Association Between Pulmonary Embolism and COVID-19 in Emergency Department Patients Undergoing Computed Tomography Pulmonary Angiogram: The PEPCOV International Retrospective Study.
Freund Y, Drogrey M, Miró Ò, Marra A, Féral-Pierssens AL, Penaloza A, Hernandez BAL, Beaune S, Gorlicki J, Vaittinada Ayar P, Truchot J, Pena B, Aguirre A, Fémy F, Javaud N, Chauvin A, Chouihed T, Montassier E, Claret PG, Occelli C, Roussel M, Brigant F, Ellouze S, Le Borgne P, Laribi S, Simon T, Lucidarme O, Cachanado M, Bloom B; IMPROVING EMERGENCY CARE FHU Collaborators. | Acad Emerg Med. 2020 Sept;27(9):811-20
DOI: https://doi.org/10.1111/acem.14096
Keywords: Aucun

Original Contribution

Introduction : There have been reports of procoagulant activity in patients with COVID-19. Whether there is an association between pulmonary embolism (PE) and COVID-19 in the emergency department (ED) is unknown. The aim of this study was to assess whether COVID-19 is associated with PE in ED patients who underwent a computed tomographic pulmonary angiogram (CTPA).

Méthode : A retrospective study in 26 EDs from six countries. ED patients in whom a CTPA was performed for suspected PE during a 2-month period covering the pandemic peak. The primary endpoint was the occurrence of a PE on CTPA. COVID-19 was diagnosed in the ED either on CT or reverse transcriptase-polymerase chain reaction. A multivariable binary logistic regression was built to adjust with other variables known to be associated with PE. A sensitivity analysis was performed in patients included during the pandemic period.

Résultats : A total of 3,358 patients were included, of whom 105 were excluded because COVID-19 status was unknown, leaving 3,253 for analysis. Among them, 974 (30%) were diagnosed with COVID-19. Mean (±SD) age was 61 (±19) years and 52% were women. A PE was diagnosed on CTPA in 500 patients (15%). The risk of PE was similar between COVID-19 patients and others (15% in both groups). In the multivariable binary logistic regression model, COVID-19 was not associated with higher risk of PE (adjusted odds ratio = 0.98, 95% confidence interval = 0.76 to 1.26). There was no association when limited to patients in the pandemic period.

Conclusion : In ED patients who underwent CTPA for suspected PE, COVID-19 was not associated with an increased probability of PE diagnosis. These results were also valid when limited to the pandemic period. However, these results may not apply to patients with suspected COVID-19 in general.

Conclusion (proposition de traduction) : Chez les patients aux urgences qui ont bénéficié d'une angiographie pulmonaire par tomodensitométrie pour suspicion d'embolie pulmonaire, la COVID-19 n'a pas été associé à une probabilité accrue de diagnostic d'embolie pulmonaire. Ces résultats étaient également valables lorsqu'ils étaient limités à la période pandémique.
Cependant, ces résultats peuvent ne pas s'appliquer aux patients suspectés de COVID-19 en général.

Schmutz t, Verdina m. | Ann Fr Med Urgence. 2020 sept;
DOI: https://doi.org/10.3166/afmu-2020-0255
Keywords: Aucun

Pré-publication électronique

Editorial : L’hypnose médicale fait l’objet de multiples publications et d’une expertise scientifique réalisée par l’Institut national de la santé et de la recherche médicale (Inserm) en 2015 à la demande du ministère de la Santé [1]. Aujourd’hui largement diffusée dans les services d’anesthésie ou de psychiatrie, l’hy- pnose peine à émerger dans les services d’urgence (SU). Seu- les quelques équipes s’y intéressent ; son enseignement en médecine d’urgence n’est pas formalisé.

Conclusion (proposition de traduction) : Ses indications en médecine d’urgence sont diverses et variées (hypnoanalgésie, hypnosédation, prévention de la douleur induite par les soins, gestion du stress et de l’anxiété, soins palliatifs, prévention du burn-out chez le praticien...). Les champs de recherche en médecine d’urgence hospitalière ou extrahospitalière sont inexplorés.

Commentaire : Voir l'article :
Schmutz T, Ribordy V, Aïm P, Pham-Dinh C, Braun F, Guler N. Hypnose en médecine d’urgence : bousculons nos habitudes ! Rev Med Suisse. 2020 Sep 23;16(707):1757-1762  .

Does the Use of High-Flow Nasal Cannula Compared With Conventional Oxygen Therapy in the Peri-intubation Period Reduce Severe Desaturation?.
Long DA, Long B, April MD. | Ann Emerg Med. 2020 Sep;76(3):339-342
DOI: https://doi.org/10.1016/j.annemergmed.2020.03.004
Keywords: Aucun

AIRWAY/ORIGINAL RESEARCH

Introduction : The search criteria identified 649 citations, of which 10 trials with a total of 1,017 patients met inclusion criteria. The trials included between 33 and 333 patients. All trials defined peri-intubation hypoxemia as SpO2 less than 80% in the time between administration of sedative medications or initiation of laryngoscopy to time of connection of the patient to the mechanical ventilator.

Méthode : Two reviewers screened citations independently by title and abstract and then by reviewing the full text of relevant abstracts. They included randomized controlled trials that compared high-flow nasal cannula with other noninvasive oxygen delivery techniques in the peri-intubation period. They included trials with both hypoxemic and nonhypoxemic patients. The primary outcome was severe desaturation, defined as SpO2 less than 80% during intubation. Secondary outcomes included peri-intubation complications (composite outcome including severe hypoxemia, significant hypotension or vasopressor use, and cardiac arrest), apneic time, PaO2 (measured post-preoxygenation and postintubation), postintubation PaCO2, ICU length of stay, and 28-day mortality. Hypoxemia was defined by saturation less than 80%, although hypotension was defined differently across studies. Post-preoxygenation PaO2 was from the first arterial blood gas sample gathered after the defined preoxygenation period was complete, and postintubation PaO2 was from the first arterial blood gas sample after successful intubation.

Résultats : For the primary outcome of severe desaturation, compared with conventional oxygen therapy, high-flow nasal cannula did not have any effect on peri-intubation hypoxemia. Subgroup analysis revealed no difference in peri-intubation hypoxemia with high-flow nasal cannula according to patient type (ICU or peri-operative) or comparator device (noninvasive ventilation versus face mask/bag-valve-mask device). High-flow nasal cannula did not have any effect on the secondary outcomes of 28-day mortality, peri-intubation complications, ICU length of stay, total apneic time, PaO2 before and after intubation, and PaCO2 after intubation. According to the Grading of Recommendations Assessment, Development and Evaluation criteria, the overall certainty of the evidence was moderate for the primary outcome and low to moderate for the secondary outcomes. All of the trials except one were found to be at low or probably low risk of bias.

Conclusion : Use of high-flow nasal cannula compared with conventional oxygen therapy in the peri-intubation period likely has no effect on severe desaturation.

Conclusion (proposition de traduction) : L'utilisation de l'oxygénothérapie nasale à haut débit (Optiflow) par rapport à l'oxygénothérapie conventionnelle pendant la période péri-intubation n'a probablement aucun effet sur une désaturation sévère.

Comparing Emergency Department First-Attempt Intubation Success With Standard-Geometry and Hyperangulated Video Laryngoscopes.
Driver BE, Prekker ME, Reardon RF, Fantegrossi A, Walls RM, Brown CA 3rd. | Ann Emerg Med. 2020 Sep;76(3):332-338
DOI: https://doi.org/10.1016/j.annemergmed.2020.03.011
Keywords: Aucun

Airway

Introduction : It is unclear whether laryngoscopy using a standard-geometry blade shape, able to obtain both direct and indirect views, is associated with different first-attempt success or adverse events during emergency intubation compared with using a hyperangulated blade capable of indirect laryngoscopy only. We sought to compare first-attempt intubation success between patients intubated with a standard geometry video laryngoscope versus a hyperangulated video laryngoscope.

Méthode : We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018. Patients aged 14 years or older were included if the first attempt at oral intubation was performed with a standard-geometry or hyperangulated video laryngoscope. We used multiple logistic regression to determine whether blade shape was independently associated with first-attempt intubation success.

Résultats : During the study period, 11,927 of 19,071 intubation encounters met inclusion criteria, including 7,255 (61%) with a standard blade and 4,672 (39%) with a hyperangulated blade. Unadjusted analysis revealed higher success with a standard-geometry blade, 91.9% versus 89.2% (absolute difference 2.7% [95% confidence interval 1.6% to 3.8%]; odds ratio for standard-geometry laryngoscope compared with hyperangulated laryngoscope 1.37 [95% confidence interval 1.21 to 1.55]). The logistic regression model, however, demonstrated no association between blade shape and first-attempt success (adjusted odds ratio for standard-geometry laryngoscopy compared with hyperangulated laryngoscopy 1.32 [95% confidence interval 0.81 to 2.17]).

Conclusion : In this large registry of patients intubated with video laryngoscopy in the emergency department, we observed no association between blade shape (standard-geometry versus hyperangulated laryngoscope) and first-attempt intubation success after adjusting for confounding variables.

Conclusion (proposition de traduction) : Dans ce grand registre de patients intubés avec un vidéo-laryngoscopie au service des urgences, nous n'avons observé aucune association entre la forme de la lame (géométrie standard versus laryngoscope hyperangulé) et le succès de l'intubation à la première tentative après ajustement pour les variables confondantes.

The Effect of Use of Individualized Pain Plans in Sickle Cell Patients Presenting to the Emergency Department.
Della-Moretta S, Delatore L, Purcell M, Huang Y, Heinlein M, Adkins E, Desai P. | Ann Emerg Med. 2020 Sep;76(3S):S21-S27
DOI: https://doi.org/10.1016/j.annemergmed.2020.08.008
Keywords: Aucun

Sickle Cell Disease in the Emergency Department

Introduction : Sickle cell disease (SCD) is an inherited hematologic disorder that affects approximately 100,000 US individuals and results in greater than 200,000 emergency department (ED) visits annually in the United States, with pain being the most common complaint. The objective of this retrospective study is to determine the effect of implementing individualized pain plans in the treatment of patients with SCD in the ED on time to first opioid, length of stay, and disposition.

Méthode : At The Ohio State University Wexner Medical Center, a multidisciplinary group including hematologists and ED physicians was formed and enacted a protocol for using individualized pain plans, with the goal of decreasing time to treatment for patients with SCD who presented to the ED with chief complaint of pain. In this retrospective study, data from the year before through the year of implementation were gathered. Generalized linear models were fit to compare time to first opioid, length of stay, and disposition before and after protocol implementation.

Résultats : Data showed a 48% decrease in time to first opioid and a 22% decrease in length of ED stay after protocol implementation. No significant change was found in disposition or length of inpatient admission before and after protocol initiation.

Conclusion : The use of individualized pain plans in the treatment of patients with SCD in the ED is a useful method of not only ensuring rapid and adequate treatment but also decreasing use of health care resources.

Conclusion (proposition de traduction) : L'utilisation de plans de douleur individualisés dans le traitement des patients atteints de drépanocytose aux urgences est une méthode utile non seulement pour assurer un traitement rapide et adéquat, mais aussi pour réduire l'utilisation des ressources de soins de santé.

Utility of Point-of-Care Lung Ultrasonography for Evaluating Acute Chest Syndrome in Young Patients With Sickle Cell Disease.
Cohen SG, Malik ZM, Friedman S, Russell S, Hagbom R, Alazraki A, McCracken CE, Figueroa J, Adisa OA, Mendis RD, Manoranjithan S, Simon HK, Morris CR. | Ann Emerg Med. 2020 Sep;76(3S):S46-S55
DOI: https://doi.org/10.1016/j.annemergmed.2020.08.012
Keywords: Aucun

Sickle Cell Disease in the Emergency Department

Introduction : Acute chest syndrome is a leading cause of mortality in patients with sickle cell disease (SCD). Because early detection of acute chest syndrome is directly tied to prognosis, young patients with SCD undergo countless chest radiography screenings throughout their lifetime for commonly occurring acute chest syndrome risk factors such as fever, chest pain, or cough. Chest radiography is not an ideal screening method because it is associated with radiation exposure, which accumulates with repeated imaging. Point-of-care lung ultrasonography is a nonradiating imaging modality that has been used to identify other lung pathology and may have a role in SCD. The goal of this study was to determine the accuracy of point-of-care lung ultrasound to identify an infiltrate suggestive of acute chest syndrome in patients with SCD compared to chest radiography as the gold standard.

