonary resuscitation; ILCOR; Oxygen; Oxygen delivery; Oxygenation; Ventilation.
Introduction : To perform a systematic review and meta-analysis of the literature on oxygenation and ventilation targets after successful resuscitation from cardiac arrest in order to inform an update of international guidelines.
Méthode : The review was performed according to PRISMA and registered on PROSPERO (ID: X). Medline, EMBASE, and the Cochrane Library were searched on August 22, 2019. The population included both adult and pediatric patients with cardiac arrest. Two investigators reviewed abstracts, extracted data, and assessed the risk of bias. Meta-analyses were performed for studies without excessive bias. Certainty of evidence was evaluated using GRADE.
Résultats : We included 7 trials and 36 observational studies comparing oxygenation or ventilation targets. Most of the trials and observational studies included adults with out-of-hospital cardiac arrest. There were 6 observational studies in children. Bias for trials ranged from low to high risk, with group imbalances and blinding being primary concerns. Bias for observational studies was rated as serious or critical risk with confounding and exposure classification being primary sources of bias. Meta-analyses including two trials comparing low vs high oxygen therapy and two trials comparing hypercapnia vs no hypercapnia were inconclusive. Point estimates of individual studies generally favored normoxemia and normocapnia over hyper- or hypoxemia and hyper- or hypocapnia.
Conclusion : We identified a large number of studies related to oxygenation and ventilation targets in cardiac arrest. The majority of studies did not reach statistical significance and were limited by excessive risk of bias. Point estimates of individual studies generally favored normoxemia and normocapnia.
Conclusion (proposition de traduction) : Nous avons identifié un grand nombre d'études liées aux objectifs d'oxygénation et de ventilation en cas d'arrêt cardiaque. La majorité des études n'ont pas atteint la signification statistique et étaient limitées par un risque excessif de biais. Les estimations ponctuelles des études individuelles favorisaient généralement la normoxémie et la normocapnie.
Out-of-hospital cardiac arrest across the World: First report from the International Liaison Committee on Resuscitation (ILCOR).
Kiguchi T, Okubo M, Nishiyama C, Maconochie I, Ong MEH, Kern KB, Wyckoff MH, McNally B, Christensen EF, Tjelmeland I, Herlitz J, Perkins GD, Booth S, Finn J, Shahidah N, Shin SD, Bobrow BJ, Morrison LJ, Salo A, Baldi E, Burkart R, Lin CH, Jouven X, Soar J, Nolan JP, Iwami T. | Resuscitation. 2020 Jul;152:39-49
Keywords: Epidemiology; Out-of-hospital cardiac arrest; Registry; Resuscitation; Utstein template.
Introduction : Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.
Méthode : We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.
Résultats : Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0-97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1-79.0% in all registries and 2.0-37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1-20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8-18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%.
Conclusion : This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.
Conclusion (proposition de traduction) : Ce rapport de l'ILCOR décrit les données sur les systèmes de soins et les résultats après un arrêt cardiaque extra-hospitalier provenant de neuf registres nationaux et sept registres régionaux à travers le monde. Nous avons trouvé des variations dans les résultats de survie rapportés et d'autres éléments fondamentaux des recommandations actuelles de style Utstein pour les arrêts cardiaques extra-hospitalier entre les pays et les régions.
Distribution of heart rate and responses to resuscitation among 1237 apnoeic newborns at birth.
Eilevstjønn J, Linde JE, Blacy L, Kidanto H, Ersdal HL. | Resuscitation. 2020 Jul;152:69-76
Keywords: Bag-mask; ECG; Heart rate; Newborn resuscitation; Positive pressure ventilation.
Introduction : Describe the distribution of the first recorded heart rate (HR) in apnoeic term/near-term newborns, HR responses to basic resuscitation (no intubation, chest compressions and/or medication), and relationship to 24-h outcomes. We also document patient characteristics and care provider behaviour stratified by first HR.
Méthode : Descriptive study from July 2013 through June 2018 at Haydom Hospital in Tanzania. All deliveries were observed by assistants recording data. Bag-mask ventilation and ECG data were recorded by resuscitation monitors. Newborns with ≥5 ventilations and ECG signal-data were included.
Résultats : 1237 term/near-term newborns with median (25th, 75th percentiles) gestation 38 (37, 40) weeks and birth weight 3140 (2750, 3500) grams fulfilled inclusion criteria. The first HR, measured median 102 (73, 144) s after birth following drying/stimulation, was distributed into two peaks with centres around 60 and 165 bpm, 51% were ≥100 bpm. After ventilation, the HR distribution shifted to a single-peak, with median 161 bpm. At least one low-high HR transition crossing 100 bpm was noted in 44% of newborns. The HR increase occurred over median 9.2 (6.2, 13) s, was 60 (43, 77) bpm, and 86% followed a ventilation sequence of 23 (16, 34) s duration. 72% of the newborns with first HR < 60 bpm survived following ventilations only. Both first and final HR were significantly related to 24-h outcomes.
Conclusion : The first recorded HR was distributed into two peaks on each side of 100 bpm. Ventilation increased HR in most newborns. Lower first and final HR were related to gradually more adverse 24-h outcomes.
Conclusion (proposition de traduction) : La première fréquence cardiaque enregistrée a été répartie en deux pics de chaque côté de 100 bpm. La ventilation a augmenté la fréquence cardiaque chez la plupart des nouveau-nés. Une fréquence cardiaque inférieure et finale était liée à des résultats progressivement plus défavorables sur 24 h.
Neurologically favourable outcomes of cardiogenic out-of-hospital cardiac arrest with relation to the type of witness in Japan.
Shirakawa K, Kanao K, Saito Y, Doi K, Takuma K, Okamura T, Takebayashi T. | Resuscitation. 2020 Jul;152:97-104
Keywords: Automated external defibrillator; Basic life support; Bystander CPR; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest.
Introduction : To assess the current situation and neurologically favourable outcomes after out-of-hospital cardiac arrest (OHCA) with respect to the type of witness.
Méthode : This retrospective observational study used data from the All-Japan Utstein Registry of the Fire and Disaster Management Agency collected between January 1, 2016, and December 31, 2016. Patients with cardiogenic OHCA aged ≥18 years who were witnessed by bystanders were included. The primary outcome measure was a neurologically favourable outcome 1 month after the OHCA.
