Bibliographie de Médecine d'Urgence

Mois d'octobre 2020


Academic Emergency Medicine

Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience.
Derkenne C, Jost D, Roquet F, Dardel P, Kedzierewicz R, Mignon A, Travers S, Frattini B, Prieux L, Rozenberg E, Demaison X, Gaudet J, de Charry F, Stibbe O, Briche F, Lemoine F, Lesaffre X, Maurin O, Gauyat E, Faraon E, Lemoine S, Prunet B. | Acad Emerg Med. 2020 Oct;27(10):951-962
DOI: https://doi.org/10.1111/acem.13987
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Out-of-hospital cardiac arrest (OHCA) remains associated with very high mortality. Accelerating the initiation of efficient cardiopulmonary resuscitation (CPR) is widely perceived as key to improving outcomes. The main goal was to determine whether identification and activation of nearby first responders through a smartphone application named Staying Alive (SA) can improve survival following OHCA in a large urban area (Paris).

Méthode : We conducted a nonrandomized cohort study of all adults with OHCA managed by the Greater Paris Fire Brigade during 2018, irrespective of mobile application usage. We compared survival data in cases where SA did or did not lead to the activation of nearby first responders. During dispatch, calls for OHCA were managed with or without SA. The intervention group included all cases where nearby first responders were successfully identified by SA and actively contributed to CPR. The control group included all other cases. We compared survival at hospital discharge between the intervention and control groups. We analyzed patient data, CPR metrics, and first responders' characteristics.

Résultats : Approximately 4,107 OHCA cases were recorded in 2018. Among those, 320 patients were in the control group, whereas 46 patients, in the intervention group, received first responder-initiated CPR. After adjustment for confounders, survival at hospital discharge was significantly improved for patients in the intervention group (35% vs. 16%, adjusted odds ratio = 5.9, 95% confidence interval = 2.1 to 16.5, p < 0.001). All CPR metrics were improved in the intervention group.

Conclusion : We report that mobile smartphone technology was associated with OHCA survival through accelerated initiation of efficient CPR by first responders in a large urban area.

Conclusion (proposition de traduction) : Nous rapportons que la technologie des smartphones mobiles était associée à la survie dans l'arrêt cardiaque extra-hospitalier grâce à l'initiation accélérée d'une RCP efficace par les premiers intervenants dans une grande zone urbaine.

Impact of Point-of-care Testing on Length of Stay of Patients in the Emergency Department: A Cluster-randomized Controlled Study.
Hausfater P, Hajage D, Bulsei J, Canavaggio P, Lafourcade A, Paquet AL, Arock M, Durand-Zaleski I, Riou B, Oueidat N. | Acad Emerg Med. 2020 Oct;27(10):974-983
DOI: https://doi.org/10.1111/acem.14072
Keywords: Aucun

Original contribution

Introduction : Crowding is a frequent concern in the emergency department (ED). Laboratory point-of-care testing (POCT) has been proposed to decrease patients' length of stay (LOS). Our objective was to determine whether an extended panel of POCT solutions could reduce LOS.

Méthode : This was a single-center, prospective, open-label, controlled cluster-randomized study. Blood test processing was randomized into 1-week inclusion periods: interventional arm (laboratory analyses performed on POCT analyzers implemented in the ED) or control arm (central laboratory). The primary endpoint was LOS of patients in the ED. Secondary endpoints were time to result (TTR), ED crowding surrogates, and average total cost of an ED visit in each arm.

Résultats : A total of 23,231 patients were included and 20,923 were analyzed for the main outcome measure. Mean ± SD age was 46 ± 20 years, and 7,905 (36%) underwent blood sampling. Mean ± SD LOSs were 203 ± 161 and 210 ± 168 minutes in the POCT and control arms, respectively. LOS reduction for the entire ED population was -9 minutes (95% confidence interval [CI] = -22 to 5, p = 0.22) compared to the control arm and -17 minutes (95% CI = -34.0 to 0.6, p = 0.06) for patients undergoing blood sampling. The mean ± SD TTRs were 28 ± 31 and 79 ± 34 minutes in the POCT and control arms, respectively (TTR reduction = -51 minutes, 95% CI = -54 to -48 minutes, p < 0.001).

Conclusion : The implementation of an extended panel of POCT solutions in an ED did not significantly reduce the LOS, but reduced the TTR.

Conclusion (proposition de traduction) : La mise en œuvre d'un panel élargi de solutions de test au point d'intervention dans un service d'urgence n'a pas réduit de manière significative la durée du séjour, mais a réduit le délai d'obtention des résultats.

Intravenous Magnesium Sulfate for Acute Asthma Exacerbation in Adults.
Conway J, Friedman B. | Acad Emerg Med. 2020 Oct;27(10):1061-1063
DOI: https://doi.org/10.1111/acem.14066  | Télécharger l'article au format  
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Asthma is a common chronic respiratory disease withacute exacerbations recognized clinically by the signsand symptoms of dyspnea, cough, chest tightness, andwheezing. In the United States approximately 25 million individuals currently have asthma, and in 2017, asthma exacerbations accounted for approximately 1.8 million emergency department (ED) visits and 3,500 deaths. Acute asthma exacerbations range in severity from mild to deadly. The first-line medications for the treatment of asthma exacerbations in the ED are oxygen (as needed to maintain arterial oxygen saturation of 93%–95%), short-acting beta2-agonists, and systemic corticosteroids, with ipratropium bromide being recommended for severe exacerbations. In cases of treatment failure or severe exacerbations, some studies have recommended intravenous (IV) magnesium sulfate. Magnesium is believed to treat asthma exacerbations through numerous mechanisms including direct smooth muscle relaxation, an anti-inflammatory effect, and by blocking calcium ion influx into bronchial smooth muscle. The goal of the systematic review summarized here is to provide an updated review of the safety and efficacy of IV magnesium sulfate in the treatment of moderate to severe asthma exacerbations in the ED.

Conclusion : In summary, for adults presenting to the ED with moderate to severe asthma exacerbations, IV magnesium sulfate therapy used as an adjunct to routine treatment (oxygen, short-acting beta-agonists, and systemic corticosteroids) or when these treatments fail, reduces the need for hospitalization and likely has minimal adverse events. Therefore, we have assigned a color recommendation of green (benefits > harm) tothis treatment.

Conclusion (proposition de traduction) : En résumé, chez l'adulte se présentant au service des urgences pour une exacerbation d'asthme modérée à sévère, un traitement IV par sulfate de magnésium utilisé en complément d'un traitement de routine (oxygène, bêta-agonistes à courte durée d'action et corticostéroïdes systémiques) ou lorsque ces traitements échouent, réduit le besoin d'hospitalisation et a probablement des événements indésirables minimes. Par conséquent, nous avons attribué une recommandation de couleur verte (bénéfices > dommages) à ce traitement.

Allergology International

Japanese guidelines for adult asthma 2020.
Nakamura Y, Tamaoki J, Nagase H, Yamaguchi M, Horiguchi T, Hozawa S, Ichinose M, Iwanaga T, Kondo R, Nagata M, Yokoyama A, Tohda Y; Japanese Society of Allergology. | Allergol Int. 2020 Oct;69(4):519-548
DOI: https://doi.org/10.1016/j.alit.2020.08.001  | Télécharger l'article au format  
Keywords: Definition of asthma; Diagnosis of asthma; Epidemiology of asthma; Long-term management of asthma; Management of asthma exacerbation

Invited Review Article

Editorial : Bronchial asthma is characterized by chronic airway inflammation, which manifests clinically as variable airway narrowing (wheezes and dyspnea) and cough. Long-standing asthma may induce airway remodeling and become intractable. The prevalence of asthma has increased; however, the number of patients who die from it has decreased (1.3 per 100,000 patients in 2018). The goal of asthma treatment is to control symptoms and prevent future risks. A good partnership between physicians and patients is indispensable for effective treatment. Long-term management with therapeutic agents and the elimination of the triggers and risk factors of asthma are fundamental to its treatment. Asthma is managed by four steps of pharmacotherapy, ranging from mild to intensive treatments, depending on the severity of disease; each step includes an appropriate daily dose of an inhaled corticosteroid, which may vary from low to high. Long-acting β2-agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonists are recommended as add-on drugs, while anti-immunoglobulin E antibodies and other biologics, and oral steroids are reserved for very severe and persistent asthma related to allergic reactions. Bronchial thermoplasty has recently been developed for severe, persistent asthma, but its long-term efficacy is not known. Inhaled β2-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and other approaches are used as needed during acute exacerbations, by selecting treatment steps for asthma based on the severity of the exacerbations. Allergic rhinitis, eosinophilic chronic rhinosinusitis, eosinophilic otitis, chronic obstructive pulmonary disease, aspirin-exacerbated respiratory disease, and pregnancy are also important conditions to be considered in asthma therapy.