Méthode : This was a prospective observational study in 2 urban pediatric emergency departments to evaluate the accuracy of point-of-care lung ultrasonography in identifying patients with SCD who were aged 0 to 21 years and had an infiltrate suggestive of acute chest syndrome compared with chest radiography. Clinicians and trainees with point-of-care lung ultrasonographic training obtained informed consent and performed investigational point-of-care lung ultrasonography to evaluate for lung consolidation. A blinded point-of-care lung ultrasonographic expert reviewed results for quality assurance and agreement. Accuracy, sensitivity, specificity, likelihood ratios, and positive and negative predictive value were calculated for point-of-care lung ultrasonography test performance characteristics, with chest radiography as a reference standard.

Résultats : Point-of-care lung ultrasonography was performed on 191 SCD patients with a mean age of 8 years; 41% were female patients, and there was a 17% prevalence of acute chest syndrome. Accuracy of point-of-care lung ultrasonography to detected acute chest syndrome was 92%, sensitivity was 88%, and specificity was 93% compared with that for chest radiography.

Conclusion : Point-of-care lung ultrasonography is a feasible alternative to chest radiography for screening for acute chest syndrome in young patients with SCD. Further studies are needed to determine how this test performs within clinical practice.

Conclusion (proposition de traduction) : L'échographie pulmonaire au point d'intervention est une alternative possible à la radiographie thoracique pour le dépistage du syndrome thoracique aigu chez les jeunes patients atteints de drépanocytose. D'autres études sont nécessaires pour déterminer comment ce test fonctionne dans la pratique clinique.

Self-reported anosmia and dysgeusia as key symptoms of coronavirus disease 2019.
Lee DJ, Lockwood J, Das P, Wang R, Grinspun E, Lee JM. | CJEM. 2020 Sep;22(5):595-602
DOI: https://doi.org/10.1017/cem.2020.420  | Télécharger l'article au format  
Keywords: Anosmia; COVID-19; dysgeusia; epidemiology; population health.

ORIGINAL RESEARCH

Introduction : To slow down the transmission of coronavirus disease 2019 (COVID-19), it is important to identify specific symptoms for effective screening. While anosmia/hyposmia and dysgeusia/ageusia have been identified as highly prevalent symptoms, there are wide geographic variations, necessitating the regional evaluation of the prevalence of the symptoms.

Méthode : A cross-sectional study was performed to evaluate the self-reported symptoms among adults (over 18 years old) who underwent COVID-19 tests at an ambulatory assessment centre. We identified 1,345 patients (102 positive and 1,243 negative) who visited the assessment centre between March 16 and April 15, 2020. We randomly sampled negative patients in a 1:3 ratio. The primary outcome was the prevalence of self-reported anosmia/hyposmia and dysgeusia/ageusia. Logistic regression was performed to evaluate the association between COVID-19 positivity and loss of smell and taste.

Résultats : Fifty-six of 102 (50%) positive patients and 72 of 306 (23.5%) negative patients completed the survey. Anosmia/hyposmia and dysgeusia/ageusia were more prevalent among COVID-19 positive patients (41.1% v. 4.2%, p < 0.001 for smell and 46.4% v. 5.6%, p < 0.001 for taste). Anosmia/hyposmia and dysgeusia/ageusia were independently highly associated with COVID-19 positivity (adjusted odds ratios 14.4 and 11.4 for smell and taste, respectively).

Conclusion : In this Canadian study, smell and taste loss may be key symptoms of COVID-19. This evidence can be helpful in the clinical diagnosis of COVID-19, particularly settings of limited testing capacity.

Conclusion (proposition de traduction) : Dans cette étude canadienne, la perte de l'odorat et du goût peuvent être des symptômes clés de la COVID-19. Ces preuves peuvent être utiles dans le diagnostic clinique de la COVID-19, en particulier dans les cas où la capacité de test est limitée.

Just the facts: What drugs are safe and effective for COVID-19?.
Long B, Liang SY, Rosenberg H, Hicks C, Gottlieb M. | CJEM. 2020 Sep;22(5):591-594
DOI: https://doi.org/10.1017/cem.2020.403  | Télécharger l'article au format  
Keywords: COVID-19; medications; therapeutics.

Review

Editorial : A 53-year-old male presents with cough, fever, and myalgias for 7 days. Vitals include temperature, 38.0°C; heart rate, 110; blood pressure, 118/70 mm Hg; respiration rate, 28; and oxygen saturation 83% on room air. His only past medical history is hypertension. Your community is in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The patient is hypoxic but responds to oxygen supplementation with nasal cannula and a face mask. His chest x-ray demonstrates multifocal infiltrates. Are there any therapeutic agents currently available for COVID-19?

Conclusion : There are no approved therapeutics for COVID-19. Many recommendations are extrapolated from severe acute respiratory syndrome coronavirus – 1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV). The literature evaluating therapeutics specifically for COVID-19 suffers from extensive limitations, including the lack of a comparator group, selection bias, industry sponsorship, and very few studies of patient-centered outcomes. Many trials are underway, which may assist our management of COVID-19 in the near future.

Conclusion (proposition de traduction) : Il n'y a pas de traitement approuvée pour la COVID-19. De nombreuses recommandations sont extrapolées du coronavirus du syndrome respiratoire aigu sévère – 1 (SARS-CoV-1) et du coronavirus du syndrome respiratoire du Moyen-Orient (MERS-CoV). La littérature évaluant les traitements spécifiquement pour la COVID-19 souffre de limitations importantes, notamment l'absence d'un groupe de comparaison, le biais de sélection, le parrainage de l'industrie et très peu d'études sur les résultats centrés sur le patient. De nombreux essais sont en cours, ce qui pourrait aider notre gestion de la COVID-19 dans un avenir proche.

Commentaire : 

Prevention of Asthma: Targets for Intervention.
Maciag MC , Phipatanakul W. | Chest. 2020 Sep;158(3):913-922
DOI: https://doi.org/10.1016/j.chest.2020.04.011
Keywords: asthmaimmunotherapyomalizumabpreventionvitamin D

Asthma: CHEST Reviews

Editorial : Approximately 300 million people worldwide are estimated to be affected by asthma, and the number of patients affected is growing exponentially—with potential for an additional 100 million people affected by the condition by 2025. With this increasing burden of disease, there is high motivation to discover effective prevention strategies. Strategies aimed at stalling the atopic progression, modifying the microbiome, preventing respiratory viral infections, and reducing the impact of toxin/pollutant exposure through dietary supplements have had limited success in the prevention of asthma. This is likely because asthma is heterogenous and is influenced by different genetic and environmental factors. Genes underlie a predisposition to asthma and allergic sensitization, whereas exposure to allergens, respiratory infections, and pollution may modify asthma pathogenesis and the variation in severity seen among individuals. Future advances in asthma prevention may include a more personalized approach: genetic variations among susceptible individuals with distinct asthma phenotypes or different biomarkers of disease may help individualize prevention strategies and render them more . In this article, we summarize interventions that have been studied for the prevention of asthma and identify some of the clinical trials that are actively underway in asthma prevention.

Conclusion : Given the significant burden of asthma, effective prevention strategies are desperately needed. Early-life intervention may be instrumental in limiting initial deficits in lung function. Strategies aimed at stalling the atopic progression, modifying the microbiome, preventing respiratory viral infections, and reducing the impact of toxin/pollutant exposure through dietary supplements have had limited success in the prevention of asthma. Distinct endotypes and phenotypes may require different strategies for prevention. Asthma is heterogenous, influenced by both genetic and environmental factors. Genes underlie a predisposition to sensitization, whereas exposure to allergens, respiratory infections, and pollution maymodify asthma severity. For example, allergic sensitization, particularly to house dust mite and mouse, combined with early-life viral infection increases the risk of developing asthma and its severity. Individual differences make finding a universally applicable prevention strategy challenging. Future advances in asthma prevention may include a more personalized approach. Understanding genetic variations among susceptible individuals and different biomarkers of disease may help individualize prevention strategies and improve efficacy. Agents such as omalizumab, which target multiple factors in the pathogenesis of asthma simultaneously, may prove effective in asthma prevention and are being studied in randomized controlled trials.

Conclusion (proposition de traduction) : Compte tenu du le poids considérable imputable à l'asthme, des stratégies de prévention efficaces sont absolument nécessaires. Une intervention précoce peut contribuer à limiter les atteintes initiales de la fonction pulmonaire. Les stratégies visant à freiner la progression atopique, à modifier le microbiome, à prévenir les infections virales respiratoires et à réduire l'impact de l'exposition aux toxines/polluants par le biais de compléments alimentaires ont eu un succès limité dans la prévention de l'asthme. Des endotypes et phénotypes distincts peuvent nécessiter des stratégies de prévention différentes. L'asthme est hétérogène, influencé à la fois par des facteurs génétiques et environnementaux. Les gènes sous-tendent une prédisposition à la sensibilisation, tandis que l'exposition aux allergènes, aux infections respiratoires et à la pollution peut modifier la gravité de l'asthme. Par exemple, la sensibilisation allergique, en particulier aux acariens et à la souris, associée à une infection virale précoce augmente le risque de développer l'asthme et sa gravité. Les différences individuelles rendent difficile la recherche d'une stratégie de prévention universellement applicable. Les progrès futurs dans la prévention de l'asthme pourraient inclure une approche plus personnalisée. Comprendre les variations génétiques entre les individus sensibles et les différents biomarqueurs de la maladie peut aider à individualiser les stratégies de prévention et à améliorer l'efficacité. Des agents tels que l'omalizumab, qui ciblent simultanément plusieurs facteurs de la pathogenèse de l'asthme, peuvent s'avérer efficaces dans la prévention de l'asthme et sont actuellement étudiés dans des essais contrôlés randomisés.

A Systematic Review of the Effect of Delayed Appropriate Antibiotic Treatment on the Outcomes of Patients With Severe Bacterial Infections.
Zasowski EJ, Bassetti M, Blasi F, Goossens H, Rello J, Sotgiu G, Tavoschi L, Arber MR, McCool R, Patterson JV, Longsha CMw, Lopes S, Manissero D, Nguyen ST, Tone K, Aliberti S. | Chest. 2020 sep:158(3):929-938,
DOI: https://doi.org/10.1016/j.chest.2020.03.087
Keywords: appropriate antibiotic therapy; mortality; severe infections; treatment delay.

Chest Infections: Original Research

Introduction : Patients with severe bacterial infections often experience delay in receiving appropriate treatment. Consolidated evidence of the impact of delayed appropriate treatment is needed to guide treatment and improve outcomes.
/ Research question: What is the impact of delayed appropriate antibacterial therapy on clinical outcomes in patients with severe bacterial infections?

Méthode : Literature searches of MEDLINE and Embase, conducted on July 24, 2018, identified studies published after 2007 reporting the impact of delayed appropriate therapy on clinical outcomes for hospitalized adult patients with bacterial infections. Where appropriate, results were pooled and analyzed with delayed therapy modeled three ways: delay vs no delay in receiving appropriate therapy; duration of delay; and inappropriate vs appropriate initial therapy. This article reports meta-analyses on the effect of delay and duration of delay.

Résultats : The eligibility criteria were met by 145 studies, of which 37 contributed data to analyses of effect of delay. Mortality was significantly lower in patients receiving appropriate therapy without delay compared with those experiencing delay (OR, 0.57; 95% CI, 0.45-0.72). Mortality was also lower in the no-delay group compared with the delay group in subgroups of studies reporting mortality at 20 to 30 days, during ICU stay, or in patients with bacteremia (OR, 0.57 [95% CI, 0.43-0.76]; OR, 0.47 [95% CI, 0.27-0.80]; and OR, 0.54 [95% CI, 0.40-0.75], respectively). No difference was found in time to appropriate therapy between those who died and those who survived (P = .09), but heterogeneity between studies was high.

Conclusion : Avoiding delayed appropriate therapy is essential to reduce mortality in patients with severe bacterial infections.

Conclusion (proposition de traduction) : Il est essentiel d'éviter de retarder l'administration d'un traitement approprié pour réduire la mortalité des patients atteints d'infections bactériennes sévères.

Better With Ultrasound: Detection of DVT.
Shiloh AL, McPhee C, Eisen L, Koenig S, Millington SJ. | Chest. 2020 Sep;158(3):1122-1127.
DOI: https://doi.org/10.1016/j.chest.2020.01.038  | Télécharger l'article au format  
Keywords: DVT; medical education; ultrasound.

Education and Clinical Practice: Special Features

Editorial : Ultrasound studies to detect DVT are traditionally performed and interpreted by sonographers and radiologists, respectively, but the growth of point-of-care ultrasound is putting this powerful tool in the hands of front-line physicians. Literature from ambulatory patients in the ED suggests this tool performs well in the hands of nonconventional users, and it is now being commonly deployed to aid in the management of critically ill patients. This article presents an approach for incorporating these tools into bedside practice, including illustrative figures and narrated video presentations to demonstrate the techniques described.