Résultats : Among the 123,554 patients with OHCA registered between January 1, 2016, and December 31, 2016, 24,856 patients were included. Of them, 15,139 were witnessed by family, and 9717 were witnessed by non-family (friends, 1306; colleagues, 951; passers-by, 997; others, 6463). When witnessed by family, the rate of neurologically favourable outcomes was significantly lower than that when witnessed by non-family (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.41-0.49, P < 0.001). After adjusting for potential confounders, the rate of neurologically favourable outcomes remained lower when OHCA was witnessed by family (OR = 0.88, 95% CI = 0.79-0.99, P = 0.03). However, in subgroup analysis, adjusted ORs for neurologically favourable outcomes were slightly greater for 65-84-year-old women and ≥85-year-old women with family witnesses than for those with non-family witnesses. For all other groups, non-family witnesses outperformed family witnesses.
Conclusion : Family-witnessed OHCA events had fewer neurologically favourable outcomes before and after adjusting for confounders. BLS education for family members may lead to improved prognosis of witnessed cardiogenic OHCAs.
Conclusion (proposition de traduction) : Les arrêts cardiaques extra-hospitaliers observés dans le cercle familial ont eu moins de résultats neurologiquement favorables avant et après ajustement avec les facteurs de confusion. L'éducation aux gestes de réanimation cardio-pulmonaire de base pour les membres de la famille peut conduire à un meilleur pronostic des arrêts cardiaques cardiogéniques extra-hospitaliers.
Effect of airway management strategies during resuscitation from out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis.
Behrens NH, Fischer M, Krieger T, Monaco K, Wnent J, Seewald S, Gräsner JT, Bernhard M. | Resuscitation. 2020 Jul;152:157-164
Keywords: Airway management; Cardiopulmonary resuscitation; Endotracheal intubation; Matched-pair analysis; Out-of-hospital cardiac arrest.
Introduction : An effective airway management is pivotal for treating hypoxia and to ensure reoxygenation during cardiopulmonary resuscitation (CPR). This matched-pair analysis from the German Resuscitation Registry (GRR) investigates the outcomes of various methods of airway management used on out-of-hospital cardiac arrest (OHCA) patients.
Méthode : 89,220 OHCA patients were reported between 01/01/2007 and 12/31/2017. After applying exclusion and inclusion criteria, the resulting 19,196 patient's data were analyzed. Endpoints were return of spontaneous circulation (ROSC), hospital admission, 24-h survival, hospital discharge, and discharge with cerebral performance categories 1,2 (CPC1,2). Three categories of airway management were defined: endotracheal tube ("ETT"), laryngeal tube ("LT_only"), and laryngeal to endotracheal tube exchange ("LTEX"). The groups were matched with respect to age, gender, aetiology or location of OHCA, witnessing or CPR by lay people, initial rhythm, and use of epinephrine and amiodarone.
Résultats : "ETT" versus "LT_only" was associated with higher short- and long-term outcome rates and better neurological recovery (CPC_1.2: 7.7 vs. 5.8%, OR = 1.35, 95%-CI = 1.09-1.67, n = 5552). "LTEX" versus "LT_only" showed significantly higher ROSC- and 24-h survival rate (33.7 vs. 21.8%, OR = 1.82, 95%-CI = 1.51-2.2, n = 2302). "LTEX" versus "ETT" revealed significantly higher ROSC- and 24-h survival rate (34.6 vs. 30.4%, OR = 1.21, 95%-CI = 1.03-1.42, n = 2608).
Conclusion : "ETT" was associated with higher survival rates and better neurological outcomes in comparison to "LT_only". The strategy of "LTEX" versus "LT_only" or "ETT" was only associated with better short-term outcomes. Our observational registry data suggests that endotracheal intubation by physician staffed EMS is the optimal airway strategy for OHCA in our system.
Conclusion (proposition de traduction) : L'« IOT » était associé à des taux de survie plus élevés et de meilleurs résultats neurologiques par rapport au « dispositif supra-laryngé ». La stratégie « intubation à travers le dispositif supra-laryngé » contre « dispositif supra-laryngé » ou « IOT » n'était associée qu'à de meilleurs résultats à court terme. Nos données de registre d'observation suggèrent que l'intubation endotrachéale par un service médical d'urgence équipé d'un médecin est la stratégie optimale des voies aériennes pour l'arrêt cardiaque extra-hospitalier dans notre système.
Commentaire : Dans cette étude allemande et autrichienne, les médecins prenant en charge les arrêts cardiaques avaient un taux de succès de l'intubation orotrachéale de plus de 99 % contrairement aux paramédicaux de l'étude américaine PART (Resuscitation. 2016 Apr;101:57–64 ) dont le taux de réussite n'était que de 51 %.
Par conséquent, les systèmes d'urgence pré-hospitaliers des deux études ne sont pas comparables en ce qui concerne les fournisseurs de soins spécialisés et les compétences avancées en gestion des voies aériennes.
Pour mémoire, l'étude du Pr Adnet (JAMA. 2018;319(8):779-787 ) a démontré que l'intubation orotrachéale était non inférieure à la ventilation au masque facial sans démontrer de supériorité de la prise en charge spécialisée des voies aériennes supérieures.
Exploration of strategies to reduce aerosol-spread during chest compressions: A simulation and cadaver model.
Ott M, Milazzo A, Liebau S, Jaki C, Schilling T, Krohn A, Heymer J. | Resuscitation. 2020 Jul;152:192-198
Simulation and Education
Introduction : To evaluate the effect of strategies to reduce the spread of simulated aerosol during chest compressions on manikin and cadaver experimental models.
Méthode : To evaluate aerosol-spread we nebulized ultraviolet sensitive detergents into the artificial airway of a resuscitation dummy and performed CPR. The spread of the visualized aerosol was documented by a camera. In a further approach we applied nebulized detergents into the airways of human cadavers and detected the simulated spread on the same way. Among others we did recordings with undergoing compression-only-CPR, with a surgical mask or an oxygen mask on the patients face and with an inserted supraglottic airway device with and without a connected airway filter.