Conclusion : The aim of asthma management and treatment is symptomcontrol and the prevention of future risks. Thus, it isimportant to alleviate airway inflammation and fully dilate theconstricted airway by eliminating the inducers of airway inflam-mation and adopting pharmacotherapy. In this way, respiratoryfunction can be normalized to improve patients' quality of life (QoL)and enable normal and healthy living.

Conclusion (proposition de traduction) : Le but de la prise en charge et du traitement de l'asthme est le contrôle des symptômes et la prévention des risques futurs.
Ainsi, il est important de soulager l'inflammation des voies respiratoires et de dilater complètement la bronchoconstriction des voies aériennes en éliminant les inducteurs de l'inflammation des voies respiratoires et en adoptant une pharmacothérapie. De cette manière, la fonction respiratoire peut être normalisée pour améliorer la qualité de vie des patients (QoL) et permettre une vie normale et saine.

Annals of Emergency Medicine

Outcome of Immediate Versus Early Antibiotics in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis.
Rothrock SG, Cassidy DD, Barneck M, Schinkel M, Guetschow B, Myburgh C, Nguyen L, Earwood R, Nanayakkara PWB, Nannan Panday RS, Briscoe JG. | Ann Emerg Med. 2020 Oct;76(4):427-441
DOI: https://doi.org/10.1016/j.annemergmed.2020.04.042
Keywords: Aucun

Infectious Disease

Introduction : Debate exists about the mortality benefit of administering antibiotics within either 1 or 3 hours of sepsis onset. We performed this meta-analysis to analyze the effect of immediate (0 to 1 hour after onset) versus early (1 to 3 hours after onset) antibiotics on mortality in patients with severe sepsis or septic shock.

Méthode : This review was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searched databases included PubMed, EMBASE, Web of Science, and Cochrane Library, as well as gray literature. Included studies were conducted with consecutive adults with severe sepsis or septic shock who received antibiotics within each period and provided mortality data. Data were extracted by 2 independent reviewers and pooled with random effects. Two authors independently assessed quality of evidence across all studies with Cochrane's Grading of Recommendations Assessment, Development and Evaluation methodology and risk of bias within each study, using the Newcastle-Ottawa Scale.

Résultats : Thirteen studies were included: 5 prospective longitudinal and 8 retrospective cohort ones. Three studies (23%) had a high risk of bias (Newcastle-Ottawa Scale). Overall, quality of evidence across all studies (Grading of Recommendations Assessment, Development and Evaluation) was low. Pooling of data (33,863 subjects) showed no difference in mortality between patients receiving antibiotics in immediate versus early periods (odds ratio 1.09; 95% confidence interval 0.98 to 1.21). Analysis of severe sepsis studies (8,595 subjects) found higher mortality in immediate versus early periods (odds ratio 1.29; 95% confidence interval 1.09 to 1.53).

Conclusion : We found no difference in mortality between immediate and early antibiotics across all patients. Although the quality of evidence across studies was low, these findings do not support a mortality benefit for immediate compared with early antibiotics across all patients with sepsis.

Conclusion (proposition de traduction) : Nous n'avons trouvé aucune différence en terme de mortalité entre l'antibiothérapie immédiate et précoce chez tous les patients. Bien que la qualité des preuves entre les études soit faible, ces résultats ne soutiennent pas un bénéfice de mortalité immédiat par rapport à l'antibiothérapie précoce chez tous les patients présentant une septicémie.

Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.
Baugh CW, Levine M, Cornutt D, Wilson JW, Kwun R, Mahan CE, Pollack CV Jr, Marcolini EG, Milling TJ Jr, Peacock WF, Rosovsky RP, Wu F, Sarode R, Spyropoulos AC, Villines TC, Woods TD, McManus J, Williams J. | Ann Emerg Med. 2020 Oct;76(4):470-485
DOI: https://doi.org/10.1016/j.annemergmed.2019.09.001  | Télécharger l'article au format  
Keywords: Aucun

General Medicine

Editorial : Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

Conclusion : In conclusion, we developed a multidisciplinary anticoagulant reversal and replacement guidance statement supported by literature and consensus definitions to support evaluation and treatment of the bleeding patient and nonbleeding patient requiring emergency invasive procedures. Emergency physicians encounter a majority of anticoagulation-associated hemorrhages and should be supported by hospital resources to rapidly deploy evidence- based treatments. New resources such as reversal and replacement agents offer more treatment options but increase the complexity of treatment decisions. Further research is needed to answer key questions that could further clarify the role of specific reversal or replacement agent treatment regimens to aid targeting of therapies to where they have the most clinical influence.

Conclusion (proposition de traduction) : En conclusion, nous proposons un guide d'orientation multidisciplinaire sur la réversion et la correction de l'anticoagulation, conforme à la littérature et aux définitions consensuelles, pour supporter l'évaluation et le traitement du patient hémorragique et du patient non hémorragique nécessitant des procédures invasives d'urgence.
Les médecins urgentistes sont confrontés majoritairement à des hémorragies associées à l'utilisation des anticoagulants et devraient pouvoir disposer des moyens hospitalières pour déployer rapidement les traitements fondés sur des données probantes. De nouvelles ressources telles que les agents de réversion et de correction offrent plus d'options de traitement mais augmentent la complexité des décisions de traitement. Des recherches supplémentaires sont nécessaires pour répondre aux questions clés qui pourraient clarifier davantage le rôle des schémas thérapeutiques spécifiques de réversion ou de correction pour aider à cibler les thérapeutiques là où elles ont le plus d'influence clinique.

BMC Emergency Medicine

Ketamine-propofol (Ketofol) for procedural sedation and analgesia in children: a systematic review and meta-analysis.
Foo TY, Mohd Noor N, Yazid MB, Fauzi MH, Abdull Wahab SF, Ahmad MZ. | BMC Emerg Med. 2020 Oct 8;20(1):81
DOI: https://doi.org/10.1186/s12873-020-00373-4  | Télécharger l'article au format  
Keywords: Children; Ketamine-propofol; Ketofol; Meta-analysis; Paediatric; Procedural sedation and analgesia; Systematic review.

Research article

Introduction : The aim of this review is to elucidate the efficacy and side effects of ketofol in comparison to other anaesthetic agents during procedural sedation and analgesia.

Méthode : The Cochrane Central Register of Controlled Trials (1996 to Feb 2019) and MEDLINE (1966 to Feb 2019) were searched, including the related randomised control trials and reviewed articles to find unpublished trials or trials not obtained via electronic searches. Inclusion criteria for the studies included comparing recovery time, recording clinician satisfaction, and assessing the adverse effects of ketofol.