Conclusion : Examination of the deep vascular system of the lower extremities with ultrasound is achievable for point-of- care providers with modest training requirements, and the tool performs well compared with a comprehensive examination. For patients in whom a pulmonary embolism is being contemplated as the cause of their critical illness, the probability calculations can be complex. Detecting a DVT will certainly increase the likelihood of a pulmonary embolism as the cause of shock and combining it with other aspects of the point- of-care examination can add further value.

Conclusion (proposition de traduction) : L'examen du système vasculaire profond des membres inférieurs par échographie est réalisable par les praticiens au point d'intervention avec des besoins de formation modestes, et l'outil fonctionne bien par rapport à un examen complet. Pour les patients chez qui une embolie pulmonaire est considérée comme la cause de leur pathologie grave, les calculs de probabilité peuvent être complexes. La détection d'une thrombophlébite veineuse profonde augmentera certainement la probabilité d'une embolie pulmonaire en tant que cause de choc et sa combinaison avec d'autres aspects de l'examen au point d'intervention peut ajouter une valeur supplémentaire.

Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding.
Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. | Cochrane Database Syst Rev. 2010 Sep 8;2010(9):CD002907
DOI: https://doi.org/10.1002/14651858.cd002907.pub2  | Télécharger l'article au format  
Keywords: Aucun

Review

Introduction : Bacterial infections are a frequent complication in patients with cirrhosis and upper gastrointestinal bleeding. Antibiotic prophylaxis seems to decrease the incidence of bacterial infections. Oral antibiotics, active against enteric bacteria, have been commonly used as antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding. This is an update of a Cochrane review first published in 2002.
Objectives: To assess the benefits and harms of antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding.

Méthode : We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index EXPANDED until June 2010. In addition, we handsearched the references of all identified studies.
titre_en_plus: Randomised clinical trials comparing different types of antibiotic prophylaxis with no intervention, placebo, or another antibiotic to prevent bacterial infections in cirrhotic patients with upper gastrointestinal bleeding.
Data collection and analysis: Three authors independently assessed trial quality, risk of bias, and extracted data. We contacted study authors for additional information. Association measures were relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes.

Résultats : Twelve trials (1241 patients) evaluated antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis. All trials were at risk of bias. Antibiotic prophylaxis compared with no intervention or placebo was associated with beneficial effects on mortality (RR 0.79, 95% CI 0.63 to 0.98), mortality from bacterial infections (RR 0.43, 95% CI 0.19 to 0.97), bacterial infections (RR 0.36, 95% CI 0.27 to 0.49), rebleeding (RR 0.53, 95% CI 0.38 to 0.74), days of hospitalisation (MD -1.91, 95% CI -3.80 to -0.02), bacteraemia (RR 0.25, 95% CI 0.15 to 0.40), pneumonia (RR 0.45, 95% CI 0.27 to 0.75), spontaneous bacterial peritonitis (RR 0.29, 95% CI 0.15 to 0.57), and urinary tract infections (RR 0.23, 95% CI 0.12 to 0.41). No serious adverse events were reported. The trials showed no significant heterogeneity of effects. Another five trials (650 patients) compared different antibiotic regimens. Data could not be combined as each trial used different antibiotic regimen. None of the examined antibiotic regimen was superior to the control regimen regarding mortality or bacterial infections.

Conclusion : Prophylactic antibiotic use in patients with cirrhosis and upper gastrointestinal bleeding significantly reduced bacterial infections, and seems to have reduced all-cause mortality, bacterial infection mortality, rebleeding events, and hospitalisation length. These benefits were observed independently of the type of antibiotic used; thus, no specific antibiotic can be preferred. Therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment cost.

Conclusion (proposition de traduction) : L'utilisation d'antibiotiques prophylactiques chez les patients atteints de cirrhose et d'hémorragie gastro-intestinale haute a réduit considérablement les infections bactériennes et semble avoir réduit la mortalité toutes causes confondues, la mortalité due aux infections bactériennes, les épisodes de récidive et la durée de l'hospitalisation. Ces bénéfices ont été observés indépendamment du type d'antibiotique utilisé ; ainsi, aucun antibiotique spécifique ne peut être préféré. Par conséquent, la sélection des antibiotiques doit être faite en tenant compte des conditions locales telles que le profil de résistance bactérienne et le coût du traitement.

Commentaire : Voir l'analyse de l'article sur le site JournalFeed : UGIB + Cirrhosis = Antibiotics?  . Rédigé par Kevin Stoffer, le 2 septembre 2020.
Voir également l'article : Prophylactic Antibiotics In Cirrhotic Patients With Upper Gastrointestinal Bleeding. Acad Emerg Med. 2020 Aug 6  . doi: 10.1111/acem.14103. Online ahead of print.

Combatting COVID-19: is ultrasound an important piece in the diagnostic puzzle?.
McDermott C, Daly J, Carley S. | Emerg Med J. 2020 Oct;37(10):644-649
DOI: https://doi.org/10.1136/emermed-2020-209721  | Télécharger l'article au format  
Keywords: emergency department; imaging; infectious diseases; ultrasound; viral.

PRACTICE REVIEW

Editorial : The current COVID-19 pandemic is causing diagnostic and risk stratification difficulties in Emergency Departments (ED) worldwide. Molecular tests are not sufficiently sensitive, and results are usually not available in time for decision making in the ED. Chest x-ray (CXR) is a poor diagnostic test for COVID-19, and computed tomography (CT), while sensitive, is impractical as a diagnostic test for all patients. Lung ultrasound (LUS) has an established role in the evaluation of acute respiratory failure and has been used during the COVID-19 outbreak as a decision support tool. LUS shows characteristic changes in viral pneumonitis, and while these changes are not specific for COVID-19, it may be a useful adjunct during the diagnostic process. It is quick to perform and repeat and may be done at the bedside. The authors believe that LUS can help to mitigate uncertainty in undifferentiated patients with respiratory symptoms. This review aims to provide guidance regarding indications for LUS, describe the typical sonographic abnormalities seen in patients with COVID-19 and provide recommendations around the logistics of performing LUS on patients with COVID-19 and managing the infection control risk of the procedure. The risk of anchoring bias during a pandemic and the need to consider alternative pathologies are emphasised throughout this review. LUS may be a useful point-of-care test for emergency care providers during the current COVID-19 pandemic if used within a strict framework that governs education, quality assurance and proctored scanning protocols.

Conclusion : LUS appears promising as a comprehensive imaging modality in clinically suspected or diagnosed COVID-19, when implemented mindfully and in conjunction with other diagnostic modalities. LUS findings should be interpreted alongside a careful history, physical examination and with pretest probability in mind. Point-of-care ultrasound may help to identify the need for further investigations or may guide the physician towards an alternative diagnosis. Incorporating ultrasound into the evaluation of COVID-19 patients will depend on available resources, expertise of personnel and logistic configurations unique to each situation.

Conclusion (proposition de traduction) : Le LUS semble prometteur en tant que modalité d'imagerie complète dans le COVID-19 cliniquement suspecté ou diagnostiqué, lorsqu'il est mis en œuvre consciemment et en conjonction avec d'autres modalités de diagnostic. Les résultats de la LUS doivent être interprétés parallèlement à une anamnèse minutieuse, à un examen physique et en tenant compte de la probabilité du prétest. L'échographie au point de service peut aider à identifier le besoin d'investigations supplémentaires ou peut guider le médecin vers un autre diagnostic. L'échographie pulmonaire semble prometteuse en tant que modalité d'imagerie complète dans le COVID-19 cliniquement suspecté ou diagnostiqué, lorsqu'elle est mise en œuvre consciemment et en conjonction avec d'autres modalités de diagnostic. Les résultats de l'échographie pulmonaire doivent être interprétés parallèlement à une anamnèse minutieuse, à un examen physique et en tenant compte de la probabilité du prétest. L'échographie au point de service peut aider à identifier le besoin d'investigations supplémentaires ou peut guider le médecin vers un autre diagnostic. L'intégration de l'échographie dans l'évaluation des patients COVID-19 dépendra des ressources disponibles, de l'expertise du personnel et des configurations logistiques propres à chaque situation.

Commentaire : La technique à 12 zones pour l'échographie pulmonaire en cas de suspicion de COVID-19.
(A) zones antérieures droites, (B) zones latérales droites et (C) zones postérieures droites. La pathologie précoce a tendance à se produire au niveau des zones pulmonaires postéro-basales, et celles-ci devraient être des zones de contrôle particulier (marquées d'astérisques). En comparaison, le protocole FUSIC utilise trois zones de chaque côté de la poitrine : deux zones antérieures (R1 + R2) et une zone postéro-latérale (R4).

Au fur et à mesure que la gravité de la maladie augmente, les lignes B augmentent en nombre et se produisent plus près les unes des autres (configuration confluente) à des sites éloignés des bases pulmonaires.
À gauche : lignes B discrètes issues d'une fine ligne pleurale (le plus souvent cardiogénique). À droite : lignes B confluentes comme on peut les voir dans la pneumopathie de la COVID-19.
On pense qu’un large motif de lignes B verticales en forme de bande (artéfact de « faisceau lumineux raquo;) est représentatif de la maladie COVID-19 précoce.

La ligne pleurale apparaît grossière, irrégulière et fragmentée et de petites consolidations périphériques localisées (moins de 1,5 cm) apparaissent comme des zones sombres immédiatement sous la ligne pleurale.

Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia.
Zieleskiewicz L, Markarian T, Lopez A, Taguet C, Mohammedi N, Boucekine M, Baumstarck K, Besch G, Mathon G, Duclos G, Bouvet L, Michelet P, Allaouchiche B, Chaumoître K, Di Bisceglie M, Leone M; AZUREA Network. . | Intensive Care Med. 2020 Sep;46(9):1707-1713
DOI: https://doi.org/10.1007/s00134-020-06186-0  | Télécharger l'article au format  
Keywords: Chest computed tomography; Diagnostic accuracy; Lung ultrasound; SARS-CoV-2.

Original

Introduction : The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO2)/fractional inspired oxygen (FiO2) ratio.

Méthode : A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included.

Résultats : One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68-0.87; p < 0.0001). A high LUS score was associated with the use of mechanical ventilation, and with a SpO2/FiO2 ratio below 357.

Conclusion : In known SARS-CoV-2 pneumonia patients, the LUS score was predictive of pneumonia severity as assessed by a chest CT scan and clinical features. Within the limitations inherent to our study design, LUS can be used to assess SARS-CoV-2 pneumonia severity.

Conclusion (proposition de traduction) : Chez les patients présentant une pneumopathie connue à SRAS-CoV-2, le score échographique pulmonaire était prédictif de la sévérité de la pneumonie telle qu'évaluée par un scanner thoracique et les caractéristiques cliniques. Dans les limites inhérentes à la conception de notre étude, l'échographique pulmonaire peut être utilisé pour évaluer la gravité d'une pneumopathie à SRAS-CoV-2.

Commentaire : Voir les articles sur le même sujet :
Zhang Y, Xue H, Wang M, He N, Lv Z, Cui L. Lung Ultrasound Findings in Patients With Coronavirus Disease (COVID-19). Am J Roentgenol. 2020 Jul;1–5  .
Lichter Y, Topilsky Y, Taieb P, Banai A, Hochstadt A, Merdler I, et al. Lung ultrasound predicts clinical course and outcomes in COVID-19 patients. Intensive Care Med [Internet]. 2020;46(10):1873–83  .

Management of acute pulmonary embolism 2019: what is new in the updated European guidelines?.
Konstantinides S, Meyer G. | Intern Emerg Med. 2020 Sep;15(6):957-966
DOI: https://doi.org/10.1007/s11739-020-02340-0  | Télécharger l'article au format  
Keywords: Anticoagulation; Diagnosis; Guidelines; Pulmonary embolism; Treatment.

IM - REVIEW

Editorial : Pulmonary embolism (PE) is the third most frequent acute cardiovascular syndrome. Annual PE incidence and PE-related mortality rates rise exponentially with age, and consequently, the disease burden imposed by PE on the society continues to rise as the population ages worldwide. Recently published landmark trials provided the basis for new or changed recommendations included in the 2019 update of the European Society of Cardiology Guidelines (developed in cooperation with the European Respiratory Society). Refinements in diagnostic algorithms were proposed and validated, increasing the specificity of pre-test clinical probability and D-dimer testing, and thus helping to avoid unnecessary pulmonary angiograms. Improved diagnostic strategies were also successfully tested in pregnant women with suspected PE. Non-vitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase (with or without a brief lead-in period of parenteral heparin or fondaparinux) and over the long term. Primary reperfusion is reserved for haemodynamically unstable patients. Besides, the 2019 Guidelines endorse multidisciplinary teams for coordinating the acute-phase management of high-risk and (in selected cases) intermediate-risk PE. For normotensive patients, physicians are advised to include the assessment of the right ventricle on top of clinical severity scores in further risk stratification, especially if early discharge of the patient is envisaged. Further important updates include guidance (1) on extended anticoagulation after PE, taking into account the improved safety profile of NOACs; and (2) on the overall care and follow-up of patients who have suffered PE, with the aim to prevent, detect and treat late sequelae of venous thromboembolism.