Résultats : Most aerosol-spread at the direction of the provider was visualized during compression-only-CPR. The use of a surgical mask and of an oxygen mask on the patient's face deflected the spread. Inserting a supraglottic airway device connected to an airway filter lead to a remarkable reduction of aerosol-spread.
Conclusion : The early insertion of a supraglottic airway device connected to an airway filter before starting chest compression may be beneficial for staff protection during CPR.
Conclusion (proposition de traduction) : L'insertion précoce d'un appareil respiratoire supraglottique connecté à un filtre respiratoire avant de commencer la compression thoracique peut être bénéfique pour la protection du personnel pendant la RCP.
ReACanROC: Towards the creation of a France-Canada research network for out-of-hospital cardiac arrest.
Heidet M, Fraticelli L, Grunau B, Cheskes S, Baert V, Vilhelm C, Hubert H, Tazarourte K, Vaillancourt C, Tallon J, Christenson J, El Khoury C; Gr-ReAC CanROC investigators. | Resuscitation. 2020 Jul;152:133-140
Keywords: Emergency medical services; Out-of-hospital cardiac arrest; Prehospital; Registry.
Introduction : There are large differences between emergency medical systems, which may account for variability in outcomes. We seek to compare prehospital organizations, response modes, patient characteristics and outcomes after out-of-hospital cardiac arrest, between France and Canada, and discuss the need for the first European-North American prehospital research network on out-of-hospital cardiac arrest.
Méthode : Preliminary comparative description of data drawn from two nation-wide, population-based, Utstein-style prospectively implemented registries for out-of-hospital cardiac arrest in France and Canada (France: RéAC, Canada: CanROC), covering approximately 80 million people, and soon to be participating in an international research network in 2020.
Résultats : Since creation, 103,722 cases were included in France and approximately 99,317 in Canada. Data used in this work were drawn from 2011 to 2016, and comprised around 33,688 adult, non-traumatic, treated cases in Canada, and 55,358 in France, leading to estimated incidence rates of 75.3/100,000 inhabitants in France and 83/100,000 in Canada. In both countries, out-of-hospital cardiac arrest predominantly occurred in male patients, in their late sixties, at home, of presumed cardiac aetiology. Bystander cardiopulmonary resuscitation was provided in half of the cases. First assessed cardiac rhythm was shockable in 16% (France) vs. 22% (Canada). Professional resuscitation was attempted in 82% (France) and 60% (Canada). Prehospital organizations and response modes differed in the constitution of responding teams (France: physician-led advanced life support, Canada: trained paramedics), in response time intervals (call to first professional responders' arrival at scene 6.5 min (interquartile range IQR [5.2-8.3]) (Canada) vs. 10 min [7-15] (France)), in on-scene interventions, type of referral at hospital (France: systematic bypass of emergency department, tertiary hospital first, Canada: occasional bypass, mainly closest hospital first), and in outcomes (overall survival at hospital discharge in France: 5% vs. Canada: 11%).
Conclusion : Despite similarities in some out-of-hospital cardiac arrest Utstein variables, several differences exist between French and Canadian prehospital systems, and ultimately, between outcomes. The creation of the ReACanROC research network will facilitate the conduction of further analyses to better understand predictors of this variability.
Conclusion (proposition de traduction) : Malgré les similitudes de certaines variables d'Utstein relatives aux arrêts cardiaques extra-hospitalier, il existe plusieurs différences entre les systèmes préhospitaliers français et canadien, et, en fin de compte, entre les résultats. La création du réseau de recherche ReACanROC facilitera la réalisation d'autres analyses afin de mieux comprendre les prédicteurs de cette variabilité.
Effects of different adrenaline doses on cerebral oxygenation and cerebral metabolism during cardiopulmonary resuscitation in pigs.
Putzer G, Martini J, Spraider P, Hornung R, Pinggera D, Abram J, Altaner N, Hell T, Glodny B, Helbok R, Mair P. | Resuscitation. 2020 Jul 8:S0300-9572(20)30260-4
Keywords: Adrenaline; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral cortex/metabolism; Heart arrest/therapy; Microdialysis/methods; Near infrared spectroscopy; Oxygen/blood; Oxygen/metabolism; Pigs.
Article in Press: Corrected Proof
Introduction : The influence of adrenaline during cardiopulmonary resuscitation (CPR) on the neurological outcome of cardiac arrest survivors is unclear. As little is known about the pathophysiological effects of adrenaline on cerebral oxygen delivery and cerebral metabolism we investigated its effects on parameters of cerebral oxygenation and cerebral metabolism in a pig model of CPR.
Méthode : Fourteen pigs were anesthetized, intubated and instrumented. After 5 min of cardiac arrest CPR was started and continued for 15 min. Animals were randomized to receive bolus injections of either 15 or 30 μg/kg adrenaline every 5 min after commencement of CPR.
Résultats : Measurements included mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2), arterial and cerebral venous blood gases and cerebral microdialysis parameters, e.g. lactate/pyruvate ratio. Adrenaline induced a significant increase in MAP and CPP in all pigs. However, increases in MAP and CPP were short-lasting and tended to decrease with repetitive bolus administration. There was no statistical difference in any parameter of cerebral oxygenation or metabolism between study groups.
Conclusion : Both adrenaline doses resulted in short-lasting CPP peaks which did not translate into improved cerebral tissue oxygen tension and metabolism. Further studies are needed to determine whether other dosing regimens targeting a sustained increase in CPP, may lead to improved brain oxygenation and metabolism, thereby improving neurological outcome of cardiac arrest patients.
Conclusion (proposition de traduction) : Les deux doses d’adrénaline ont entraîné des pics de pression de perfusion cérébrale de courte durée qui ne se sont pas traduits par une amélioration de la pression tissulaire cérébrale en oxygène (PtiO2) et du métabolisme cérébral. D’autres études sont nécessaires pour déterminer si d’autres schémas posologiques ciblant une augmentation persistante de la pression tissulaire cérébrale en oxygène peuvent améliorer l’oxygénation et le métabolisme cérébral, améliorant ainsi les résultats neurologiques des patients victimes d’arrêt cardiaque.