Résultats : Eleven trials consisting of a total of 1274 patients met our criteria and were included in this meta-analysis. Five trials compared ketofol with a single agent, while six trials compared ketofol with combined agents. While comparing between ketofol and a single agent (either ketamine or propofol), ketofol showed significant effect on recovery time (MD: -9.88, 95% CI: - 14.30 to - 5.46; P = 0.0003; I2 = 92%). However, no significant difference was observed while comparing ketofol with combined agents (RR: 0.75, 95% CI: - 6.24 to 7.74; P < 0.001; I2 = 98%). During single-agent comparison, ketofol showed no significant differences in terms of clinician satisfaction (RR: 2.86, 95% CI: 0.64 to 12.69; P = 0.001; I2 = 90%), airway obstruction (RR: 0.72, 95% CI: 0.35 to 11.48; P = 0.81; I2 = 0%), apnoea (RR: 0.9, 95% CI: 0.33 to 2.44; P = 0.88; I2 = 0%), desaturation (RR: 1.11, 95% CI: 0.64 to 1.94; P = 0.28; I2 = 21%), nausea (RR: 0.52, 95% CI: 0.91 to 1.41; P = 0.2; I2 = 38%), and vomiting (RR: 0.63, 95% CI: 0.25 to 1.61; P = 0.18; I2 = 42%). During comparison with combined agents, ketofol was more effective in reducing hypotension (RR: 4.2, 95% CI: 0.2 to 0.85; P = 0.76; I2 = 0%), but no differences were observed in terms of bradycardia (RR: 0.70, 95% CI: 0.14 to 03.63; P = 0.09; I2 = 53%), desaturation (RR: 1.9, 95% CI: 0.15 to 23.6; P = 0.11; I2 = 61%), and respiratory depression (RR: 1.98, 95% CI: 0.18 to 21.94; P = 0.12; I2 = 59%).

Conclusion : There is low certainty of evidence that ketofol improves recovery time and moderate certainty of evidence that it reduces the frequency of hypotension. There was no significant difference in terms of other adverse effects when compared to other either single or combined agents.

Conclusion (proposition de traduction) : Il y a une faible certitude des preuves que le kétofol améliore le temps de récupération et une certitude modérée des preuves qu'il réduit la fréquence de l'hypotension. Il n'y avait pas de différence significative en termes d'autres effets indésirables par rapport à d'autres agents uniques ou combinés.

Early detection of non-invasive ventilation failure among acute respiratory failure patients in the emergency department.
Liengswangwong W, Yuksen C, Thepkong T, Nakasint P, Jenpanitpong C. | BMC Emerg Med. 2020 Oct 7;20(1):80
DOI: https://doi.org/10.1186/s12873-020-00376-1  | Télécharger l'article au format  
Keywords: NIV failure; Predictive score.

Research article

Introduction : Non-invasive mechanical ventilation (NIV) has become an alternative to an invasive artificial airway for the management of acute respiratory failure (ARF). NIV failure causes delayed intubation, which eventually has been associated with increased morbidity and mortality. This study aimed to develop the clinical scoring system of NIV failure in ARF patients.

Méthode : This study was a diagnostic, retrospectively cross-sectional, and exploratory model at the Emergency Medicine Department in Ramathibodi Hospital between February 2017 and December 2017. We included all of the acute respiratory failure patients aged > 18 years and received non-invasive ventilation (NIV). Clinical factors associated with NIV failure were recorded. The predictive model and prediction score for NIV failure were developed by multivariable logistic regression analysis.

Résultats : A total of 329 acute respiratory failure patients have received NIV success (N = 237) and failure (N = 92). This study showed that NIV failure was associated with heart rate > 110 bpm, systolic BP < 110 mmHg, SpO2 < 90%, arterial pH < 7.30 and serum lactate. The clinical scores were classified into three groups: low, moderate, and high.

Conclusion : We suggested that the novel clinical scoring of the NIV failure in this study may use as a good predictor for NIV failure in the emergency room.

Conclusion (proposition de traduction) : Nous suggérons que le nouveau score clinique de l'échec de la VNI dans cette étude puisse être utilisé comme un bon prédicteur de l'échec de la VNI dans le service des urgences.

Prehospital naloxone administration – what influences choice of dose and route of administration?.
Tylleskar I, Gjersing L, Bjørnsen LP, Braarud AC, Heyerdahl F, Dale O, Skulberg AK. | BMC Emerg Med. 2020 Sep 5;20(1):71
DOI: https://doi.org/10.1186/s12873-020-00366-3  | Télécharger l'article au format  
Keywords: Administration and dosage; Drug Administration Routes; Drug Overdose/drug therapy; Emergency medical services; Heroin; Mortality; Naloxone.

Research article

Introduction : Amidst the ongoing opioid crisis there are debates regarding the optimal route of administration and dosages of naloxone. This applies both for lay people administration and emergency medical services, and in the development of new naloxone products. We examined the characteristics of naloxone administration, including predictors of dosages and multiple doses during patient treatment by emergency medical service staff in order to enlighten this debate.

Méthode : This was a prospective observational study of patients administered naloxone by the Oslo City Center emergency medical service, Norway (2014-2018). Cases were linked to The National Cause of Death Registry. We investigated the route of administration and dosage of naloxone, clinical and demographic variables relating to initial naloxone dose and use of multiple naloxone doses and one-week mortality.

Résultats : Overall, 2215 cases were included, and the majority (91.9%) were administered intramuscular naloxone. Initial doses were 0.4 or 0.8 mg, and 15% of patients received multiple dosages. Unconscious patients or those in respiratory arrest were more likely to be treated with 0.8 mg naloxone and to receive multiple doses. The one-week mortality from drug-related deaths was 4.1 per 1000 episodes, with no deaths due to rebound opioid toxicity.

Conclusion : Intramuscular naloxone doses of 0.4 and 0.8 mg were effective and safe in the treatment of opioid overdose in the prehospital setting. Emergency medical staff appear to titrate naloxone based on clinical presentation.

Conclusion (proposition de traduction) : Des doses intramusculaires de naloxone de 0,4 et 0,8 mg se sont révélées efficaces et sûres dans le traitement du surdosage de morphiniques en milieu préhospitalier. Le personnel médical d'urgence semble titrer la naloxone en fonction de la présentation clinique.

Circulation

Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ; Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups. | Circulation. 2020 Oct 20;142(16_suppl_2):S337-S357
DOI: https://doi.org/10.1161/cir.0000000000000918  | Télécharger l'article au format  
Keywords: aha scientific statements

REVIEW ARTICLE

Editorial : The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care provides a comprehensive review of evidence-based recommendations for resuscitation and emergency cardiovascular care. The initial guidelines for CPR were published in 1966 by an ad hoc CPR Committee of the Division of Medical Sciences, National Academy of Sciences—National Research Council.1 This occurred in response to requests from several organizations and agencies about the need for standards and guidelines regarding training and response.

Conclusion : Cardiac arrest remains a condition with considerable morbidity and mortality that broadly affects individuals across age, gender, race, geography, and socioeconomic status. Although there have been modest improvements in survival, there is still considerable work to be done to address the significant burden of this disease. This executive summary provides an overview of new or updated recommendations that are based on rigorous evidence evaluations and included in the 2020 Guidelines.
To continue to make progress toward addressing this condition over the next decade will require further strengthening the Chain of Survival and enhancing coordinated systems of care. Knowledge gaps identified in the 2020 Guidelines point to critically important research questions that should be addressed and that represent opportunities for funding the future trajectory of resuscitation science. Developing guidelines is an important initial step that can advance efforts that will ultimately result in improved outcomes for patients.

Conclusion (proposition de traduction) : L'arrêt cardiaque reste une maladie avec une morbidité et une mortalité considérables qui affecte largement les individus de tout âge, sexe, race, géographie et statut socio-économique. Même si la survie s’est légèrement améliorée, il reste encore beaucoup à faire pour réduire le poids important imputable à cette maladie. Ce sommaire donne un aperçu des nouvelles recommandations ou mises à jour qui reposent sur des évaluations rigoureuses des données probantes et qui sont incluses dans les Lignes directrices de 2020.
Pour continuer à faire des progrès dans la lutte contre cette maladie au cours de la prochaine décennie, iil faudra renforcer davantage la chaîne de survie et améliorer la coordination des systèmes de soins. Les lacunes dans les connaissances identifiées dans les Lignes directrices 2020 mettent en évidence des questions de recherche d'une importance cruciale qui devraient être abordées et qui représentent des possibilités de financement de la trajectoire future de la science de la réanimation. L'élaboration de lignes directrices est une première étape importante qui peut faire progresser les efforts qui aboutiront finalement à de meilleurs résultats pour les patients.

Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, Donoghue A, Berg KM, Lee HC, Raymond TT, Lavonas EJ. . | Circulation. 2020 Oct 20;142(16_suppl_2):S358-S365
DOI: https://doi.org/10.1161/cir.0000000000000898  | Télécharger l'article au format  
Keywords: aha scientific statements; cardiac arrest; evidence evaluation

REVIEW ARTICLE

Editorial : The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.

Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O'Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; Adult Basic and Advanced Life Support Writing Group. | Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468
DOI: https://doi.org/10.1161/cir.0000000000000916  | Télécharger l'article au format  
Keywords: aha scientific statements; apnea; cardiopulmonary; defibrillators; delivery; electric countershock; of health care; resuscitation

RESEARCH ARTICLE

Editorial : These guidelines contain recommendations for basic life support (BLS) and advanced life support (ALS) for adult patients and are based on the best available resuscitation science. The Chain of Survival, introduced in Major Concepts, is now expanded to emphasize the important component of survivorship during recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from lay rescuers, emergency dispatchers, and first responders. In addition, specific recommendations about the training of resuscitation providers are provided in “Part 6: Resuscitation Education Science,” and recommendations about systems of care are provided in “Part 7: Systems of Care.”

Conclusion : Top 10 Take-Home Messages for Adult Cardiovascular Life Support
1. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR).
2. Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions,
3. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia.
4. Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms.
5. Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery).
6. The opioid epidemic has resulted in an increase in opioid-associated out-of-hospital cardiac arrest, with the mainstay of care remaining the activation of the emergency response systems and performance of high-quality CPR.
7. Post–cardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system that requires consistent implementation for optimal patient outcomes.
8. Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome.
9. Accurate neurological prognostication in brain-injured cardiac arrest survivors is critically important to ensure that patients with significant potential for recovery are not destined for certain poor outcomes due to care withdrawal.
10. Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to optimize transitions of care to home and to the outpatient setting.

Conclusion (proposition de traduction) : Top 10 des message à retenir pour la réanimation cardiovasculaire de l'adulte
1. Lorsqu’un ACR est reconnu, un témoin doit simultanément et rapidement activer le système d’intervention d’urgence et débuter une réanimation cardiopulmonaire.
2. La performance de la RCP de haute qualité inclut une profondeur et une vitesse de compression adéquates tout en minimisant les pauses dans les compressions,
3. Une défibrillation précoce accompagnée d’une RCP de haute qualité est essentielle à la survie lorsque l’ACR est causé par une fibrillation ventriculaire ou une tachycardie ventriculaire sans pouls.
4. L’administration concomitante d’adrénaline et de RCP de haute qualité améliore la survie, en particulier chez les patients dont le rythme cardiaque n’est pas choquable.
5. Il est essentiel de reconnaître que tous les ACR ne sont pas identiques pour obtenir des résultats optimaux, et une prise en charge spécialisée est nécessaire pour de nombreuses affections (anomalies électrolytiques, grossesse, post-chirurgie cardiaque).
6. L’épidémie d’opioïdes a entraîné une augmentation du nombre d’ACR extra-hospitaliers associés aux opioïdes, le principal pilier des soins demeurant l’activation des systèmes d’intervention d’urgence et la prestation d’une RCP de haute qualité.
7. Les soins post-ACR sont une composante essentielle de la chaîne de survie et exigent un système global, structuré et multidisciplinaire qui exige une mise en oeuvre cohérente pour obtenir des résultats optimaux pour les patients.
8. Pour tous les patients inconscient après un retour à une circulation spontanée, il est nécessaire de mettre en place rapidement une gestion ciblée de la température afin de garantir un résultat fonctionnel et neurologique optimal.
9. Une évaluation du pronostic neurologique précis chez les survivants à un ACR causé par une atteinte cérébrale est d'une importance capitale pour garantir que les patients ayant un potentiel de guérison important ne soient pas voués à de mauvais résultats en raison d'un arrêt des soins.
10. Les attentes en matière de récupération et de stratégies de survie qui traitent du traitement, de la surveillance et de la réadaptation doivent être exposés aux survivants d'arrêts cardiaques et aux soignants de ville à la sortie de l'hôpital afin d'optimiser la transition des soins du domicile et ambulatoire.

Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL Jr, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM; Pediatric Basic and Advanced Life Support Collaborators. | Circulation. 2020 Oct 20;142(16_suppl_2):S469-S523
DOI: https://doi.org/10.1161/cir.0000000000000901  | Télécharger l'article au format  
Keywords: aha scientific statements; arrhythmia; cardiac arrest care; cardiopulmonary; defibrillation; heart arrest; pediatrics; post; resuscitation

REVIEW ARTICLE

Editorial : These guidelines contain recommendations for pediatric basic and advanced life support, excluding the newborn period, and are based on the best available resuscitation science. The Chain of Survival (Section 2), which is now expanded to include recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from bystanders, emergency dispatchers, and first responders. In addition, specific recommendations about the training of resuscitation providers are provided in Part 6: Resuscitation Education Science, and recommendations about systems of care are provided in Part 7.

Conclusion : Top 10 Take-Home Messages
1. High-quality cardiopulmonary resuscitation (CPR) is the foundation of resuscitation. New data reaffirm the key components of high-quality CPR: providing adequate chest compression rate and depth, minimizing interruptions in CPR, allowing full chest recoil between compressions, and avoiding excessive ventilation.
2. A respiratory rate of 20 to 30 breaths per minute is new for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse.
3. For patients with nonshockable rhythms, the earlier epinephrine is administered after CPR initiation, the more likely the patient is to survive.
4. Using a cuffed endotracheal tube decreases the need for endotracheal tube changes.
5. The routine use of cricoid pressure does not reduce the risk of regurgitation during bag-mask ventilation and may impede intubation success.
6. For out-of-hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions such as endotracheal intubation.
7. Resuscitation does not end with return of spontaneous circulation (ROSC). Excellent post–cardiac arrest care is critically important to achieving the best patient outcomes. For children who do not regain consciousness after ROSC, this care includes targeted temperature management and continuous electroencephalography monitoring. The prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia is important.
8. After discharge from the hospital, cardiac arrest survivors can have physical, cognitive, and emotional challenges and may need ongoing therapies and interventions.
9. Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest.
10. Fluid resuscitation in sepsis is based on patient response and requires frequent reassessment. Balanced crystalloid, unbalanced crystalloid, and colloid fluids are all acceptable for sepsis resuscitation. Epinephrine or norepinephrine infusions are used for fluid-refractory septic shock.

Conclusion (proposition de traduction) : Top 10 des messages à emporter
1. La réanimation cardio-pulmonaire (RCP) de haute qualité est le fondement de la réanimation. De nouvelles données réaffirment les éléments clés d'une RCP de haute qualité : fournir une fréquence et une profondeur de compression thoracique adéquats, minimiser les interruptions de la RCP, permettre une décompression thoracique complète entre les compressions et éviter une ventilation excessive.
2. Une fréquence respiratoire de 20 à 30 ventilations par minute est dorénavant recommandée pour les nourrissons et les enfants qui bénéficient d'une RCP avec une gestion spécialisée des voies aériennes ou bénéficient d'une ventilation artificielle et ont un pouls.
3. Pour les patients ayant un rythme non choquable, plus l'adrénaline est administrée tôt après le début de la RCP, plus le patient a de chances de survivre.
4. L'utilisation d'une sonde endotrachéale à ballonnet réduit la nécessité de changer la sonde endotrachéale.
5. L'utilisation systématique de la pression cricoïde ne réduit pas le risque de régurgitation pendant la ventilation au BAVU et peut nuire au succès de l'intubation.
6. Pour les ACR extra-hospitaliers, la ventilation au BAVU donne les mêmes résultats de réanimation que la gestion spécialisée des voies aériennes telles que l'intubation endotrachéale.
7. La réanimation ne se termine pas avec la reprise d'activité cardiaque spontanée (RACS). D'excellents soins post-arrêt cardiaque sont d'une importance cruciale pour obtenir les meilleurs résultats pour les patients. Pour les enfants qui ne reprennent pas conscience après une RACS, cette prise en charge comprend une gestion ciblée de la température et une surveillance électroencéphalographique continue. La prévention et/ou le traitement de l'hypotension, de l'hyperoxie ou de l'hypoxie et de l'hypercapnie ou de l'hypocapnie sont importants.
8. Après leur sortie de l'hôpital, les survivants d'un arrêt cardiaque peuvent avoir des difficultés physiques, cognitives et émotionnelles et peuvent avoir besoin de traitements et d'interventions continues.