Conclusion : Take-home messages for the contemporary management of acute PE

(1) Perform bedside transthoracic echocardiography as the immediate diagnostic test of choice in a patient presenting with haemodynamic instability (suspected high-risk PE).
(2) For haemodynamically stable patients with suspected PE, use a validated diagnostic algorithm including a standardised assessment of pre-test clinical probability and D-dimer testing.
(3) Start anticoagulation therapy upon suspicion acute PE, while the diagnostic work-up is ongoing, if the clinical (pre-test) probability is intermediate or high, unless there is active bleeding or the patient has absolute contraindications to anticoagulants.
(4) If the CTPA report speaks of single subsegmental PE, discuss the findings again with the radiologist or obtain a second opinion to avoid misdiagnosis.
(5) Evaluate the size and/or function of the RV along with clinical findings and comorbidity in all patients presenting without haemodynamic instability.
(6) In a patient with strongly suspected or confirmed high-risk PE, and in initially normotensive patients with haemodynamic decompensation after admission to the hospital, determine the best reperfusion option (systemic thrombolysis, surgical embolectomy, or catheter-directed treatment), through consensus in an interdisciplinary team, taking into account the resources and expertise available at your hospital.
(7) Start oral anticoagulation with an NOAC, as these drugs have become the standard of care for the majority of patients with acute PE. The LMWH − VKA regimen is an alternative for patients with contraindications to NOACs.
(8) In a patient who suffered acute PE not provoked by a strong transient/reversible risk factor, perform a personalised assessment of the benefits versus risks of continuing anticoagulation treatment after the first 3–6 months. Consider the good safety profile of NOACs in your decision, and also take into account the patient’s fears and preferences. Do not forget to perform regular follow-up examinations, as a rule once a year.
(9) If PE is suspected in a pregnant patient, use formal diagnostic pathways and risk assessment. If needed, do not hesitate to perform a CTPA or ventilation–perfusion lung scan to reliably confirm or exclude the diagnosis. Manage haemodynamically unstable pregnant patients based on the same emergency algorithm as for non-pregnant patients.…

Conclusion (proposition de traduction) : Messages à retenir :
(1) Effectuer une ETT au point d'intervention comme choix de test diagnostique immédiat chez un patient présentant une instabilité hémodynamique (suspicion d'embolie pulmonaire [EP] à haut risque).
(2) Pour les patients hémodynamiquement stables avec suspicion d'EP, utiliser un algorithme de diagnostic validé comprenant une évaluation standardisée de la probabilité clinique pré-test et des D-dimères.
(3) Commencer un traitement anticoagulant en cas de suspicion d'EP aiguë, pendant que le bilan diagnostique est en cours, si la probabilité clinique (pré-test) est moyenne ou élevée, à moins qu'il y ait un saignement actif ou que le patient ait des contre-indications absolues aux anticoagulants.
(4) Si le contrat-rendu d'angiographie pulmonaire par tomodensitométrie parle d'EP sous-segmentaire unique, discutez à nouveau des résultats avec le radiologue ou obtenez un deuxième avis pour éviter un diagnostic erroné.
(5) Évaluer la taille et/ou la fonction du ventricule droit ainsi que les signes cliniques et les comorbidités chez tous les patients se présentant sans instabilité hémodynamique.
(6) Chez un patient avec une EP à haut risque, fortement suspectée ou confirmée, et chez des patients initialement normotendus avec décompensation hémodynamique après admission à l'hôpital, déterminer la meilleure option de reperfusion (thrombolyse systémique, embolectomie chirurgicale ou traitement dirigé par cathéter), par consensus au sein d'une équipe interdisciplinaire, en tenant compte des ressources et de l'expertise disponibles dans votre hôpital.
(7) Commencer une anticoagulation orale avec un AOD, car ces médicaments sont devenus la norme de soins pour la majorité des patients souffrant d'EP aiguë. Le traitement par HBPM/AVK est une alternative pour les patients présentant des contre-indications aux AOD.
(8) Chez un patient ayant souffert d'une EP aiguë non provoquée par un facteur de risque transitoire/réversible important, effectuer une évaluation personnalisée des bénéfices par rapport aux risques de poursuivre le traitement anticoagulant après les 3 à 6 premiers mois. Tenez compte du bon profil de sécurité des AOD dans votre décision et tenez également compte des craintes et des préférences du patient. N'oubliez pas d'effectuer des examens de suivi réguliers, en règle générale une fois par an.
(9) Si une EP est suspectée chez une patiente enceinte…

The efficacy and safety of evaluating elderly patients using a comprehensive diagnostic protocol via a chest pain unit.
Fardman A, Livne M, Goldkorn R, Goitein O, Shlomo N, Asher E, Grupper A, Naroditsky M, Matetzky S, Beigel R. | Intern Emerg Med. 2020 Sep;15(6):1061-1066
DOI: https://doi.org/10.1007/s11739-020-02289-0
Keywords: Chest pain · Elderly · Chest pain unit · Acute coronary syndrome

EM - ORIGINAL

Editorial : Elderly patients are often excluded from a chest pain unit (CPU)-based evaluation of chest pain due to concern about adverse events and poorer outcomes. The aim of this study was to assess the feasibility and safety of thoroughly evaluating elderly patients ≥ 65 years of age presented with acute chest pain via a CPU. We evaluated 1220 consecutive patients admitted to our CPU, and stratified them according to age: those over and those under 65 years. Patients were evaluated for outcomes during hospitalization and for a composite endpoint at 60 days post discharge which included: recurrent hospitalization due to chest pain, need for coronary revascularization, acute coronary syndrome, and death. Overall, 241 (20%) patients were in the ≥ 65-year-old group and 979 (80%) patients in the group < 65 years of age. Older patients were more likely to be female, have more co-morbidities, and a history of prior coronary artery disease. There was no difference between the two groups regarding in-hospital course, including hospitalization in the CPU (9.5% vs. 11.6%, p = 0.37), coronary angiography (7.9% vs. 9.8%, p = 0.37), and revascularization performed during the evaluation period (4.5% vs. 3.3%, p = 0.42). Of those discharged, the primary endpoint at 60 days was observed in 11 (1.5%) and 7 (3.9%) patients in those under and over 65 years, respectively, (p = 0.13). No mortalities were recorded. Comprehensive evaluation via a CPU of patients who are ≥ 65 years of age is feasible and safe with in-hospital and short-term outcomes compared to their younger counterparts.

Conclusion : Evaluation of elderly patients presenting with acute chest pain via a CPU is feasible and safe with comparable outcomes compared with those of their younger counterparts.

Conclusion (proposition de traduction) : L'évaluation des patients âgés présentant une douleur thoracique aiguë via une unité de douleur thoracique est faisable et sûre avec des résultats comparables à ceux de leurs homologues plus jeunes.

Inadequate prophylactic effect of low-molecular weight heparin in critically ill COVID-19 patients.
Stattin K, Lipcsey M, Andersson H, Pontén E, Anderberg SB, Gradin A, et al.. | J Crit Care [Internet]. 2020;In Press:1–13
DOI: https://doi.org/10.1016/j.scitotenv.2020.140714  | Télécharger l'article au format  
Keywords: COVID-19Intensive careThrombelastographyLow-molecular-weight heparinThromboembolism

In Press, Journal Pre-proof

Introduction : The aim of this study was to investigate potential markers of coagulopathy and the effects of thromboprophylaxis with low-molecular-weight heparin (LMWH) on thromboelastography (TEG) and anti-factor Xa in critically ill COVID-19 patients.

Méthode : We conducted a prospective study in 31 consecutive adult intensive care unit (ICU) patients. TEG with and without heparinase and anti-factor Xa analysis were performed. Standard thromboprophylaxis was given with dalteparin (75–100 IU/kg subcutaneously).

Résultats : Five patients (16%) had symptomatic thromboembolic events. All patients had a maximum amplitude (MA) > 65 mm and 13 (42%) had MA > 72 mm at some point during ICU stay. Anti-factor Xa activity were below the target range in 23% of the patients and above target range in 46% of patients. There was no significant correlation between dalteparin dose and anti-factor Xa activity.

Conclusion : Patients with COVID-19 have hypercoagulability with high MA on TEG. The effect of LMWH on thromboembolic disease, anti-factor Xa activity and TEG was variable and could not be reliably predicted. This indicates that standard prophylactic doses of LMWH may be insufficient. Monitoring coagulation and the LMWH effect is important in patients with COVID-19 but interpreting the results in relation to risk of thromboembolic disease poses difficulties.

Conclusion (proposition de traduction) : Les patients atteints de COVID-19 présentent une hypercoagulabilité avec une amplitude maximale élevée lors de la thromboélastographie. L'effet de l'héparine de bas poids moléculaire sur la maladie thromboembolique, l'activité anti-facteur Xa et la thromboélastographie était variable et ne pouvait pas être prédit de manière fiable. Cela indique que les doses prophylactiques standard d'héparine de bas poids moléculaire peuvent être insuffisantes. La surveillance de la coagulation et de l'effet de l'héparine de bas poids moléculaire est importante chez les patients atteints de COVID-19, mais l'interprétation des résultats en relation avec le risque de maladie thromboembolique pose des difficultés.

Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial.
Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. | JAMA. 2018 Sep 25;320(12):1259-1265
DOI: https://doi.org/10.1001/jama.2018.13201  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis, but long-term outcomes are not known.
Objective : To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis.

Méthode : Five-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial comparing appendectomy with antibiotic therapy, in which 530 patients aged 18 to 60 years with computed tomography–confirmed uncomplicated acute appendicitis were randomized to undergo an appendectomy (n = 273) or receive antibiotic therapy (n = 257). The initial trial was conducted from November 2009 to June 2012 in Finland; last follow-up was September 6, 2017. This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone.
Interventions : Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.
Main Outcomes and Measures: In this analysis, prespecified secondary end points reported at 5-year follow-up included late (after 1 year) appendicitis recurrence after antibiotic treatment, complications, length of hospital stay, and sick leave.

Résultats : Of the 530 patients (201 women; 329 men) enrolled in the trial, 273 patients (median age, 35 years [IQR, 27-46]) were randomized to undergo appendectomy, and 257 (median age, 33 years, [IQR, 26-47]) were randomized to receive antibiotic therapy. In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%]; 70/256), 30 additional antibiotic-treated patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) underwent appendectomy between 1 and 5 years. The cumulative incidence of appendicitis recurrence was 34.0% (95% CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI, 33.1%-45.3%; 100/256) at 5 years. Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, 2 had complicated appendicitis, and 7 did not have appendicitis. At 5 years, the overall complication rate (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) was 24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI, 3.8%-10.4%) (n = 16/246) in antibiotic group (P < .001), which calculates to 17.9 percentage points (95% CI, 11.7-24.1) higher after surgery. There was no difference between groups for length of hospital stay, but there was a significant difference in sick leave (11 days more for the appendectomy group).

Conclusion : Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 years was 39.1%. This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.

Conclusion (proposition de traduction) : Parmi les patients initialement traités par antibiotique pour une appendicite aiguë non compliquée, la probabilité de récidive tardive dans les 5 ans était de 39,1%. Ce suivi à long terme confirme la faisabilité d'un traitement antibiotique seul comme alternative à la chirurgie pour l'appendicite aiguë non compliquée.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.
Rowell SE, Meier EN, McKnight B, Kannas D, May S, Sheehan K, Bulger EM, Idris AH, Christenson J, Morrison LJ, Frascone RJ, Bosarge PL, Colella MR, Johannigman J, Cotton BA, Callum J, McMullan J, Dries DJ, Tibbs B, Richmond NJ, Weisfeldt ML, Tallon JM, Garrett JS, Zielinski MD, Aufderheide TP, Gandhi RR, Schlamp R, Robinson BRH, Jui J, Klein L, Rizoli S, Gamber M, Fleming M, Hwang J, Vincent LE, Williams C, Hendrickson A, Simonson R, Klotz P, Sopko G, Witha. | JAMA. 2020 Sep 8;324(10):961-974
DOI: https://doi.org/10.1001/jama.2020.8958
Keywords: Aucun

Original Investigation

Introduction : Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI.
Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI.

Méthode : Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher.
Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309).
Main outcomes and measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events.

Résultats : Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16).

Conclusion : Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended.

Conclusion (proposition de traduction) : Parmi les patients atteints d'un traumatisme crânien modéré à sévère, l'administration d'acide tranexamique extra-hospitalière dans les 2 heures suivant la blessure par rapport au placebo n'a pas amélioré de manière significative les résultats neurologiques à 6 mois, tels que mesurés par l'échelle de résultats de Glasgow étendue.

Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest.
Grunau B, Kime N, Leroux B, Rea T, Van Belle G, Menegazzi JJ, Kudenchuk PJ, Vaillancourt C, Morrison LJ, Elmer J, Zive DM, Le NM, Austin M, Richmond NJ, Herren H, Christenson J. | JAMA. 2020 Sep 15;324(11):1058-1067
DOI: https://doi.org/10.1001/jama.2020.14185
Keywords: Aucun

Original Investigation

Introduction : There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear.
Objective: To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA.

Méthode : Cohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed.
Exposures: Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation.
Main outcomes and measures: The primary outcome was survival to hospital discharge, and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale <3) at hospital discharge.

Résultats : The full cohort included 43 969 patients with a median age of 67 years (interquartile range, 55-80), 37% were women, 86% of cardiac arrests occurred in a private location, 49% were bystander- or EMS-witnessed, 22% had initial shockable rhythms, 97% were treated by out-of-hospital advanced life support, and 26% underwent intra-arrest transport. Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation. In the propensity-matched cohort, which included 27 705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0%- 5.1%]). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%]). Subgroups of initial shockable and nonshockable rhythms as well as EMS-witnessed and unwitnessed cardiac arrests all had a significant association between intra-arrest transport and lower probability of survival to hospital discharge.

Conclusion : Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.

Conclusion (proposition de traduction) : Parmi les patients ayant subi un arrêt cardiaque extra-hospitalier, le transport à l'hôpital du patient en arrêt cardiaque par rapport à la réanimation continue sur place était associé à une probabilité de survie plus faible jusqu'à la sortie de l'hôpital. Les résultats de l'étude sont limités par des facteurs de confusion potentiels en raison de la conception observationnelle.

Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest.
Grunau B, Kime N, Leroux B, Rea T, Van Belle G, Menegazzi JJ, Kudenchuk PJ, Vaillancourt C, Morrison LJ, Elmer J, Zive DM, Le NM, Austin M, Richmond NJ, Herren H, Christenson J. | JAMA. 2020 Sep 15;324(11):1058-1067
DOI: https://doi.org/10.1001/jama.2020.14185
Keywords: Aucun

Observational Study

Editorial : There is wide variability among emergency medical systems (EMS) with respect to transport to hospital during out-of-hospital cardiac arrest (OHCA) resuscitative efforts. The benefit of intra-arrest transport during resuscitation compared with continued on-scene resuscitation is unclear.
Objective: To determine whether intra-arrest transport compared with continued on-scene resuscitation is associated with survival to hospital discharge among patients experiencing OHCA.

Introduction : Cohort study of prospectively collected consecutive nontraumatic adult EMS-treated OHCA data from the Resuscitation Outcomes Consortium (ROC) Cardiac Epidemiologic Registry (enrollment, April 2011-June 2015 from 10 North American sites; follow-up until the date of hospital discharge or death [regardless of when either event occurred]). Patients treated with intra-arrest transport (exposed) were matched with patients in refractory arrest (at risk of intra-arrest transport) at that same time (unexposed), using a time-dependent propensity score. Subgroups categorized by initial cardiac rhythm and EMS-witnessed cardiac arrests were analyzed.
Exposures : Intra-arrest transport (transport initiated prior to return of spontaneous circulation), compared with continued on-scene resuscitation.
Main outcomes and measures: The primary outcome was survival to hospital discharge, and the secondary outcome was survival with favorable neurological outcome (modified Rankin scale <3) at hospital discharge.

Résultats : The full cohort included 43 969 patients with a median age of 67 years (interquartile range, 55-80), 37% were women, 86% of cardiac arrests occurred in a private location, 49% were bystander- or EMS-witnessed, 22% had initial shockable rhythms, 97% were treated by out-of-hospital advanced life support, and 26% underwent intra-arrest transport. Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation. In the propensity-matched cohort, which included 27 705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0%- 5.1%]). Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%]). Subgroups of initial shockable and nonshockable rhythms as well as EMS-witnessed and unwitnessed cardiac arrests all had a significant association between intra-arrest transport and lower probability of survival to hospital discharge.

Conclusion : Among patients experiencing out-of-hospital cardiac arrest, intra-arrest transport to hospital compared with continued on-scene resuscitation was associated with lower probability of survival to hospital discharge. Study findings are limited by potential confounding due to observational design.

Conclusion (proposition de traduction) : Parmi les patients victimes d'un arrêt cardiaque en dehors de l'hôpital, le transport du patient en arrêt vers l'hôpital par rapport à la poursuite de la réanimation sur place était associé à une probabilité plus faible de survie jusqu'à la sortie de l'hôpital. Les résultats de l'étude sont limités par une confusion potentielle due à la conception observationnelle.

Commentaire : Voir l'analyse de l'article sur le site de la RLF : Transport à l’hôpital per-réanimation versus réanimation sur place dans l’arrêt cardiaque extrahospitalier  . Rédigé par le Dr Patricia Jabre, le 27/01/2021.

Tirolien JA, Garnier M. | Prat Anesth Reanim. 2020 Sep; 24(4): 225–229.
DOI: https://doi.org/10.1016/j.pratan.2020.07.001  | Télécharger l'article au format  
Keywords: SARS-coV2; COVID-19; Acute respiratory distress syndrome; Protective ventilation

MISE AU POINT

Editorial : L’infection au nouveau coronavirus Sars-Cov2 est responsable d’une forme sévère de pneumonie, la COVID-19 pouvant évoluer vers un tableau de syndrome de détresse respiratoire aiguë. Cependant, bien que les critères d’hypoxémie soient présents, ce SDRA diffère des formes classiques, notamment en raison d’une compliance pulmonaire le plus souvent normale au stade initial. Ceci suggère des mécanismes physiopathologiques spécifiques encore mal compris, qui aboutissent à des profils de la maladie devant faire repenser la ventilation protectrice, afin de limiter la genèse des lésions pulmonaires induites par la ventilation.

Conclusion (proposition de traduction) : La pneumonie COVID-19 est responsable d’une forme unique de SDRA en lien avec des lésions pulmonaires spécifiques. Elle diffère des SDRA classiques en raison d’une compliance pulmonaire relativement conservée à la phase initiale. Les patients présentant des formes sévères ont besoin d’une ventilation mécanique prolongée associant des séances de décubitus ventral pour améliorer les rapports ventilation/perfusion et corriger l’hypoxémie. Lorsque la compliance pulmonaire diminue du fait de la constitution d’atélectasies par surinfection bactérienne, le régime de ventilation doit changer pour une ventilation protectrice évitant la survenue d’un barotrausmatisme. L’adaptation aux conditions de ventilation nécessite une sédation prolongée

Intranasal Fentanyl and Midazolam for Procedural Analgesia and Anxiolysis in Pediatric Urgent Care Centers.
Williams JM, Schuman S, Regen R, Berg A, Stuart L, Raju J, Mabry W, Kink RJ. | Pediatr Emerg Care. 2020 Sep;36(9):e494-e499
DOI: https://doi.org/10.1097/pec.0000000000001782
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Intranasal fentanyl and midazolam use is increasing in the acute care setting for analgesia and anxiolysis, but there is a lack of literature demonstrating their use, alone or in combination, at pediatric urgent care centers.

Méthode : This retrospective study investigated intranasal fentanyl and midazolam use at an urgent care center located within Le Bonheur Children's Hospital and 2 affiliated off-site centers from September 22, 2011, to December 30, 2015. Data collected included patient demographics, initial fentanyl dose, initial midazolam dose, type of procedure, and serious adverse drug reactions.

Résultats : Of the 490 patients who met the inclusion criteria, 143 patients received intranasal fentanyl alone, 92 received intranasal midazolam alone, and 255 received fentanyl in combination with midazolam. The overall patient population was 50% male with a median (range) age of 4.5 (0.2-17.9) years, and most patients were black at 57.1%. The median (range) initial intranasal fentanyl dose was 2.02 (0.99-4.22) μg/kg, and the median initial (range) intranasal midazolam dose was 0.19 (0.07-0.42) mg/kg. In cases where fentanyl and midazolam were administered in combination, the median (range) initial fentanyl dose was 2.23 (0.6-4.98) μg/kg and median (range) initial midazolam dose was 0.2 (0.03-0.45) mg/kg. There were no serious adverse drug reactions reported.

Conclusion : Intranasal fentanyl and midazolam when administrated alone and in combination can provide analgesia and anxiolysis for minor procedures in pediatric patients treated in the urgent care setting.

Conclusion (proposition de traduction) : Le fentanyl et le midazolam par voie intranasale, administrés seuls et en association, peuvent fournir une analgésie et une anxiolyse pour les interventions mineures chez les patients pédiatriques traités dans le cadre de soins d'urgence.

Pediatric Syncope: A Systematic Review.
Zavala R, Metais B, Tuckfield L, DelVecchio M, Aronoff S. | Pediatr Emerg Care. 2020 Sep;36(9):442-445
DOI: https://doi.org/10.1097/pec.0000000000002149  | Télécharger l'article au format  
Keywords: Aucun

REVIEW ARTICLE

Introduction : The aims of the study were to perform the first systematic review of pediatric syncope etiologies and to determine the most common diagnoses with credible intervals (CredIs).

Méthode : Review was performed within Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and used Embase, Scopus, PubMed, and the Cochrane Controlled Trial databases. The following inclusion criteria for the articles were used: minimum of 10 patients, standard definition of syncope used, subjects who were 21 years or younger, and subjects who were either a consecutive retrospective group or a prospective group. No restrictions were made regarding language of the studies, but an English abstract was required. The following information was collected: purpose of the study, definition of syncope, number of patients, patient age range, inclusion/exclusion criteria, and etiologies of syncope.

Résultats : Of the 500 articles initially identified, 11 studies met the inclusion criteria and were the basis for this review. Three thousand seven hundred patients were included, ranging in age from 3 months to 21 years. The most common etiologies identified were vasovagal (52.2%; 95% CredI, 50.6-53.9), postural orthostatic tachycardia syndrome (13.1%; 95% CredI, 12.1-14.2), and cardiac causes (4.0%; 95% CredI, 3.39-4.65). A total of 18.3% (95% CredI, 17.0-19.5) of patients were found to have syncope of unknown cause.

Conclusion : Syncope is a common pediatric complaint. Most cases seen are a result of benign causes, with only a small percentage because of serious medical conditions. In addition, most syncopal episodes in the pediatric population are diagnosed clinically or with minimally invasive testing, emphasizing the importance of a detailed history and physical examination.

Conclusion (proposition de traduction) : La syncope est une plainte pédiatrique courante. La plupart des cas observés sont le résultat de causes bénignes, avec seulement un petit pourcentage en raison de conditions médicales graves. En outre, la plupart des épisodes syncopaux dans la population pédiatrique sont diagnostiqués cliniquement ou avec des tests mini-invasifs, soulignant l'importance d'une anamnèse détaillée et d'un examen physique.

Point-of-Care Ultrasound for Undifferentiated Abdominal Pain in a Pediatric Patient: A Proposed Algorithm.
Leviter J, Constantine E. | Pediatr Emerg Care. 2020 Sep;36(9):446-451
DOI: https://doi.org/10.1097/pec.0000000000002033
Keywords: Aucun

Ultrasound Case Review

Editorial : Abdominal pain is a common presentation in the pediatric emergency department and may pose a diagnostic challenge to the physician. Although most abdominal pain is benign, the presence of abdominal pain may represent a surgical emergency. We present an atypical presentation of perforated appendicitis in a child with 2 weeks of abdominal pain, in whom point-of-care ultrasound expedited diagnosis and patient disposition. We then recommend a diagnostic approach for using point-of-care ultrasound in a pediatric patient with undifferentiated abdominal pain.

Conclusion : systematic way in the pediatric patient with undifferentiated abdominal pain to rule-in time-sensitive diagnoses, using an approach tailored to the location of pain. For those with lower quadrant, suprapubic, or periumbilical tenderness, the physi- cian should begin by looking for signs of appendicitis, kidney stones, and gonadal pathology, including intrauterine or ec- topic pregnancy for girls of childbearing potential. A patient with upper quadrant pain should be investigated for renal, gall- bladder, and lung pathologies. Those with generalized pain should prompt a search for small bowel obstruction or intussus- ception. Point-of-care ultrasound, performed by a PED pro- vider experienced in its use, can provide useful and timely information that may save time, cost, and radiation exposure and expedite diagnosis and management.