Commentaire : Voir le commentaire :
Kilbaugh TJ , Morgan RW, Berg RA. The neurologic impact of epinephrine during cardiac arrest: Much to learn. Resuscitation. September 02, 2020 .
The impact of ventilation rate on end-tidal carbon dioxide level during manual cardiopulmonary resuscitation.
Ruiz de Gauna S, Gutiérrez JJ, Ruiz J, Leturiondo M, Azcarate I, González-Otero DM, Corcuera C, Russell JK, Daya MR. | Resuscitation. 2020 Jul 1:S0300-9572(20)30243-4
Keywords: Advanced life support (ALS); Cardiopulmonary resuscitation (CPR); End-tidal carbon dioxide (ETCO(2)); Out-of-hospital cardiac arrest (OHCA); Ventilation; Ventilation rate; Waveform capnography.
Article in Press
Introduction : Ventilation rate is a confounding factor for interpretation of end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR). The aim of our study was to model the effect of ventilation rate on ETCO2 during manual CPR in adult out-of-hospital cardiac arrest (OHCA).
Méthode : We conducted a retrospective analysis of OHCA monitor-defibrillator files with concurrent capnogram, compression depth, transthoracic impedance and ECG. We annotated pairs of capnogram segments presenting differences in average ventilation rate and average ETCO2 value but with other influencing factors (e.g. compression rate and depth) presenting similar values within the pair. ETCO2 variation as a function of ventilation rate was adjusted through curve fitting using non-linear least squares as a measure of goodness of fit.
Résultats : A total of 141 pairs of segments from 102 patients were annotated. Each pair provided a single data point for curve fitting. The best goodness of fit yielded a coefficient of determination R2 of 0.93. Our model described that ETCO2 decays exponentially with increasing ventilation rate. The model showed no differences attributable to the airway type (endotracheal tube or supraglottic King-LT-D).
Conclusion : Capnogram interpretation during CPR is challenging since many factors influence ETCO2. For adequate interpretation, we need to know the effect of each factor on ETCO2. Our model allows quantifying the effect of ventilation rate on ETCO2 variation. Our findings could contribute to better interpretation of ETCO2 during CPR.
Conclusion (proposition de traduction) : L'interprétation de la capnographie pendant la RCP est difficile car de nombreux facteurs influencent les valeurs d'ETCO2. Pour une interprétation adéquate, nous devons connaître l'effet de chaque facteur sur l'ETCO2. Notre modèle permet de quantifier l'effet de la fréquence de la ventilation sur la variation de l'ETCO2. Nos résultats pourraient contribuer à une meilleure interprétation de l'ETCO2 pendant la RCP.
Commentaire : Voir les commentaires dans :
Noordergraaf GJG, Vormer AJMA. ETCO2 values during CPR: Your ventilation tempo matters. Resuscitation. 2020 Aug 28:S0300-9572(20)30433-0 .
Seizure-like presentation in OHCA creates barriers to dispatch recognition of cardiac arrest.
Schwarzkoph M, Yin L, Hergert L, Drucker C, Counts CR, Eisenberg M. | Resuscitation. 2020 Jul 13:S0300-9572(20)30275-6
Keywords: Cardiac arrest; Dispatcher; OHCA; Seizure; TCPR; Telephone-CPR.
Online ahead of print
Introduction : Early recognition of out-of-hospital cardiac arrest (OHCA) by 9-1-1 dispatchers is a critical first step along the resuscitation pathway. Barriers to recognition may lead to adverse outcomes among patients. This study aims to determine the impact of seizure-like activity among OHCA patients during 9-1-1 calls.
Méthode : We evaluated a retrospective cohort study of all adult, non-traumatic OHCAs that occurred prior to emergency medical services (EMS) arrival on scene in a major metropolitan area from 2014-2018. Dispatch recordings were reviewed to determine if seizure-like activity was reported by the caller using key descriptor phrases such as "seizing," "shaking," or "convulsing." We compared patient demographics, arrest factors, and hospital outcomes using a regional OHCA quality improvement database.
Résultats : Among 3502 OHCAs meeting our inclusion criteria, 149 (4.3%) contained seizure-like activity. When compared to patients without seizure-like activity (3353; 95.7%), patients presenting with seizure-like activity were younger (54 vs. 66 years old; p < 0.05), had a witnessed arrest (88% vs 45%; p < 0.05), presented with an initial shockable rhythm (52% vs. 24%; p < 0.05), and survived to hospital discharge (44% vs. 16%; p < 0.05). The seizure-like activity group also had a longer median time to dispatcher identification of the cardiac arrest [130 s (72,193) vs 62 s (43,102); p < 0.05].
Conclusion : Reported seizure-like activity among patients in cardiac arrest poses a barrier to recognition of cardiac arrests by dispatchers leading to delays in resuscitation instructions.
Conclusion (proposition de traduction) : La présentation sous la forme d'une crise convulsive rapportée pour des patients en arrêt cardiaque constitue un obstacle à la reconnaissance des arrêts cardiaques par les régulateurs, ce qui entraîne des retards dans les instructions de réanimation.
Commentaire : Voir le commentaire dans :
Seaman KG. Seizure-like presentation in OHCA creates barriers to dispatch recognition of cardiac arrest. Resuscitation. 2020 Aug 25:S0300-9572(20)30330-0 .
Comparison of the Effects of Metoclopramide and Ondansetron on Emergency Service Observation Times in Acute Gastroenteritis-Related Nausea and Vomiting Cases.
Afacan MA, Tayfur İ. | Sisli Etfal Hastan Tip Bul. 2019 Jul 11;53(2):186-189
DOI: https://doi.org/10.14744/semb.2019.80217 | Télécharger l'article au format
Keywords: Gastroenteritis; metoclopramide; nausea; ondansetron; vomiting.
Introduction : The aim of the present study was to compare the effect of metoclopramide and ondansetron treatments on the emergency department observation time in acute gastroenteritis-related nausea and vomiting (NV).
Méthode : The study was conducted retrospectively on 297 patients diagnosed with acute gastroenteritis in a training and research hospital's emergency service observation unit within 6 months. Patients with gastroenteritis who were diagnosed with NV were divided into two groups according to the treatment they received in the observation unit. Patients who received 4 mg ondansetron slow infusion therapy were classified as Group 1, and patients who received 10 mg metoclopramide slow infusion therapy were classified as Group 2.