Commentaire : 9. La naloxone peut réverser l'arrêt respiratoire dû à un surdosage d'opioïdes, mais rien ne prouve qu'elle profite aux patients en ACR.
10. La réanimation liquidienne en cas de septicémie est basée sur la réponse du patient et nécessite une réévaluation fréquente. Les liquides cristalloïdes équilibrés, cristalloïdes simples et colloïdes sont tous acceptables pour la réanimation du sepsis. Les perfusions d'adrénaline ou de noradrénaline sont utilisées dans le choc septique réfractaire au remplissage.

Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. | Circulation. 2020 Oct 20;142(16_suppl_2):S524-S550
DOI: https://doi.org/10.1161/cir.0000000000000902  | Télécharger l'article au format  
Keywords: 2020 american heart association; aha scientific statements; cardiopulmonary resuscitation; neonatal resuscitation; neonate

REVIEW ARTICLE

Editorial : Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of resuscitation providers, and implementation of effective and timely resuscitation.8 The 2020 neonatal guidelines contain recommendations, based on the best available resuscitation science, for the most impactful steps to perform in the birthing room and in the neonatal period. In addition, specific recommendations about the training of resuscitation providers and systems of care are provided in their respective guideline Parts.

Conclusion : Top 10 Take-Home Messages for Neonatal Life Support
1. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams.
2. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth.
3. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth.
4. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions.
5. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals.
6. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation.
7. The heart rate response to chest compressions and medications should be monitored electrocardiographically.
8. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route.
9. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion.
10. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family.

Conclusion (proposition de traduction) : Top 10 des messages importants pour réanimation néonatale
1. La réanimation néonatale nécessite une anticipation et une préparation de la part des intervenants qui se forment individuellement et en équipe.
2. La plupart des nouveau-nés ne nécessitent pas de clampage du cordon ou de réanimation immédiats et peuvent être évalués et surveillés lors d'un contact peau à peau avec leur mère après la naissance.
3. L'oxygénation et la ventilation des poumons sont la priorité chez les nouveau-nés qui ont besoin d'une réanimation après la naissance.
4. Une augmentation de la fréquence cardiaque est l'indicateur le plus important d'une ventilation et d'une réponse efficaces aux interventions de réanimation.
5. L'oxymétrie de pouls est utilisée pour guider l'oxygénothérapie et atteindre les objectifs de saturation en oxygène.
6. Des compressions thoraciques sont effectuées en cas de mauvaise réponse de la fréquence cardiaque à la ventilation après des étapes correctives de ventilation appropriées, qui comprennent de préférence une intubation endotrachéale.
7. La réponse de la fréquence cardiaque aux compressions thoraciques et aux médicaments doit être surveillée par électrocardiographie. 8. Si la réponse aux compressions thoraciques est faible, il peut être raisonnable de fournir de l'adrénaline, de préférence par voie intraveineuse.
9. L'absence de réponse à l'adrénaline chez un nouveau-né avec des antécédents ou un examen compatible avec une perte de sang peut nécessiter une augmentation du volume (ndlr ,: par remplissage).
10. Si toutes ces étapes de réanimation sont effectivement terminées et qu'il n'y a pas de réponse de la fréquence cardiaque dans les 20 minutes, la réorientation des soins (ndlr : cad arrêt de la réanimation) doit être discutée avec l'équipe et la famille.

Commentaire : Oxygénothérapie du nouveau-né :
La ventilation à pression positive peut être initiée avec de l'air (21 % d'oxygène) chez les bébés à terme et prématurés tardifs, et jusqu'à 30 % d'oxygène chez les bébés prématurés.
L'oxymétrie est utilisée pour cibler la plage naturelle des niveaux de saturation en oxygène qui surviennent chez les bébés nés à terme.
Chez les nouveau-nés respirant l'air ambiant, la saturation normale en oxygène du sang artériel est de 86 à 92 %.

Voir au sujet de la saturation normal du nouveau :
Bhargava R, Mathur M, Patodia J. Oxygen saturation trends in normal healthy term newborns: normal vaginal delivery vs. elective cesarean section. J Perinat Med. 2018 Feb 23;46(2):191-195  .

Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, Dainty KN, Diederich E, Lin Y, Leary M, Mahgoub M, Mancini ME, Navarro K, Donoghue A. | Circulation. 2020 Oct 20;142(16_suppl_2):S551-S579
DOI: https://doi.org/10.1161/cir.0000000000000903  | Télécharger l'article au format  
Keywords: aha scientific statements

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Editorial : The International Liaison Committee on Resuscitation Formula for Survival (Figure) emphasizes 3 essential components influencing survival outcomes from cardiac arrest: guidelines based on current resuscitation science, effective education of resuscitation providers, and local implementation of guidelines during patient care.3 Greater emphasis on effective education will improve provider performance, enhance local implementation of guidelines, and potentially increase survival rates from cardiac arrest.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, Levy A, Lin Y, Magid DJ, Mahgoub M, Peberdy MA, Rodriguez AJ, Sasson C, Lavonas EJ; Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, and Resuscitation Education Science Writing Groups. | Circulation. 2020 Oct 20;142(16_suppl_2):S580-S604
DOI: https://doi.org/10.1161/cir.0000000000000899  | Télécharger l'article au format  
Keywords: AHA Scientific Statements; cardiopulmonary resuscitation; delivery of health care; emergency medical dispatcher; hospital rapid response team; organ transplantation; patient care team; quality improvement

REVIEW ARTICLE

Editorial : Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post–cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Conclusion : Top 10 Take-Home Messages: Systems of Care
1. Recovery is a critical component of the resuscitation Chain of Survival.
2. Efforts to support the ability and willingness of members of the general public to perform cardiopulmonary resuscitation (CPR), and to use an automated external defibrillator, improve resuscitation outcomes in communities.
3. Novel methods to use mobile phone technology to alert trained lay rescuers of events requiring CPR have shown promise in some urban communities and deserve more study.
4. Emergency system telecommunicators can instruct bystanders to perform hands-only CPR for adults. The No-No-Go framework is effective.
5. Early warning scoring systems and rapid response teams can prevent cardiac arrest in both pediatric and adult hospitals, but the literature is too varied to understand what components of these systems are associated with benefit.
6. Cognitive aids may improve resuscitation performance by untrained laypersons, but their use results in a delay to starting CPR. More development and study are needed before these systems can be fully endorsed.
7. Surprisingly little is known about the effect of cognitive aids on the performance of emergency medical services or hospital-based resuscitation teams.
8. Although specialized cardiac arrest centers offer protocols and technology not available at all hospitals, the available literature about their impact on resuscitation outcomes is mixed.
9. Team feedback matters. Structured debriefing protocols improve the performance of resuscitation teams in subsequent resuscitation events. 10. System-wide feedback matters. Implementing structured data collection and review leads to improved resuscitation processes and survival in both in-hospital and out-of-hospital settings.