Conclusion (proposition de traduction) : Nous avons présenté le cas d'un enfant souffrant de douleurs abdominales indifférenciées dont le diagnostic d'appendicite perforée a été accéléré par l'échographie au point d'intervention. L'échographie au point d'intervention doit être utilisée de manière systématique chez le patient pédiatrique souffrant de douleurs abdominales indifférenciées pour établir des diagnostics sensibles au temps, en utilisant une approche adaptée à la localisation de la douleur. Pour ceux qui ont une sensibilité du quadrant inférieur, suprapubienne ou péri-bilicale, le médecin doit commencer par rechercher des signes d'appendicite, de calculs rénaux et de pathologie gonadique, y compris une grossesse intra-utérine ou extra-utérine pour les filles en âge de procréer. Un patient souffrant de douleurs du quadrant supérieur doit être examiné pour des pathologies rénales, vésiculaires et pulmonaires. Ceux qui ont une douleur généralisée devraient inciter à rechercher une occlusion intestinale grêle ou une invagination intestinale. L'échographie au point d'intervention, effectuée par un professionnel du service des urgences, expérimenté dans son utilisation, peut fournir des informations utiles et opportunes qui peuvent économiser du temps, des coûts et une exposition aux rayonnements et accélérer le diagnostic et la gestion.

Commentaire : Algorithme pour aborder les douleurs abdominales indifférenciées chez un patient pédiatrique à l'aide de POCUS. SBO indique une occlusion de l'intestin grêle.

Prehospital management of traumatic brain injury across Europe: a CENTER-TBI study.
Gravesteijn B, Sewalt CA, Stocchetti N, Citerio G, Ercole A, Lingsma HF, von Steinbüchel N, Steyerberg EW, Wilson L, Maas AIR, Menon DK, Lecky FE; CENTER-TBI collaborators. | Prehosp Emerg Care. 2020 Sep 2:1-22
DOI: https://doi.org/10.1080/10903127.2020.1817210
Keywords: Guidelines; Practice; Prehospital Care; Prospective; Traumatic brain injury.

Online ahead of print

Editorial : Prehospital care for traumatic brain injury (TBI) is important to prevent secondary brain injury. We aim to compare prehospital care systems within Europe and investigate the association of system characteristics with the stability of patients at hospital arrival. We studied TBI patients who were transported to CENTER-TBI centers, a pan-European, prospective TBI cohort study, by emergency medical services between 2014 and 2017. The association of demographic factors, injury severity, situational factors, and interventions associated with on-scene time was assessed using linear regression. We used mixed effects models to investigate the case mix adjusted variation between countries in prehospital times and interventions. The case mix adjusted impact of on-scene time and interventions on hypoxia (oxygen saturation <90%) and hypotension (systolic blood pressure <100mmHg) at hospital arrival was analysed with logistic regression. Among 3878 patients, the greatest driver of longer on-scene time was intubation (+8.3 min, 95% CI: 5.6 - 11.1). Secondary referral was associated with shorter on-scene time (-5.0 min 95% CI: -6.2- -3.8). Between countries, there was a large variation in response (range: 12-25 min), on-scene (range: 16-36 min) and travel time (range: 15-32 min) and in prehospital interventions. These variations were not explained by patient factors such as conscious level or severity of injury (expected OR between countries: 1.8 for intubation, 1.8 for IV fluids, 2.0 for helicopter). On-scene time was not associated with the regional EMS policy (p = 0.58). Hypotension and/or hypoxia were seen in 180 (6%) and 97 (3%) patients in the overall cohort and in 13% and 7% of patients with severe TBI (GCS ≤8). The largest association with secondary insults at hospital arrival was with major extracranial injury: the OR was 3.6 (95% CI: 2.6- 5.0) for hypotension and 4.4 (95% CI: 2.9 - 6.7) for hypoxia. To conclude, hypoxia and hypotension continue to occur in patients who suffer a TBI, and remain relatively common in severe TBI. Substantial variation in prehospital care exists for patients after TBI in Europe, which is only partially explained by patient factors.

Conclusion : Across Europe, there are large variations in prehospital interventions for patients after TBI and in the associated on scene times. This variation is only partially explained by patient factors. Additional drivers of variation are likely to include EMS resource and organizational differences, and a low evidence base. While hypoxia and hypotension are less common than observed in past studies, they continue to occur in a substantial minority of patients after TBI, are particularly frequent following severe TBI or extracranial injury, and are associated with substantially worse outcomes. These data make a strong case for further research to facilitate the development and implementation of guidelines that support best practice in the prehospital care of patients with TBI.

Conclusion (proposition de traduction) : Partout en Europe, il existe de grandes disparités dans la prise en charge préhospitalière des patients victimes d'un traumatisme crânien et dans l'organisation des soins sur les lieux de l'accident. Cette variation n'est que partiellement expliquée par les facteurs liés au patient. D'autres critères de variation sont susceptibles d'inclure les ressources des services médicaux d'urgence et les différences organisationnelles, ainsi qu'une faible base de données probantes. Bien que l'hypoxie et l'hypotension soient moins fréquentes que celles observées dans les études précédentes, elles continuent de survenir chez une minorité substantielle de patients après un traumatisme crânien, sont particulièrement fréquentes après une lésion cérébrale traumatique grave ou une lésion extracrânienne, et sont associées à des résultats nettement pires. Ces données plaident en faveur de recherches supplémentaires pour faciliter le développement et la mise en œuvre de lignes directrices qui soutiennent les meilleures pratiques dans les soins préhospitaliers des patients atteints de traumatisme crânien.

Ketamine for prehospital pain management does not prolong emergency department length of stay.
Robinson EJ, Watanabe BL, Brown LH. | Prehosp Emerg Care. 2020 Sep 4:1-13
DOI: https://doi.org/10.1080/10903127.2020.1819493
Keywords: emergency medical services; ketamine; pain management.

Aticle

Introduction : Ketamine is gaining acceptance as an agent for prehospital pain control, but the associated risks of agitation, hallucinations and sedation have raised concern about its potential to prolong emergency department (ED) length of stay (LOS). This study compared ED LOS among EMS patients who received prehospital ketamine, fentanyl or morphine specifically for pain control. We hypothesized ED LOS would not differ between patients receiving the three medications.

Méthode : This retrospective observational study utilized the 2018 ESO Research Database, which includes more than 7.5 million EMS events attended by more than 1,200 agencies. Inclusion criteria were: a 9-1-1 scene response; age ≥18 years; a recorded pain score greater than 4; an initial complaint or use of a treatment protocol indicating a painful condition; prehospital administration of ketamine, fentanyl or morphine; and ED LOS data available. Patients were excluded if they received a combination of the medications, or if there were indications that medication administration could have been for airway management (i.e., altered mental status, head injury, respiratory distress/depression) or agitation control (e.g., behavioral complaints). Kruskal-Wallis test was used to compare ED LOS among patients receiving each of the three medications. Post-hoc evaluations of between-group differences were conducted using Wilcoxon Rank Sum test and a Bonferroni-corrected alpha value of 0.017.

Résultats : Of 9,548 patients who met the inclusion criteria, 119 received ketamine, 1,359 received morphine, and 8,070 received fentanyl. Patient and event characteristics did not significantly differ between the three groups. Median (IQR) ED LOS was 3.5 (2.5-6.1) hours for patients who received ketamine, 4.0 (2.7-6.1) hours for patients who received morphine, and 3.7 (2.6-5.4) hours for patients who received fentanyl (p = 0.002). In post-hoc pairwise comparisons, patients who received morphine had significantly longer ED LOS than patients who received fentanyl (p < 0.001); there was no significant difference in ED LOS for patients who received ketamine vs. morphine (p = 0.161) or for patients who received ketamine vs. fentanyl (p = 0.809).

Conclusion : ED LOS is not longer for patients who receive prehospital ketamine, versus morphine or fentanyl, for management of isolated painful non-cardiorespiratory conditions.

Conclusion (proposition de traduction) : La durée du séjour aux urgences n'est pas plus longue pour les patients qui reçoivent de la kétamine préhospitalière, par rapport à la morphine ou au fentanyl, pour la prise en charge des affections douloureuses non cardiorespiratoires isolées.

Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review.
Mercer CB, Ball M, Cash RE, Rivard MK, Chrzan K, Panchal AR. | Prehosp Emerg Care. 2020 Sep 17:1-17
DOI: https://doi.org/10.1080/10903127.2020.1811815
Keywords: EMS; prehospital; trauma; ultrasound; wounds and injuries.

Article

Introduction : Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined.
Objectives: We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients.

Méthode : We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed.

Résultats : Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality.

Conclusion : Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.

Conclusion (proposition de traduction) : L'utilisation de l'échographie dans le cadre préhospitalier pour un traumatisme est faisable et démontre un potentiel. Cependant, les preuves dans la littérature médicale consistent principalement en des études observationnelles prospectives de médecins utilisant l'échographie pour un traumatisme dans un service médical d'urgence par hélicoptère. Des recherches scientifiques supplémentaires doivent être entreprises pour établir fermement le rôle de l'échographie préhospitalière dans la gestion des traumatismes par tous les types de prestataires de services médicaux d'urgence.

Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardiopulmonary resuscitation: A substudy of the CAAM trial.
Baekgaard JS, Triba MN, Brandeis M, Steinmetz J, Cohen Y, Gorlicki J, Rasmussen LS, Deltour S, Lapostolle F, Adnet F. | Resuscitation. 2020 Sep;154:12-18
DOI: https://doi.org/10.1016/j.resuscitation.2020.06.011
Keywords: Airway management; Aspiration pneumonia; Cardiopulmonary resuscitation; Early-onset pneumonia; Out-of-hospital cardiac arrest; Resuscitation.

Clinical paper

Introduction : Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP.

Méthode : Adult patients from the CAAM trial that survived beyond 12 h of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary aim was to compare the incidence of EOP in the BMV and ETI group using a series of bivariate analysis adjusting for one variable at a time and a logistic regression controlled for survival beyond 96 h, age, gender, catecholamine administration, no flow time, and initial shockable rhythm.

Résultats : Of 627 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 h and thus included (202 randomized to BMV and 20 7 randomized to ETI). Patients in the BMV group had a significantly longer period of unsecured airway during prehospital cardiopulmonary resuscitation (BMV (median): 33 min; ETI (median): 17 min, p < 0.0001). No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 53%, ETI: 53%, Odds Ratio 1.0 [0.7-1.5], p = 1.0). We found no difference in the development of EOP according to airway management in the series of bivariate analyses or in the multivariable regression analysis either.

Conclusion : In this substudy of the CAAM trial, development of early-onset pneumonia in out-of-hospital cardiac arrest survivors did not depend on airway management technique during CPR.

Conclusion (proposition de traduction) : Dans cette sous-étude de l'étude CAAM, le développement d'une pneumonie précoce chez les survivants après un arrêt cardiaque extra-hospitalier ne dépendait pas de la technique de gestion des voies aériennes pendant la RCP.

The impact of increased chest compression fraction on survival for out-of-hospital cardiac arrest patients with a non-shockable initial rhythm.
Vaillancourt C, Petersen A, Meier EN, Christenson J, Menegazzi JJ, Aufderheide TP, Nichol G, Berg R, Callaway CW, Idris AH, Davis D, Fowler R, Egan D, Andrusiek D, Buick JE, Bishop TJ, Colella MR, Sahni R, Stiell IG, Cheskes S; Resuscitation Outcomes Consortium Investigators. | Resuscitation. 2020 Sep;154:93-100
DOI: https://doi.org/10.1016/j.resuscitation.2020.06.016
Keywords: Cardiopulmonary resuscitation; Heart arrest; Resuscitation.

Clinical paper

Introduction : We evaluated the effect of chest compression fraction (CCF) on survival to hospital discharge and return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythms.

Méthode : This is a retrospective analysis (completed in 2016) of a prospective cohort study which included OHCA patients from ten U.S. and Canadian sites (Resuscitation Outcomes Consortium Epistry and PRIMED study (2007-2011)). We included all OHCA victims of presumed cardiac aetiology, not witnessed by emergency medical services (EMS), without automated external defibrillator shock prior to EMS arrival, receiving > 1 min of CPR with CPR process measures available, and initial non-shockable rhythm. We measured CCF using the first 5 min of electronic CPR records.

Résultats : Demographics of 12,928 adult patients were: mean age 68; male 59.9%; public location 8.5%; bystander witnessed 35.2%; bystander CPR 39.3%; median interval from 911 to defibrillator turned on 10 min:04 s; initial rhythm asystole 64.8%, PEA 26.0%, other non-shockable 9.2%; compression rate 80-120/min (69.1%); median CCF 74%; ROSC 25.6%; survival to hospital discharge 2.4%. Adjusted odds ratio (OR); 95% confidence intervals (95%CI) of survival for each CCF category were: 0-40% (2.00; 1.16, 3.32); 41-60% (0.83; 0.54, 1.24); 61-80% (1.02; 0.77, 1.35); and 81-100% (reference group). Adjusted (OR; 95%CI) of ROSC for each CCF category were: 0-40% (1.02; 0.79, 1.30); 41-60% (0.83; 0.72, 0.95); 61-80% (0.85; 0.77, 0.94); and 81-100% (reference group).