Résultats : The average age of the patients was 39.57±18.75 years. Of the 297 participants, 56.6% (168) were female. Among them, 51.5% (153) received ondansetron (Group 1), and 48.5% (144) received metoclopramide (Group 2). 6.9% weakness-numbness and 4.9% akathisia were detected due to metoclopramide use. There were no adverse effects related to ondansetron use. The duration of observation ranged from 19 to 75 min in Group 1 and from 42 to 122 min in Group 2. Nineteen (13.2%) patients in Group 2 and 5 (3.3%) patients in Group 1 revisited the emergency department within 24 h due to ongoing complaints.
Conclusion : In conclusion, side effects of weakness and akathisia due to metoclopramide use were observed. However, no side effects were observed due to ondansetron use. Additionally, the use of ondansetron showed a shorter observation time and less recurrent admission to the emergency department. Therefore, ondansetron is a more effective drug in the treatment of NV associated with acute gastroenteritis.
Conclusion (proposition de traduction) : En conclusion, des effets secondaires de sensation faiblesse et d'akathisie (symptômes extrapyramidaux) dus à l'utilisation de métoclopramide ont été observés. Cependant, aucun effet secondaire n'a été observé en raison de l'utilisation d'ondansétron. De plus, l'utilisation de l'ondansétron a montré un temps d'observation plus court et moins d'admissions récurrentes aux urgences. Par conséquent, l'ondansétron est un médicament plus efficace dans le traitement des nausées et des vomissements associés à une gastro-entérite aiguë.
Does intramuscular ondansetron have an effect on intramuscular ketamine-associated vomiting in children? A prospective, randomized, double blind, controlled study.
Nejati A, Davarani SS, Talebian MT, Hossein F, Akbari H. | Am J Emerg Med. 2020 Jul;38(7):1301-1304
Keywords: Children; Ketamine; Ondansetron.
Introduction : This study was conducted to determine the effect of intramuscular ondansetron on ketamine-associated vomiting in children undergoing procedural sedation.
Méthode : This randomized, double-blind, placebo-controlled, parallel-group clinical trial was conducted at the emergency departments of two university-affiliated tertiary care hospitals. Eligible participants included all 6-month to 16-year-old children who received IM ketamine for PSA in the ED. A convenience sampling approach was used and a block randomization method was applied (blocks of four) using a computer-generated random sequence. Patients received ketamine 4 mg/kg or ketamine 4 mg/kg plus ondansetron 0.1 mg/kg intramuscularly. All findings including the occurrence of vomiting and its frequency were then recorded in the data collection sheets.
Résultats : Of 56 patients who received ondansetron plus ketamin, 7 (12.5%) and 1 (1.8%) experienced vomiting during recovery and before discharge and Of 65 patients in the control group, 14 (21.5%) and 6 (9.2%) experienced vomiting during recovery and before discharge, respectively. The observed differences in the rates of vomiting during recovery and at discharge were statistically significant between the two groups (P-value of 0.03 and <0.001, respectively).
Conclusion : Intramuscular ondansetron is effective in controlling ketamine-associated vomiting.
Conclusion (proposition de traduction) : L'ondansétron intramusculaire est efficace pour contrôler les vomissements associés à la kétamine.
Is epistaxis associated with high blood pressure and hypertension? Propensity score matching study.
Kim C, Kim C, Chung JH, Shin JH. | Am J Emerg Med. 2020 Jul;38(7):1319-1321
Keywords: Epistaxis; High blood pressure; Hypertension.
Introduction : We aimed to investigate whether high blood pressure and hypertension are associated with epistaxis.
Méthode : A retrospective study with a propensity score matching analysis was performed at the emergency departments (EDs) of a tertiary university hospital. The mean blood pressure (BP, systolic and diastolic) and proportion of subjects with elevated BP (systolic >120 and/or diastolic >80 mmHg) at presentation were compared between the epistaxis group and matched control group. The proportion of patients with newly diagnosed hypertension within six months between the two groups was also compared.
Résultats : A total of 1353 patients with epistaxis and the same number of those with simple lacerations were matched. The mean systolic and diastolic BPs of the epistaxis group were significantly higher than those of the matched control group (157.1 ± 26.4 and 91.4 ± 17.0 mmHg versus 144.9 ± 32.4 and 84.2 ± 13.5 mmHg) (P < 0.001). The proportion of patients with elevated BP at presentation was also significantly higher in the epistaxis group (91.4%) than in the matched control group (86.2%) (P < 0.001). Of the 724 (53.5%) patients without pre-existing hypertension in the epistaxis group, 660 patients were followed, of whom 107 (16.2%) were newly diagnosed with hypertension within 6 months, which was a significantly higher percentage than among the matched controls (4.9%, P < 0.001).
Conclusion : The patients with epistaxis had elevated BP at presentation and a higher proportion of newly diagnosed hypertension within six months compared to the matched controls.
Conclusion (proposition de traduction) : Les patients présentant une épistaxis avaient une pression artérielle élevée à l'adminission et une proportion plus importante d'hypertension nouvellement diagnostiquée dans les six mois par rapport aux témoins appariés.
Impact of endotracheal tube twisting on the diagnostic accuracy of ultrasound for intubation confirmation.
Gottlieb M, Burns K, Holladay D, Chottiner M, Shah S, Gore SR. | Am J Emerg Med. 2020 Jul;38(7):1332-1334
Keywords: Endotracheal; Intubation; Twist; Ultrasound.
Introduction : Ultrasound is a readily-available technique used to identify accurate placement of an endotracheal tube (ETT) after an intubation attempt. There is limited research on using manipulation of the ETT to improve the diagnostic accuracy of ETT location confirmation. Our study sought to directly assess whether ETT twisting during the standard grayscale technique influenced the accuracy of intubation confirmation by ultrasound.
Méthode : The study was performed using two different fresh cadavers. During each trial, the cadavers were randomized to either tracheal or esophageal intubation. Three blinded, ultrasound fellowship-trained sonographers assessed the location of the ETT post-intubation alternating between using either a technique with no ETT movement or a technique with ETT twisting. In the latter technique, the sonographers manipulated the ETT in using a side-to-side, twisting motion while performing the ultrasound exam. The study measured the accuracy of ETT location identification, time to identification, and sonographer confidence.