Conclusion (proposition de traduction) : Top 10 des messages à retenir
1. La récupération (ndlr : guérison) est un élément essentiel de la chaîne de survie de la réanimation.
2. Les efforts visant à soutenir la capacité et la volonté des membres du grand public d'effectuer une réanimation cardio-pulmonaire (RCP) et d'utiliser un défibrillateur externe automatisé, améliorent les résultats de la réanimation dans les communautés.
3. De nouvelles méthodes d'utilisation de la technologie de la téléphonie mobile pour alerter les secouristes non professionnels formés aux événements nécessitant une RCP se sont révélées prometteuses dans certaines communautés urbaines et méritent d'être étudiées plus en détail.
4. Les assistant de régulation du système d'urgence peuvent demander aux témoins d'effectuer une RCP avec massage cardiaque seulement chez l'adults. Le message No-No-Go est efficace.
5. Les systèmes d'alerte précoce et les équipes d'intervention rapide peuvent prévenir l'arrêt cardiaque dans les hôpitaux pédiatriques et adultes, mais la littérature est trop variée pour comprendre quels composants de ces systèmes sont associés à des avantages.
6. Les aides cognitives peuvent améliorer les performances de réanimation par des témoins non formés, mais leur utilisation entraîne un retard dans le démarrage de la RCP. Des développements et des études supplémentaires sont nécessaires avant que ces systèmes puissent être pleinement approuvés.
7. Étonnamment, on en sait peu sur l'effet des aides cognitives sur la performance des services médicaux d'urgence ou des équipes de réanimation en milieu hospitalier.

Commentaire : 8. Bien que les centres spécialisés dans l'ACR offrent des protocoles et une technologie qui ne sont pas disponibles dans tous les hôpitaux, la littérature disponible sur leur impact sur les résultats de la réanimation est mitigée.
9. La rétroaction de l'équipe est importante. Des protocoles de débriefing structurés améliorent les performances des équipes de réanimation lors des événements de réanimation ultérieurs.
10. La rétroaction à l'échelle du système est importante. La mise en œuvre d'une collecte et d'un examen structurés des données permet d'améliorer les processus de réanimation et la survie dans les milieux hospitaliers et extra-hospitaliers.

Cochrane Database of Systematic Reviews

Prophylactic anticoagulants for people hospitalised with COVID‐19.
Flumignan RLG, Tinôco JD, Pascoal PIF, Areias LL, Cossi MS, Fernandes MICD, Costa IKF, Souza L, Matar CF, Tendal B, Trevisani VFM, Atallah ÁN, Nakano LCU. | Cochrane Database Syst Rev. 2020, Issue 10. Art. No.: CD013739
DOI: https://doi.org/10.1002/14651858.CD013739  | Télécharger l'article au format  
Keywords: Aucun

Rapid

Introduction : La maladie à coronavirus 2019 (COVID‐19) est une maladie grave causée par le coronavirus 2 du syndrome respiratoire aigu sévère (SARS‐CoV‐2). La principale manifestation est l'insuffisance respiratoire qui peut également être liée à la microthrombose pulmonaire diffuse chez les personnes atteintes de la COVID‐19. Cette maladie provoque également des événements thromboemboliques, tels que l'embolie pulmonaire, la thrombose veineuse profonde, la thrombose artérielle, la thrombose par cathéter et la coagulopathie intravasculaire disséminée. Des études récentes ont indiqué un pronostic plus défavorable pour les personnes atteintes de la COVID‐19 qui ont développé une thromboembolie. Les anticoagulants sont des médicaments utilisés dans la prévention et le traitement des événements thromboemboliques veineux ou artériels. Plusieurs médicaments sont utilisés dans la prophylaxie et le traitement des événements thromboemboliques, tels que les héparinoïdes (héparines ou pentasaccharides), les antagonistes de la vitamine K et les anticoagulants directs. Outre leurs propriétés anticoagulantes, les héparinoïdes ont un potentiel anti‐inflammatoire supplémentaire, qui pourrait affecter l'évolution clinique des personnes atteintes de COVID‐19. Certaines recommandations de bonnes pratiques cliniques traitent de l'utilisation des anticoagulants pour la thromboprophylaxie chez les personnes atteintes de la COVID‐19, cependant, le bénéfice de l’utilisation des anticoagulants chez les personnes atteintes de la COVID‐19 est toujours en débat.

Méthode : Évaluer les effets des anticoagulants à dose prophylactique par rapport à un comparateur actif, au placebo ou à l’absence d’intervention, sur la mortalité et le besoin d'assistance respiratoire chez les personnes hospitalisées pour la COVID‐19.
Stratégie de recherche documentaire : Nous avons effectué des recherches dans les bases de données CENTRAL, MEDLINE, Embase, LILACS et IBECS, dans le registre d'étude Cochrane sur la COVID‐19 et dans la base de données de prépublications medRxiv depuis leur création jusqu'au 20 juin 2020. Nous avons également vérifié les références bibliographiques de toutes les revues systématiques pertinentes identifiées et avons contacté les spécialistes du domaine pour obtenir des références supplémentaires sur les essais.
Critères de sélection : Essais contrôlés randomisés (ECR), essais quasi‐randomisés, essais randomisés en grappes et études de cohortes qui comparent les anticoagulants à dose prophylactique (héparine, antagonistes de la vitamine K, anticoagulants directs et pentasaccharides) à un comparateur actif, un placebo ou à l’absence d’intervention dans la prise en charge des personnes hospitalisées pour la COVID‐19. Nous avons exclu les études sans groupe de comparaison. Les critères de jugement principaux sont la mortalité toutes causes confondues et la nécessité d'une assistance respiratoire supplémentaire. Les critères de jugement secondaires étaient la mortalité liée à la COVID‐19, la thrombose veineuse profonde (TVP), l'embolie pulmonaire, les hémorragies graves, les événements indésirables, la durée du séjour à l'hôpital et la qualité de vie.
Recueil et analyse des données : Nous avons utilisé les procédures méthodologiques standards de Cochrane. Nous avons utilisé ROBINS‐I pour évaluer le risque de biais pour les études non randomisées et GRADE pour évaluer le niveau de conf

Résultats : Nous n'avons pas identifié d’ECR ou d’essais quasi‐randomisés répondant aux critères d'inclusion. Nous avons inclus sept études non randomisées rétrospectives (5 929 participants), dont trois étaient disponibles sous forme de prépublication. Les études ont été menées en Chine, en Italie, en Espagne et aux États‐Unis. Toutes les études ont porté sur des personnes hospitalisées pour la COVID‐19, dans des unités de soins intensifs, des services hospitaliers ou des services d'urgence. L'âge moyen des participants (indiqué dans 6 études) se situait entre 59 et 72 ans. Seules trois études incluses ont rapporté la période de suivi, qui variait de 8 à 35 jours. Les études n'ont pas rapporté la plupart de nos critères de jugement d'intérêt: besoin d'une assistance respiratoire supplémentaire, mortalité liée à la COVID‐19, TVP, embolie pulmonaire, événements indésirables et qualité de vie. Anticoagulants (tous types) par rapport à l’absence de traitement (6 études non randomisées rétrospectives, 5 685 participants) Une étude a rapporté une réduction de la mortalité toutes causes confondues (rapport des cotes ajusté (RC) 0,42, intervalle de confiance (IC) à 95% 0,26 à 0,66 ; 2 075 participants). Une étude a rapporté une réduction de la mortalité uniquement dans un sous‐groupe de 395 personnes qui avaient besoin d'une ventilation mécanique (rapport des risques instantanés (HR) 0,86, IC à 95% 0,82 à 0,89). Trois études n'ont pas rapporté de différence sur la mortalité (RC ajusté de 1,64, IC à 95 % de 0,92 à 2,92 ; 449 participants ; RC non ajusté de 1,66, IC à 95 % de 0,76 à 3,64 ; 154 participants et risque relatif (RR) ajusté de 1,15, IC à 95 % de 0,29 à 2,57 ; 192 participants). Une étude n’a pas rapporté d’événement dans les deux groupes d'intervention (42 participants). Le risque global de biais pour la mortalité toutes causes confondues était critique et le niveau de confiance des données probantes était très faible. Une étude non randomisée a rapporté des événements hémorragiques chez 3 % du groupe d'intervention et 1,9 % du groupe témoin (RC 1,62, IC à 95 % 0,96 à 2,71 ; 2 773 participants ; données probantes d’un niveau de confiance faible). Anticoagulants à dose thérapeutique par rapport aux anticoagulants à dose prophylactique (1 étude non randomisée rétrospective, 244 participants) L'étude a rapporté une réduction de la mortalité toutes causes confondues (HR ajusté 0,21, IC à 95 % 0,10 à 0,46) et un taux absolu de décès plus faible dans le group

Conclusion : There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulants for people hospitalised with COVID‐19. Since there are 22 ongoing studies that plan to evaluate more than 15,000 participants in this setting, we will add more robust evidence to this review in future updates.