Conclusion : We observed an incremental benefit from higher CCF on the incidence of ROSC, but not survival, among non-shockable OHCA patients with CCF higher than 40%

Conclusion (proposition de traduction) : Nous avons observé un bénéfice supplémentaire d'une fraction de compression thoracique plus élevée sur l'incidence de retour à une circulation spontanée, mais pas sur la survie, chez les patients en arrêt cardiaque extra-hospitalier non choquable avec une fraction de compression thoracique supérieure à 40 %.

Commentaire : La fraction de compression thoracique (CCF) ou Fraction du flux est définie comme la proportion de temps passé à fournir des compressions thoraciques pendant que le patient est sans pouls et en arrêt cardiaque (c'est le pourcentage de temps de compression).
Elle est donc affectée par les interruptions des compressions thoraciques. La fraction de compression est améliorée si l'on réduit le nombre et la durée des interruptions des compressions.
L'objectif des recommandations en matière de réanimation cardiorespiratoire (RCR) et de soins d’urgence cardiovasculaire (SUC) de l’American Heart Association (AHA) de 2015 était d’obtenir une fraction de compression aussi élevée que possible, à savoir d’au moins 60 %, en réduisant au minimum les interruptions.

Lactate dehydrogenase levels predict coronavirus disease 2019 (COVID-19) severity and mortality: A pooled analysis.
Henry BM, Aggarwal G, Wong J, Benoit S, Vikse J, Plebani M, Lippi G. | Am J Emerg Med. 2020 Sep;38(9):1722-1726
DOI: https://doi.org/10.1016/j.ajem.2020.05.073  | Télécharger l'article au format  
Keywords: COVID-19; Coronavirus; Lactate dehydrogenase.

Original Contribution

Editorial : Coronavirus disease 2019 (COVID-19) infection has now reached a pandemic state, affecting more than a million patients worldwide. Predictors of disease outcomes in these patients need to be urgently assessed to decrease morbidity and societal burden. Lactate dehydrogenase (LDH) has been associated with worse outcomes in patients with viral infections. In this pooled analysis of 9 published studies (n = 1532 COVID-19 patients), we evaluated the association between elevated LDH levels measured at earliest time point in hospitalization and disease outcomes in patients with COVID-19. Elevated LDH levels were associated with a ~6-fold increase in odds of developing severe disease and a ~16-fold increase in odds of mortality in patients with COVID-19. Larger studies are needed to confirm these findings.

Conclusion : In our pooled analysis, elevated LDH values were associated with 6-fold increased odds of severe COVID-19 disease. More importantly, elevated LDH was associated with a N16-fold increase in odds of mortality. As such, patients'LDH should be closely monitored for any of signs of disease progression or decompensation. Since the LDH levels used in the study were at admission or earliest time during hospitalization, admission LDH levels could be considered for inclusion in future risk stratification models for COVID-19 severity and mortality. Larger studies are needed to confirm these findings.

Conclusion (proposition de traduction) : Dans notre analyse groupée, des valeurs élevées de LDH étaient associées à une probabilité multipliée par 6 de maladie grave à COVID-19. Plus important encore, une LDH élevée était associée à une multiplication par 16 de la probabilité de mortalité. En tant que tel, les taux de LDH des patients doit être étroitement surveillé pour déceler tout signe de progression de la maladie ou de décompensation. Étant donné que les taux de LDH utilisés dans l'étude étaient à l'admission ou au début de l'hospitalisation, les taux de LDH à l'admission pourraient être envisagés pour être inclus dans les futurs modèles de stratification des risques pour la gravité et la mortalité de la COVID-19. Des études plus importantes sont nécessaires pour confirmer ces résultats.

COVID-19 in health care workers - A systematic review and meta-analysis.
Sahu AK, Amrithanand VT, Mathew R, Aggarwal P, Nayer J, Bhoi S. | Am J Emerg Med. 2020 Sep;38(9):1727-1731
DOI: https://doi.org/10.1016/j.ajem.2020.05.113  | Télécharger l'article au format  
Keywords: Aucun

Original Contribution

Introduction : It is essential to know the proportion of health care workers (HCW) who are COVID 19 positive, as well as the severity and mortality among them.

Méthode : This systematic review was performed according to the Preferred Reporting Items for Systematic review and meta-analysis. Databases including PubMed, EMBASE and Web of Science were searched from December-31, 2019 to April-23, 2020. The search was limited to the studies that reported the data on the number of COVID-19 positive healthcare workers, among the COVID-19 positive patients. Case reports, duplicate publications, reviews, and family-based studies were excluded. The methodological quality of studies was assessed by the Appraisal tool for Cross-Sectional Studies (AXIS) tool.

Résultats : In this systematic review and meta-analysis, we pooled eleven studies to investigate the above factors. The overall proportion of HCW who were SARS-CoV-2 positive among all COVID-19 patients was 10.1% (95%CI: 5.3-14.9). This proportion varied according to the country of study i.e. China (7 studies) - 4.2%, 95%CI:2.4-6.0; United States (3 studies) - 17.8%, 95%CI:7.5-28.0; and Italy (1 study) - 9.0%, 95%CI:8.6-9.4. The incidence of severe or critical disease in HCW (9.9%, 95%CI:0.8-18.9) was significantly lower (p < 0.001) than the incidence of severe or critical disease in all COVID-19 positive patients (29.4%, 95%CI:18.6-40.2). Similarly, the mortality among HCW (0.3%, 95%CI:0.2-0.4) was also significantly lower (p < 0.001) as compared to that of all patients (2.3%, 95%CI:2.2-2.4).

Conclusion : Health care workers who are COVID-19 positive constituted a significant proportion of all COVID-19 patients; but the severity and mortality were lower among them.

Conclusion (proposition de traduction) : Les professionnels de santé qui sont positifs à la COVID-19 constituaient une proportion importante de tous les patients atteints de COVID-19 ; mais la gravité et la mortalité étaient plus faibles parmi eux.

Dog leash-related injuries treated at emergency departments.
Forrester MB | Am J Emerg Med. 2020 Sep;38(9):1782-1786
DOI: https://doi.org/10.1016/j.ajem.2020.05.082
Keywords: Dog leash; Emergency department; Injury.

Original Contribution

Introduction : Although dog ownership may provide health benefits, interactions with dogs and their leashes can result in injuries. The intent of this study was to describe dog leash-related injuries treated at United States (US) emergency departments (EDs).

Méthode : Cases were dog leash-related injuries during 2001-2018 reported to the National Electronic Injury Surveillance System (NEISS), from which national estimates of dog leash-related injuries treated at US EDs were calculated. The distribution of the cases and estimated number of dog leash-related injuries was determined for selected variables, such as the circumstances of the injury, patient demographics, and diagnosis.

Résultats : A dog leash was involved in 8189 injuries, resulting in a national estimate of 356,746 injuries and an estimated rate of 63.4 injuries per 1,000,000 population. Of these injuries, 193,483 resulted from a pull, 136,767 from a trip/tangle, and 26,496 from other or unknown circumstances. The total injury rate per 1,000,000 population increased from 25.4 in 2001 to 105.5 in 2018. Adults accounted for 314,712 (88.2%) of the patients; 260,328 (73.0%) of the patients were female. The injury occurred at home in 133,549 (37.4%) cases. The most common injuries were 95,677 (26.8%) fracture, 92,644 (26.0%) strain or sprain, and 62,980 (17.7%) contusions or abrasions.

Conclusion : The most common type of dog leash-related injuries resulted from a pull followed by a trip/tangle. The number of dog leash-related injuries increased during the time period. The majority of the persons sustaining such injuries were adults and female. Over one-third of the injuries occurred at home.

Conclusion (proposition de traduction) : Le type le plus courant de blessures liées à la laisse de chien résultait d'une traction suivie d'un trébuchement/enchevêtrement. Le nombre de blessures liées à la laisse de chien a augmenté au cours de la période. La majorité des personnes ayant subi de telles blessures étaient des adultes et des femmes. Plus du tiers des blessures sont survenues à domicile.

Commentaire : Les adultes représentaient 88,2 % des patients parmi lesquels 73 % étaient des femmes. La blessure est survenue à domicile dans 37,4 % des cas.
Les blessures les plus courantes étaient des fractures dans 26,8 % des cas, une foulure ou entorse dans 26 % des cas et une contusion ou une écorchure dans 17,7 % des cas.

Hemodynamic comparison of intravenous push diltiazem versus metoprolol for atrial fibrillation rate control.
Nicholson J, Czosnowski Q, Flack T, Pang PS, Billups K. | Am J Emerg Med. 2020 Sep;38(9):1879-1883
DOI: https://doi.org/10.1016/j.ajem.2020.06.034
Keywords: Atrial fibrillation; Diltiazem; Hemodynamics; Metoprolol; Rapid ventricular rate.

Original Contribution

Introduction : Intravenous push (IVP) diltiazem and metoprolol are commonly used for management of atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED). This study's objective was to determine if there was a significant difference in blood pressure reduction between agents.

Méthode : This was a single-center, retrospective study of adult patients initially treated with IVP diltiazem or metoprolol in the ED from 2008 to 2018. Primary endpoint was mean reduction in systolic blood pressure (SBP) from baseline to nadir during the study period. Study period was defined as time from first dose of IVP intervention to 30 min after last dose of IVP intervention or first dose of maintenance therapy, whichever came first.

Résultats : A total of 63 diltiazem patients and 45 metoprolol patients met eligibility criteria. Baseline characteristics were similar except for initial ventricular rate (VR) and home beta-blocker use. Median dose of initial intervention was 10 [10-20] mg and 5 [5-5] mg for diltiazem and metoprolol respectively. Mean SBP reduction was 18 ± 22 mmHg for diltiazem compared to 14 ± 15 mmHg for metoprolol (p = .33). Clinically relevant hypotension was similar between groups 14% vs. 16% (p = .86). Rate control was achieved in 35 (56%) of the diltiazem group and 16 (36%) of the metoprolol group (p = .04).

Conclusion : Intravenous push diltiazem and metoprolol caused similar systolic blood pressure reduction and hypotension when used for initial management of atrial fibrillation with rapid ventricular rate in the Emergency Department. However, rate control was achieved more often with diltiazem.

Conclusion (proposition de traduction) : Le diltiazem et le métoprolol par injection intraveineuse ont provoqué une réduction de la pression artérielle systolique similaire et une hypotension lorsqu'ils sont utilisés pour la prise en charge initiale de la fibrillation auriculaire avec fréquence ventriculaire rapide au service d'urgence. Cependant, le contrôle de la fréquence a été obtenu plus souvent avec le diltiazem.

Intradermal injection for hiccup therapy in the Emergency Department.
Kocak AO, Akbas I, Betos Kocak M, Akgol Gur ST, Cakir Z. | Am J Emerg Med. 2020 Sep;38(9):1935-1937
DOI: https://doi.org/10.1016/j.ajem.2020.03.044
Keywords: Aucun

Original contribution

Editorial : Hiccup is a condition caused by involuntary contraction of inspiratory muscles, especially the diaphragm. Although it is generally considered as a physiological. response, if hiccup persists for a long time, it can lead to many undesirable conditions such as depression, weight loss, insomnia, and fatigue. A 35-year-old male patient was admitted to our emergency department with hiccup lasting for 15 h. He had a history of several hiccup attacks. Classical non-pharmacological and pharmacological therapies were used to treat the condition without any response. As an alternative method, an intradermal injection was applied. A mixture of thiocolchicoside and lidocaine was administered intradermally to a depth of 1-3 mm at the epigastric region and adjacent to the sternocleidomastoid muscle. The patient's hiccup ended after the intradermal injection procedure. During 48 h of follow-up the hiccup attack did not develop again. No complications related to the process were detected.

Conclusion : This is the first case in the literature demonstrating the use of intradermal injection to terminate hiccups. The intradermal injection approach can be administered in cases of hiccups that do not respond to medical treatment.

Conclusion (proposition de traduction) : C'est le premier cas de la littérature démontrant l'utilisation de l'injection intradermique pour mettre fin au hoquet. L'approche par injection intradermique peut être administrée en cas de hoquet qui ne répond pas au traitement médical.

Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis.
Oliveira J E Silva L, Lee JY, Bellolio F, Homme JL, Anderson JL. | Am J Emerg Med. 2020 Sep;38(9):1860-1866
DOI: https://doi.org/10.1016/j.ajem.2020.05.094
Keywords: Aucun

Reviews

Introduction : To assess the efficacy and safety of intranasal analgesic-dose ketamine as compared to intranasal fentanyl for pediatric acute pain.