Résultats : 540 assessments were performed with equal numbers of tracheal and esophageal intubations. The accuracy of ultrasound using the static technique was 97.8% (95% CI 95.2% to 99.0%) and the accuracy using the ETT twisting technique was 100% (95% CI 98.6% to 100%). The ETT twisting group showed a faster time to identification with a mean time to identification of 4.97 s (95% CI 4.36 to 5.57 s) compared to 6.87 s (95% CI 6.30 to 7.44 s) for the static ETT group. Operator confidence was also higher in the ETT twisting group at 4.84/5.0 (95% CI 4.79 to 4.90) compared to 4.71/5.0 (95% CI 4.63 to 4.78) in the static ETT group.
Conclusion : There was no statistically significant difference in the accuracy of ETT location identification between the two groups. However, utilizing the ETT twisting technique showed a statistically significant improvement in the time to identification and sonographer confidence.
Conclusion (proposition de traduction) : Il n'y avait pas de différence statistiquement significative dans la précision de l'identification de l'emplacement du tube endotrachéal entre les deux groupes. Cependant, l'utilisation de la technique de torsion du tube endotrachéal a montré une amélioration statistiquement significative du temps d'identification et de confiance de l'opérateur en échographie.
Heart rate and heart rate variability in emergency medicine.
Jenks S, Frank Peacock W, Cornelius AP, Shafer S, Pillow MT, Rayasam SS. | Am J Emerg Med. 2020 Jul;38(7):1335-1339
Keywords: Episodic tachycardia; Heart rate; Residents; Stress.
Introduction : Tachycardia may be indicative of mental stress, which in turn can decrease performance, reduce information processing capacity, and hinder memory recall. The objective of this study is to examine heart rate trends present among emergency medicine trainees over a standard emergency room shift to measure the frequency and severity of stress experienced while on shift.
Méthode : We assessed heart rate in emergency medicine residents using the Empatica E4 device, a mobile wrist-worn physiological monitor. The 31 consenting residents received training in wearing the monitor and uploading the data during a typical critical care shift. Data was deindividualized, compiled, and analyzed with descriptive statistics using Microsoft Excel.
Résultats : Data collected from 31 critical care shifts illustrated that the mean range in HR was 53.9-162.7 bpm per shift and the overall range in HR across all shifts was 49-202.7 bpm. There was a mean of 10.2 peaks in the 120-129.9 bpm range, 11.3 peaks within 130-159.9 bpm, and 1.06 peaks above 160 bpm per shift. The mean length of time that HR rose above 130 bpm was 660.6 s per shift. Only 2 of the 31 shifts examined did not have any accelerations above 130 bpm.
Conclusion : Continuous monitoring of HR in emergency medicine residents during standard critical care shifts using a wrist-worn device found marked elevations suggestive of episodic tachycardia.
Conclusion (proposition de traduction) : Une surveillance continue de la fréquence cardiaque chez les résidents en médecine d'urgence pendant les quarts de travail standard des soins intensifs à l'aide d'un appareil porté au poignet a révélé des élévations marquées suggérant une tachycardie épisodique.
Comparison of non-invasive CPAP with mask use in carbon monoxide poisoning.
Turgut K, Yavuz E. | Am J Emerg Med. 2020 Jul;38(7):1454-1457
Keywords: CPAP; Carbon monoxide; Carboxyhemoglobin.
Introduction : Carbon monoxide (CO) is one of the major causes of poisoning worldwide. We aimed to investigate the efficacy of the continuous positive airway pressure (CPAP) use in CO poisoning.
Méthode : After CO poisoning, one group of patients was treated with a non-rebreather mask (NRB) and another group using the CPAP mode of mechanical ventilation (CPAP). All patients received at least 90 minute treatment. The carboxyhemoglobin saturation (SpCO) levels of all patients were measured from the fingertips with a portable CO-oximeter at 0, 30, 60 and 90 min. The rates of changes in the serially measured SpCO values were obtained using the Wilcoxon signed-rank test.
Résultats : A total of 45 patients (24 in NRB and 21 in CPAP group) completed the study. The median initial SpCO levels were 24% (21-33) in NRB group, 25% (21-32) in CPAP group, with no statistically significant difference (p 0.323). At the 30th, 60th, and 90th minutes of treatment, significantly lower values were obtained from CPAP than NRB (p < 0.001). The COHb half-life was decreased significantly by CPAP [105(70-190) vs 45(30-120), p < 0.001]. In CPAP group, the fastest decline in the SpCO level was observed for the interval of 0-30 min [Median difference: 8(3-14), p < 0.001].
Conclusion : CPAP lowered the amount of CO in the blood faster than the mask; therefore, it may be effective in the treatment of CO poisoning.
Conclusion (proposition de traduction) : La CPAP a réduit la quantité de CO dans le sang plus rapidement qu'avec le masque [ndlr : à oxygène]; par conséquent, il peut être efficace dans le traitement de l'intoxication au CO.
High-flow nasal cannula oxygen therapy in acute respiratory failure at Emergency Departments: A systematic review.
Marjanovic N, Guénézan J, Frat JP, Mimoz O, Thille AW. | Am J Emerg Med. 2020 Jul;38(7):1508-1514
Keywords: Emergency department; High-flow nasal cannula; Respiratory failure.
Introduction : The use of high-flow oxygen therapy (HFOT) through nasal cannula for the management of acute respiratory failure at the emergency department (ED) has been only sparsely studied. We conducted a systematic review of randomized-controlled and quasi-experimental studies comparing the early use of HFOT versus conventional oxygen therapy (COT) in patients with acute respiratory failure admitted to EDs.
Méthode : A systematic research of literature was carried out for all published control trials comparing HFOT with COT in adult patients admitted in EDs. Eligible data were extracted from Medline, Embase, Pascal, Web of Science and the Cochrane database. The primary outcome was the need for mechanical ventilation, i.e. intubation or non-invasive ventilation as rescue therapy. Secondary outcomes included respiratory rate, dyspnea level, ED length of stay, intubation and mortality.