Conclusion (proposition de traduction) : Il n'y a actuellement pas suffisamment de données probantes pour déterminer les risques et les bénéfices des anticoagulants à dose prophylactique chez les personnes hospitalisées pour la COVID‐19. Étant donné que 22 études qui sont en cours prévoient d'évaluer plus de 15 000 participants dans ce contexte, nous ajouterons des données probantes plus robustes à cette revue dans de futures mises à jour.

Emergency Medicine Journal

Evaluation of a novel approach to recognising community-acquired paediatric sepsis at ED triage by combining an electronic screening algorithm with clinician assessment.
Gomes S, Wood D, Ayis S, Haliasos N, Roland D. | Emerg Med J. 2020 Oct 30:emermed-2019-208746
DOI: https://doi.org/10.1136/emermed-2019-208746
Keywords: infection; paediatric emergency medicine; paediatrics; quality improvement; triage.

PAEDIATRICS

Introduction : We report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric ED.

Méthode : An electronic sepsis screening tool was implemented in the paediatric EDs of two large UK secondary care hospitals between June 2018 and January 2019. Patients eligible for screening were children < 16 years of ages excluding those with minor injuries or who were brought directly to resuscitation. Subsequently, a retrospective evaluation was performed to determine the performance of the tool alone and in combination with clinical assessment after triage, to identify septic patients, using sensitivity, specificity, positive, negative predictive values (PPV and NPV) and likelihood ratios.

Résultats : 19 912 children were triaged during the study period, of whom 90 (0.45%) were classified as having sepsis. 99% of all eligible patients were screened. The eST alerted for 2651 (13.3%) patients. After immediate physician assessment, 151 were treated for sepsis in the ED, of whom 70 had a final diagnosis of sepsis. Eight patients who were not thought to be septic returned with sepsis within 24 hours. The eST showed a sensitivity of 86.7% (95% CI 77.5% to 92.6%), specificity 87.0% (95% CI 86.5% to 87.5%), PPV 2.94% (95% CI 2.35% to 3.68%), NPV 99.9% (95% CI 99.8% to 99.9%) which improved with combined clinical assessment to a sensitivity of 90.0% (95% CI 81.4% to 95.0%), specificity 99.4 (95% CI 99.3% to 99.5%), PPV 42.0 (95% CI 35.0% to 49.3%) and NPV 99.9% (95% CI 99.9% to 99.9%).

Conclusion : Utilisation of a novel triage-based eST allowed sepsis screening in over 99% of eligible patients. The screening tool showed good accuracy to recognise sepsis at triage in the ED, which was augmented further by combining it with clinician assessment. The screening tool requires further refinement through multicentre evaluation to avoid missing sepsis cases.

Conclusion (proposition de traduction) : L'utilisation d'un nouvel outil de dépistage électronique basé sur le triage a permis le dépistage de la septicémie chez plus de 99% des patients éligibles. L'outil de dépistage a montré une bonne précision pour reconnaître la septicémie lors du triage dans le service des urgences, ce qui a été amélioré en le combinant avec l'évaluation du clinicien. L'outil de dépistage doit encore être affiné grâce à une évaluation multicentrique pour éviter de manquer des cas de septicémie.

BET 1: Esmolol-a novel adjunct to the ACLS algorithm?.
King C, McKenzie C, Saikaley K. | Emerg Med J. 2020 Oct;37(10):650-651
DOI: https://doi.org/10.1136/emermed-2020-210613.02
Keywords: Aucun

BEST EVIDENCE TOPIC REPORTS

Editorial : A short-cut review of the available medical literature was carried out to establish whether esmolol was an effective treatment for patients in cardiac arrest. After abstract review, two papers were found to answer this clinical question using the detailed search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated.

Conclusion : It is concluded that there is insufficient research addressing this question to know whether esmolol is a potential treatment for cardiac arrest.

Conclusion (proposition de traduction) : Il est conclu que les recherches sur cette question sont insuffisantes pour savoir si l'esmolol est un traitement potentiel de l'arrêt cardiaque.

European Journal of Emergency Medicine

Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference.
Lindner G, Burdmann EA, Clase CM, Hemmelgarn BR, Herzog CA, Małyszko J, Nagahama M, Pecoits-Filho R, Rafique Z, Rossignol P, Singer AJ. | Eur J Emerg Med. 2020 Oct;27(5):329-337
DOI: https://doi.org/10.1097/mej.0000000000000691  | Télécharger l'article au format  
Keywords: Aucun

Review

Editorial : Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, are associated with hyperkalemia. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened a conference in 2018 to identify evidence and address controversies on potassium management in kidney disease. This review summarizes the deliberations and clinical guidance for the evaluation and management of acute hyperkalemia in this setting. The toxic effects of hyperkalemia on the cardiac conduction system are potentially lethal. The ECG is a mainstay in managing hyperkalemia. Membrane stabilization by calcium salts and potassium-shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia. However, only dialysis, potassium-binding agents, and loop diuretics remove potassium from the body. Frequent reevaluation of potassium concentrations is recommended to assess treatment success and to monitor for recurrence of hyperkalemia.

Conclusion : In summary, acute hyperkalemia is a frequently observed problem in EDs and one with potentially fatal consequences. Monitoring of vital signs and performing a 12-lead ECG is recommended in all patients with potassium con- centration > 6 mmol/l. In all patients with hyperkalemia and presence of ECG changes, calcium salts should be promptly given. Additionally, measures to shift potassium to the intracellular compartment (i.e., insulin-glucose, β-adrenergic agonists) and remove it from the body should be taken. Frequent reevaluation of serum potassium concentrations is essential in order to monitor treatment suc- cess and screen for a rebound rise in serum potassium.

Conclusion (proposition de traduction) : En résumé, l'hyperkaliémie aiguë est un problème fréquemment observé dans les services d'urgence et avec des conséquences potentiellement mortelles. La surveillance des signes vitaux et la réalisation d'un ECG 12 dérivations sont recommandées chez tous les patients présentant une concentration de potassium > 6 mmol/l. Chez tous les patients présentant une hyperkaliémie et la présence de modifications à l'ECG, des sels de calcium (ndlr : gluconate ou chlorure) doivent être administrés rapidement. De plus, des mesures pour déplacer le potassium vers le compartiment intracellulaire (c'est-à-dire, insuline-glucose, agonistes β-adrénergiques) et l'éliminer du corps doivent être prises. Une réévaluation fréquente des concentrations sériques de potassium est essentielle afin de surveiller le succès du traitement et de dépister une augmentation de rebond de la kaliémie.

Commentaire : Clase CM, Carrero JJ, Ellison DH, Grams ME, Hemmelgarn BR, Jardine MJ, Kovesdy CP, Kline GA, Lindner G, Obrador GT, Palmer BF, Cheung M, Wheeler DC, Winkelmayer WC, Pecoits-Filho R; Conference Participants. Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2020 Jan;97(1):42-61  .

Investigation of pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study.
Lefevre-Scelles A, Jeanmaire P, Freund Y, Joly LM, Phillipon AL, Roussel M. | Eur J Emerg Med. 2020 Oct;27(5):357-361
DOI: https://doi.org/10.1097/mej.0000000000000680
Keywords: Aucun

Original Article

Introduction : Chest pain is a common main complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism remains a key concern for the clinician. There are no clear recommendations on which patients should have a formal workup for pulmonary embolism diagnosis. The objective of this study was to determine the proportion of patients with chest pain who were investigated for pulmonary embolism diagnosis and to determine the clinical profile of these patients.

Méthode : This was a retrospective multicenter study conducted in three French Emergency Departments. We included all patients who presented to these centers for chest pain during a 2-month period. The primary outcome was the initiation of pulmonary embolism workup. We also aimed to find factors associated with this outcome.