Méthode : A systematic review and meta-analysis was performed following the PRISMA guidelines. We searched PubMed, Embase, and Scopus databases for randomized controlled trials from inception to December 2019. We conducted meta-analysis with random-effects models to evaluate pain reduction, rescue analgesia, adverse events and sedation between intranasal ketamine and intranasal fentanyl. Random-effects models were used to estimate weighted mean differences (WMD) and pooled relative risks (RR).

Résultats : A total of 546 studies were screened and 4 trials were included. In the meta-analysis of 4 studies including 276 patients, ketamine had similar reductions in pain scores from baseline to all post-intervention times (10 to 15 min: WMD -1.42, 95% CI -9.95 to 7.10; 30 min: WMD 0.40, 95% CI -6.29 to 7.10; 60 min: WMD -0.64, 95% CI -6.76 to 5.47). Ketamine was associated with similar rates of rescue analgesia (RR 0.74, 95% CI 0.44 to 1.25). Ketamine had a higher risk of non-serious adverse events (RR 2.00, 95% CI 1.43 to 2.79), and no patients receiving ketamine had a serious adverse event. There was one serious adverse event (hypotension) with fentanyl that self-resolved. No patients receiving either IN fentanyl or ketamine had significant sedation.

Conclusion : Intranasal analgesic-dose ketamine may be considered as an alternative to opioids for acute pain management in children. Its accepted use will depend on the tolerability of non-serious adverse events and the desire to avoid opioids.

Conclusion (proposition de traduction) : La kétamine à dose analgésique intranasale peut être considérée comme une alternative aux opioïdes pour la gestion de la douleur aiguë chez les enfants. Son acceptabilité dépendra de la tolérance à la survenue d'événements indésirables non graves et du désir d'éviter les morphiniques.

Commentaire : Le dosage analgésique typique de kétamine est de 0,1 à 0,3 mg/kg par voie intraveineuse (IV), 0,5 mg/kg intramusculaire (IM) et 1 à 1,5 mg/kg intra-nasale; par rapport à une dose de sédation dissociative de 1 à 2 mg/kg IV, 3 à 4 mg/kg IM et 6 à 9 mg/kg par voie IN.
La posologie de fentanyl intra-nasale était de 1,5 à 2 µg/kg.

A review of guidelines on anticoagulation reversal across different clinical scenarios - Is there a general consensus?.
Milling TJ, Pollack CV. | Am J Emerg Med. 2020 Sep;38(9):1890-1903
DOI: https://doi.org/10.1016/j.ajem.2020.05.086  | Télécharger l'article au format  
Keywords: Anticoagulation reversal; Guidelines.

Reviews

Editorial : Anticoagulation is key to the treatment/prevention of thromboembolic events. The primary complication of anticoagulation is serious or life-threatening hemorrhage, which may necessitate prompt anticoagulation reversal; this could also be required for nonbleeding patients requiring urgent/emergent invasive procedures. The decision to reverse anticoagulation should weigh the benefit-risk ratio of supporting hemostasis versus post-reversal thrombosis. We appraise the available guidelines/recommendations for vitamin K antagonist (VKA) and direct oral anticoagulant (DOAC) reversal in the management of major bleeding, and also assess recent clinical data that may not yet be reflected in official guidance. In general, available guidelines are consistent in their recommendations, advocating administration of vitamin K and 4-factor prothrombin complex concentrates (4F-PCCs) rather than fresh frozen plasma to patients with VKA-associated intracranial hemorrhage and life-threatening bleeding, and specific reversal agents as essential therapy for DOAC reversal in those same severe conditions. However, guidelines also recommend off-label use of PCCs for DOAC reversal when specific reversal agents are unavailable. Limited recent evidence generally support the latter recommendation, but guidelines are likely to evolve as more data become available.

Conclusion : While VKAs have traditionally been the mainstay for anticoagulation, DOACs represent a major development in treating and preventing venous thromboembolic disease and in suppressing stroke risk in atrial fibrillation. Interest in DOAC therapy has increased significantly over time, with prescription claims rising from 15.4% to 31.0% of all oral anticoagulant claims between 2013 and 2015, according to US Medicare data. Google Trend data also indicate an increasing global interest in DOAC therapy; the greatest number of searches for dabigatran, rivaroxaban, and apixaban between 2012 and 2017 were conducted in North America, central/eastern Europe, and Australia. Interest in edoxaban was less pronounced and restricted to Germany, Japan, and the USA. Interest in warfarin therapy, in contrast to DOAC therapy, has decreased significantly over time.
A key issue with guidelines is that they become out of date as soon as they are published, due to the continuous publication of new clinical data. This is especially relevant for DOAC reversal, with several current guidelines published prior to the approval of andexanet alfa. Attempts are being made to update guidelines to address use of this agent. Recent clinical data support the use of 4F-PCC in VKA reversal and also DOAC reversal if specific agents are not available, while currently available clinical data on idarucizumab and andexanet alfa supports their use in specific DOAC reversal. It is likely that anticoagulation reversal guidelines will continue to evolve, particularly in the case of specific DOAC reversal agents, as more evidence becomes available on their appropriate use.

Conclusion (proposition de traduction) : Alors que les AVK ont traditionnellement été le pilier de l'anticoagulation, les AOD représentent un développement majeur dans le traitement et la prévention de la maladie thromboembolique veineuse et dans la suppression du risque d'accident vasculaire cérébral dans la fibrillation atrial. L'intérêt pour le traitement par AOD a augmenté de manière significative au fil du temps, avec des demandes de remboursement de médicaments sur ordonnance passant de 15,4 % à 31 % de toutes les demandes de remboursement d'anticoagulants oraux entre 2013 et 2015, selon les données de l'assurance maladie américaine (US Medicare). Les données de Google Trend indiquent également un intérêt mondial croissant pour le traitement par les AOD ; le plus grand nombre de recherches pour le dabigatran, le rivaroxaban et l'apixaban entre 2012 et 2017 ont été effectuées en Amérique du Nord, en Europe centrale et orientale et en Australie. L'intérêt pour l'edoxaban était moins prononcé et limité à l'Allemagne, au Japon et aux États-Unis. L'intérêt pour le traitement par la warfarine, contrairement au traitement par les AOD, a considérablement diminué au fil du temps.
L'un des principaux problèmes des recommandations est qu'elles deviennent obsolètes dès leur publication, en raison de la publication continue de nouvelles données cliniques. Ceci est particulièrement pertinent pour la réversion des AOD, plusieurs recommandations actuelles ayant été publiées avant l'approbation de l'andexanet alfa. Des tentatives sont en cours pour mettre à jour les recommandations relatives à l'utilisation de cet agent. Des données cliniques récentes proposent l'utilisation des concentrés de complexe prothrombinique contenant 4 facteurs de coagulation (ndlr : complexe prothrombique humain (PPSB) comme Octaplex, Confidex, Kanokad et Kaskadil) dans la réversion des AVK et également la réversion des AOD si des agents spécifiques ne sont pas disponibles, tandis que les données cliniques actuellement disponibles sur l'idarucizumab (ndlr : Praxbind, Boehringer Ingelheim) et l'andexanet alfa proposent leur utilisation dans la réversion spécifique des AOD. Il est probable que les directives relatives à la réversion de l'anticoagulation continueront d'évoluer, en particulier dans le cas des agents de réversion spécifiques des AOD, à mesure que l'on disposera de plus de preuves sur leur utilisation appropriée.

Esmolol in the management of pre-hospital refractory ventricular fibrillation: A systematic review and meta-analysis.
Miraglia D, Miguel LA, Alonso W. | Am J Emerg Med. 2020 Sep;38(9):1921-1934
DOI: https://doi.org/10.1016/j.ajem.2020.05.083
Keywords: Cardiopulmonary resuscitation; Esmolol; Out-of-hospital cardiac arrest; Pre-hospital cardiac arrest; Refractory ventricular fibrillation.

Reviews

Introduction : Esmolol has been proposed as a viable adjunctive therapy for pre-hospital refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).
Objectives: We performed a systematic review and meta-analysis to assess the effectiveness of esmolol on pre-hospital refractory VF/pVT, compared with standard of care.

Méthode : MEDLINE, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible studies. Two investigators independently extracted relevant data and assessed the methodological quality of each included study using the ROBINS-I tool. The quality of evidence for summary estimates was assessed according to GRADE guidelines. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) for each outcome of interest were calculated.

Résultats : The search yielded 3253 unique records, of which two studies were found to be in accordance with the research purpose, totaling 66 patients, of whom 33.3% (n = 22) received esmolol. Additional evidence was provided in the paper but was not relevant to the analysis and was therefore not included. Esmolol was likely associated with an increased rate of survival to discharge (RR 2.82, 95% CI 1.01-7.93, p = 0.05) (GRADE: Very low) and survival with favorable neurological outcome (RR 3.44, 95% CI 1.11-10.67, p = 0.03) (GRADE: Very low). Similar results were found for return of spontaneous circulation (ROSC) (RR 2.63, 95% CI 1.37-5.07, p = 0.004) (GRADE: Very low) and survival to intensive care unit (ICU)/hospital admission (RR 2.63, 95% CI 1.37-5.07, p = 0.004) (GRADE: Very low).

Conclusion : The effectiveness of esmolol for refractory VF/pVT remains unclear. Trial sequential analysis (TSA) indicates that the evidence is inconclusive and that further trials are required in order to reach a conclusion. Therefore, it is imperative to continue to accumulate evidence in order to obtain a higher level of scientific evidence.

Conclusion (proposition de traduction) : L'efficacité de l'esmolol dans la VF/pVT réfractaire reste incertaine. L'analyse séquentielle des essais (TSA) indique que les preuves ne sont pas concluantes et que d'autres essais sont nécessaires pour parvenir à une conclusion. Par conséquent, il est impératif de continuer à accumuler des preuves afin d'obtenir un niveau plus élevé de preuves scientifiques.

Acute pancreatitis.
Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA et al.. | Lancet. 2020 Sep;396(10252):726-734
DOI: https://doi.org/10.1016/S0140-6736(20)31310-6
Keywords: Aucun

SEMINAR

Editorial : Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.

The importance of visualization of appendix on abdominal ultrasound for the diagnosis of appendicitis in children: A quality assessment review.
Hamid MA, Afroz R, Ahmed UN, Bawani A, Khan D, Shahab R, Salim A. | World J Emerg Med. 2020;11(3):140-144
DOI: https://doi.org/10.5847/wjem.j.1920-8642.2020.03.002  | Télécharger l'article au format  
Keywords: Abdominal ultrasound; Visualization; Importance; Appendix; Abdominal pain; Acute appendicitis; Children; Paediatric population

Original Article

Introduction : Ultrasound has the first line investigation role in the diagnosis of acute appendicitis in children. The purpose of this study was to perform a quality assessment review on the visualization rate of appendix on ultrasound in children in the community hospital setting.

Méthode : A retrospective chart review of the abdominal ultrasound findings for the visualization of the appendix was performed on paediatric patients ranging from 5 to 18 years. Data were collected from the two community hospitals of Toronto by using hospital electronic medical record for the ultrasound findings in patients presented with abdominal pain.

Résultats : Data from two community hospitals indicated visualization rate of the appendix as 11.0% and 23.2% for site 1 and site 2 respectively. In cases where the ultrasound was repeated the visualization rate remains the same. A two-proportion z-test was performed to find whether the visualization of appendix increases the likelihood of diagnosing appendicitis. The results revealed that the visualization of an appendix (P=0.52), significantly improved the diagnosis of appendicitis (z=34, P<0.001).

Conclusion : Visualization of an appendix on ultrasound increases the likelihood of correctly diagnosing appendicitis. In our study, we found low visualization rate of appendix on ultrasound that could be the result of many factors that contribute towards the low visualization rate of an appendix on ultrasound. Hence, the challenges in identifying appendix should be minimized to improve the visualization and diagnosis of appendicitis on ultrasound.

Conclusion (proposition de traduction) : La visualisation d'un appendice à l'échographie augmente la probabilité de diagnostiquer correctement l'appendicite. Dans notre étude, nous avons trouvé un faible taux de visualisation de l'appendice à l'échographie qui pourrait être le résultat de nombreux facteurs contribuant au faible taux de visualisation d'un appendice à l'échographie.
Par conséquent, les défis liés à l'identification de l'appendice doivent être minimisés pour améliorer la visualisation et le diagnostic de l'appendicite à l'échographie.

Commentaire : Voir l'algorithme proposé pour explorer une douleur abdominale par échographie au point d'intervention en pédiatrie par :
Leviter J, Constantine E. Point-of-Care Ultrasound for Undifferentiated Abdominal Pain in a Pediatric Patient: A Proposed Algorithm. Pediatr Emerg Care. 2020 Sep;36(9):446–51  .