Résultats : Out of 1829 studies screened, five studies including 673 patients were retained in the analysis (350 patients treated with HFOT and 323 treated with COT). The need for mechanical ventilation was similar in both treatments (RR = 0.75; 95% CI 0.41 to 1.35; P = 0.31; I2 = 16%). Respiratory rate was lower with HFOT (Mean difference (MD) = -3.14 breaths/min; 95% CI = -4.9 to -1.4; P < 0.001; I2 = 39%), whereas sensation of dyspnea did not differ. (MD = -1.04; 95% CI = -2.29 to -0.22; P = 0.08; I2 = 67%). ED length of stay and mortality were similar between groups.
Conclusion : The early use of HFOT in patients admitted to an ED for acute respiratory failure did not reduce the need for mechanical ventilation as compared to COT. However, HFOT decreased respiratory rate.
Conclusion (proposition de traduction) : L'utilisation précoce de l'Optiflow chez les patients admis dans un service d'urgence pour insuffisance respiratoire aiguë n'a pas réduit le besoin de ventilation mécanique par rapport à l'oxygénothérapie conventionnelle. Cependant, l'Optiflow a diminué la fréquence respiratoire.
High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches.
Lentz S, Grossman A, Koyfman A, Long B. | J Emerg Med. 2020 Jul;59(1):84-95
DOI: https://doi.org/10.1016/j.jemermed.2020.05.008 | Télécharger l'article au format
Keywords: airway; hypotension; hypoxemia; metabolic acidosis; obstructive lung disease; postintubation cardiac arrest; pulmonary embolism; pulmonary hypertension; shock.
Research article - Techniques and Procedures
Introduction : Successful airway management is critical to the practice of emergency medicine. Emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this first part of a 2-part series.
Méthode : This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases that are commonly encountered in the emergency department.
Résultats : Adverse events during emergent airway management are common, with postintubation cardiac arrest reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided with the proper identification and understanding of the underlying physiology, preparation, and postintubation management. Patients with high-risk features including severe metabolic acidosis; shock and hypotension; obstructive lung disease; pulmonary hypertension, right ventricle failure, and pulmonary embolism; and severe hypoxemia must be managed with airway expertise.
Conclusion : This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.
Conclusion (proposition de traduction) : Cette revue descriptive examine les trucs et astuces, les plus courantes, des intubations physiologiques à risque élevé, en mettant l’accent sur le clinicien d’urgence.
Commentaire : Retrouvez la deuxième partie :
Lentz S, Grossman A, Koyfman A, Long B. High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II. J Emerg Med. 2020 Oct;59(4):573-585 .
Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial.
Hallifax RJ, Sivakumar P, Fairbairn I, Peter C, Leitch A, et al.. | Lancet [Internet]. 2020 Jul;396(10243):39–49
DOI: https://doi.org/10.1016/S0140-6736(20)31043-6 | Télécharger l'article au format
Keywords: ambulatory; outpatient; pleural disease; pneumothorax
Introduction : Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care.
Méthode : In this open-label, randomised controlled trial, adults (aged 16–55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis.
Résultats : Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0–3]) than in the 113 with available data who received standard care (4 days [IQR 0–8]; p<0·0001; median difference 2 days [95% CI 1–3]). 110 (47%) of 236 patients had adverse events, including 64 (55%) of 117 patients in the ambulatory care arm and 46 (39%) of 119 in the standard care arm. All 14 serious adverse events occurred in patients who received ambulatory care, eight (57%) of which were related to the intervention, including an enlarging pneumothorax, asymptomatic pulmonary oedema, and the device malfunctioning, leaking, or dislodging.
Conclusion : Ambulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention.
Conclusion (proposition de traduction) : La prise en charge ambulatoire du pneumothorax spontané primitif a considérablement réduit la durée d'hospitalisation, y compris les réadmissions au cours des 30 premiers jours, mais au détriment de l'augmentation des événements indésirables. Ces données suggèrent que le pneumothorax spontané primitif peut être une option pour les patients en consultation, en utilisant des dispositifs ambulatoires chez ceux qui nécessitent une intervention.
Commentaire : Voir l'article :
Hallifax R, Laskawiec-Szkonter M, Dobson M, Gerry S, Miller RF, Harvey JE, Rahman N. Randomised Ambulatory Management of Primary Pneumothorax (RAMPP): protocol of an open-label, randomised controlled trial. BMJ Open Respir Res. 2019 Apr 11;6(1):e000403 . Télécharger l'article au format pdf
Et les commentaires dans :
Kapp C, Feller-Kopman D. • Ambulatory management of primary spontaneous pneumothorax: when less is more. Lancet. 2020 Jul 4;396(10243):4-5 .
A history of the medical mask and the rise of throwaway culture.
Strasser BJ, Schlich T. | Lancet. 2020 Jul 4;396(10243):19-20
DOI: https://doi.org/10.1016/s0140-6736(20)31207-1 | Télécharger l'article au format
PERSPECTIVES - The art of medicine
Editorial : The shortage of face masks during the COVID-19 pandemic has become a symbol of the fragility of modern medicine and public health. Several explanations have been advanced for this situation, from a panicking public hoarding masks to the offshoring of manufacturing and the disruption of global trade. The history of medicine suggests another factor could be considered: the progressive replacement of reusable face masks by disposable ones since the 1960s. Medicine has been transformed by consumer culture—what Life Magazine enthusiastically named “Throwaway Living” in 1955. The history of the medical mask illuminates how this vulnerability was created.
Conclusion : Reusable masks were once an essential part of the medical arsenal. However, the industrial production and further research and development of reusable masks was largely halted with the transition towards disposable masks in the 1960s. Disposable masks and respirators will certainly remain an essential part of medical personal protective equipment in the future, since some of them possess specific filtration qualities designed for health-care situations. To avoid a shortage of masks during the next pandemic, one should look beyond the creation of large stockpiles of disposable face masks and consider the risks of the throwaway consumer culture applied to life-saving devices. Perhaps one day it might again be possible to say about protective face masks what medical researchers wrote in 1918: “A mask may be repeatedly washed and used indefinitely.”
Conclusion (proposition de traduction) : Les masques réutilisables faisaient autrefois partie intégrante de l'arsenal médical. Cependant, la production industrielle et la poursuite de la recherche et du développement de masques réutilisables ont été en grande partie interrompues avec la transition vers les masques jetables dans les années 1960. Les masques et respirateurs jetables resteront certainement une partie essentielle des équipements de protection individuelle médicale à l'avenir, car certains d'entre eux possèdent des qualités de filtration spécifiques conçues pour les situations de soins de santé. Pour éviter une pénurie de masques lors de la prochaine pandémie, il faut regarder au-delà de la création de vastes stocks de masques jetables et considérer les risques de la culture de consommation jetable appliquée aux dispositifs de sauvetage. Peut-être qu'un jour il sera à nouveau possible de dire à propos des masques protecteurs ce que les chercheurs médicaux ont écrit en 1918: « Un masque peut être lavé à plusieurs reprises et utilisé indéfiniment ».
Acute Ischemic Stroke.
Powers WJ | N Engl J Med. 2020;383(3):252-260
Editorial : Each year in the United States, approximately 700,000 people have an acute ischemic stroke.1 Before modern treatments, early mortality was 10%.2 Among survivors, one half had moderate-to-severe neurologic deficits, and a quarter were dependent on others.3 The introduction of intravenous alteplase in 1995 led to substantial improvement in outcomes.4 More recently, effective mechanical thrombectomy has radically altered initial management in many pa- tients.5 Understanding treatment options for acute ischemic stroke is important to ensure prompt administration of appropriate care or referral.
Conclusion : The patient in the vignette has a disabling acute ischemic stroke in the territory of the left middle cerebral artery. Because the patient is within the 4.5-hour treatment window for standard intrave- nous alteplase and has no contraindications, he should receive intravenous alteplase immediate- ly. CTA or MRA should be performed. If this cannot be done on site, the patient should be rapidly transferred to a hospital with resources to perform mechanical thrombectomy. If the patient has an occlusion of the internal carotid artery or the first segment of the middle cerebral artery, he should proceed immediately to undergo mechanical thrombectomy. Because the patient is within the 6-hour treatment window, no fur- ther neuroimaging is necessary. If there is a proximal occlusion in one of the main arterial branches off the first segment of the middle cerebral artery, thrombectomy may be reason- able because of the disabling nature of his defi- cit. The blood pressure should be maintained below 180/105 mm Hg. The patient should be admitted to an intensive care unit or specialized stroke unit for close neurologic monitoring and blood-pressure control if needed.
Conclusion (proposition de traduction) : Le patient du cas clinique présente un accident vasculaire cérébral ischémique aigu invalidant sur le territoire de l'artère cérébrale moyenne gauche. Étant donné que le patient se trouve dans la fenêtre de traitement des 4,5 heures par l'altéplase intraveineuse standard et n'a pas de contre-indications, il doit bénéficier immédiatement de la thrombolyse intraveineuse. Une angiographie par tomodensitométrie ou une angiographie par IRM doit être réalisée. Si cela ne peut être fait sur place, le patient doit être transféré rapidement dans un hôpital disposant des ressources nécessaires pour effectuer une thrombectomie mécanique. Si le patient présente une occlusion de l'artère carotide interne ou du premier segment de l'artère cérébrale moyenne, il doit bénéficier immédiatement d'une thrombectomie mécanique. Étant donné que le patient se trouve dans la fenêtre de traitement des 6 heures, aucune autre neuroimagerie n'est nécessaire. S'il y a une occlusion proximale dans l'une des principales branches artérielles du premier segment de l'artère cérébrale moyenne, la thrombectomie peut être raisonnable en raison de la nature invalidante de son déficit. La pression artérielle doit être maintenue en dessous de 180/105 mmHg. Le patient doit être admis dans une unité de soins intensifs ou une unité spécialisée de l'AVC (UNV) pour une surveillance neurologique étroite et un contrôle de la pression artérielle, si nécessaire.
Commentaire : Voir l'analyse de l'article sur le site JournalFeed : Acute Ischemic Stroke - Spoon-Feed Version . Rédigé par Alex Chen, le 31 août 2020.
Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report.
RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. | N Engl J Med. 2020 Jul 17:NEJMoa2021436
DOI: https://doi.org/10.1056/nejmoa2021436 | Télécharger l'article au format
Introduction : Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death.
Méthode : In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the preliminary results of this comparison.
Résultats : A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55).
Conclusion : In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support.
Conclusion (proposition de traduction) : Chez les patients hospitalisés pour la Covid-19, l'utilisation de la dexaméthasone a permis une baisse de la mortalité à 28 jours chez ceux qui recevaient une ventilation mécanique invasive ou de l'oxygène seul lors de la randomisation, mais pas chez ceux ne recevant aucune assistance respiratoire.
Commentaire : Dans le cadre de l’essai Recovery, la dexaméthasone a été administrée per os ou par voie IV, à raison de 6 mg une fois par jour, pendant 10 jours.
Chez la femme enceinte ou allaitante, la dexaméthasone doit être remplacée par la prednisolone à 40 mg, par voie orale (ou par l’hydrocortisone à 80 mg, deux fois par jour, par voie intraveineuse). Pour les enfants, le protocole prévoyait une dose de 150 μg/kg par jour avec une dose maximale de 6 mg
La dexaméthasone a réduit la mortalité d’environ un tiers chez des patients ventilés mécaniquement (rapport de taux : 0,65 [IC 95%: 0,51; 0,82]; valeur de p < 0,001) et d’un cinquième chez des patients ayant uniquement reçu de l’oxygène (rapport de taux : 0,80 [IC 95%: 0, 70; 0,92]; valeur de p = 0,002). Aucune différence entre le groupe dexaméthasone et soins standards pour ce qui est des patients n’ayant aucun besoin de support respiratoire (rapport de taux : 1,22 [IC 95%: 0,93; 1,61]; valeur de p = 0,14).
Les auteurs souligne que sur la base de ces résultats, 1 vie serait sauvée en traitant à la dexaméthasone 8 patients ventilés mécaniquement ou 25 patients sous oxygène [Niveau de preuve scientifique préliminaire : modéré, il est donc important d’attendre la publication de tous les résultats et leur révision par les pairs pour éventuellement augmenter le niveau de certitude].