Résultats : We included 881 patients with a main complaint of chest pain. Mean age was 50 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27-33%) had a formal pulmonary embolism workup, and pulmonary embolism was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1-5.3%). Five factors were identified as independently associated with a workup for pulmonary embolism diagnosis: female sex, young age, no ischemic heart disease, recent flight and associated dyspnea.

Conclusion : Among patients presenting to emergency department with chest pain, 30% had a workup for pulmonary embolism. We report five clinical variables independently associated with a higher probability of pulmonary embolism workup in our sample.

Conclusion (proposition de traduction) : Parmi les patients se présentant aux urgences pour des douleurs thoraciques, 30 % ont eu un bilan d'embolie pulmonaire. Nous rapportons cinq variables cliniques indépendamment associées à une probabilité plus élevée de bilan d'embolie pulmonaire dans notre échantillon.

Commentaire : Les cinq variables cliniques de l'article sont :
sexe féminin, jeune âge, voyage en avion récent, absence d'antécédents de cardiopathie ischémique et dyspnée.

Sepsis prevalence among patients with suspected infection in emergency department: a multicenter prospective cohort study.
Oberlin M, Balen F, Bertrand L, Chapeau N, San Cirilo B, Ruols E, Vandercamere T, Souchaud C, Guedj JF, Konan B, Duval A, Mur S, Specia-Fajolles AS, Salles M, Boullenger E, Vuillot O, Bobbia X. | Eur J Emerg Med. 2020 Oct;27(5):373-378
DOI: https://doi.org/10.1097/mej.0000000000000689
Keywords: Aucun

Original Article

Introduction : In the emergency department (ED), the early identification of patients suspected of infection is a challenge for emergency physicians. Sepsis prevalence among patients with suspected infection in the ED remains uncertain. Our objective was to determine how many cases of sepsis occurred among patients with suspected infections in the ED.

Méthode : This multi-center, prospective, observational study was conducted in 19 EDs in France. For 1 week, all consecutive ED patients with suspected infection (according to the emergency physician) were included. The primary endpoint was the prevalence of sepsis in the ED according to the 'sepsis-3' definition. Secondary endpoints involved comparisons among patients with and without sepsis.

Résultats : During the study period, 13 904 patients were screened; 494 (3.6%) consulted for suspected infection and were included in the study. Among them, 172 patients [39%, 95% confidence interval (CI) (34-44)] were diagnosed with sepsis. The total hospital mortality for patients with a suspected infection was 4.7% and the hospital mortality for sepsis patients was 9.9%.

Conclusion : In the ED, among patients with a suspected infection, the prevalence of sepsis as per the 'sepsis-3' definition was 39% [95% CI (34-44)].

Conclusion (proposition de traduction) : Aux urgences, parmi les patients suspectés d'infection, la prévalence de la septicémie selon la définition du « sepsis-3 » était de 39 % [IC à 953 % (34-44)].

Forces applied to maxillary incisors with different laryngoscopes.
Hanoglu DN, Goksu E, Kazanir S, Chebl RB. | Eur J Emerg Med. 2020 Oct;27(5):384-385
DOI: https://doi.org/10.1097/mej.0000000000000716
Keywords: Aucun

RESEARCH LETTER

European Respiratory Journal

Elevated D-dimers and lack of anticoagulation predict PE in severe COVID-19 patients.
Mouhat B, Besutti M, Bouiller K, Grillet F, Monnin C, Ecarnot F, Behr J, Capellier G, Soumagne T, Pili-Floury S, Besch G, Mourey G, Lepiller Q, Chirouze C, Schiele F, Chopard R, Meneveau N. | Eur Respir J. 2020 Oct 22;56(4):2001811
DOI: https://doi.org/10.1183/13993003.01811-2020  | Télécharger l'article au format  
Keywords: Aucun

Pulmonary infections

Introduction : Coronavirus disease 2019 (COVID-19) may predispose to venous thromboembolism. We determined factors independently associated with computed tomography pulmonary angiography (CTPA)-confirmed pulmonary embolism (PE) in hospitalised severe COVID-19 patients.

Méthode : Among all (n=349) patients hospitalised for COVID-19 in a university hospital in a French region with a high rate of COVID-19, we analysed patients who underwent CTPA for clinical signs of severe disease (oxygen saturation measured by pulse oximetry ⩽93% or breathing rate ⩾30 breaths·min−1) or rapid clinical worsening. Multivariable analysis was performed using Firth penalised maximum likelihood estimates.

Résultats : 162 (46.4%) patients underwent CTPA (mean±SD age 65.6±13.0 years; 67.3% male (95% CI 59.5–75.5%). PE was diagnosed in 44 (27.2%) patients. Most PEs were segmental and the rate of PE-related right ventricular dysfunction was 15.9%. By multivariable analysis, the only two significant predictors of CTPA-confirmed PE were D-dimer level and the lack of any anticoagulant therapy (OR 4.0 (95% CI 2.4–6.7) per additional quartile and OR 4.5 (95% CI 1.1–7.4), respectively). Receiver operating characteristic curve analysis identified a D-dimer cut-off value of 2590 ng·mL−1 to best predict occurrence of PE (area under the curve 0.88, p<0.001, sensitivity 83.3%, specificity 83.8%). D-dimer level >2590 ng·mL−1 was associated with a 17-fold increase in the adjusted risk of PE.

Conclusion : Elevated D-dimers (>2590ng·mL−1) and absence of anticoagulant therapy predict PE in hospitalised COVID-19 patients with clinical signs of severity. These data strengthen the evidence base in favour of systematic anticoagulation, and suggest wider use of D-dimer guided CTPA to screen for PE in acutely ill hospitalised patients with COVID-19.

Conclusion (proposition de traduction) : Des D-dimères élevés (> 2590 ng.mL−1) et l'absence de traitement anticoagulant prédisent l'embolie pulmonaire chez les patients hospitalisés pour une pneumopathie à COVID-19 présentant des signes cliniques de gravité. Ces données renforcent la base de preuves en faveur de l'anticoagulation systématique et suggèrent une utilisation plus large de l'angiographie pulmonaire par tomodensitométrie guidée par le taux de D-dimères pour dépister l'embolie pulmonaire chez les patients hospitalisés pour une pneumopathie grave à COVID-19.

Intensive Care Medicine

Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest.
Moseby-Knappe M, Westhall E, Backman S, Mattsson-Carlgren N, Dragancea I, Lybeck A, Friberg H, Stammet P, Lilja G, Horn J, Kjaergaard J, Rylander C, Hassager C, Ullén S, Nielsen N, Cronberg T. | Intensive Care Med. 2020 Oct;46(10):1852-1862
DOI: https://doi.org/10.1007/s00134-020-06080-9  | Télécharger l'article au format  
Keywords: Cardiac arrest; Coma; Guideline algorithm; Prognostic accuracy; Prognostication.

Original article

Introduction : To assess the performance of a 4-step algorithm for neurological prognostication after cardiac arrest recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM).

Méthode : Retrospective descriptive analysis with data from the Target Temperature Management (TTM) Trial. Associations between predicted and actual neurological outcome were investigated for each step of the algorithm with results from clinical neurological examinations, neuroradiology (CT or MRI), neurophysiology (EEG and SSEP) and serum neuron-specific enolase. Patients examined with Glasgow Coma Scale Motor Score (GCS-M) on day 4 (72-96 h) post-arrest and available 6-month outcome were included. Poor outcome was defined as Cerebral Performance Category 3-5. Variations of the ERC/ESICM algorithm were explored within the same cohort.

Résultats : The ERC/ESICM algorithm identified poor outcome patients with 38.7% sensitivity (95% CI 33.1-44.7) and 100% specificity (95% CI 98.8-100) in a cohort of 585 patients. An alternative cut-off for serum neuron-specific enolase, an alternative EEG-classification and variations of the GCS-M had minor effects on the sensitivity without causing false positive predictions. The highest overall sensitivity, 42.5% (95% CI 36.7-48.5), was achieved when prognosticating patients irrespective of GCS-M score, with 100% specificity (95% CI 98.8-100) remaining.

Conclusion : he ERC/ESICM algorithm and all exploratory multimodal variations thereof investigated in this study predicted poor outcome without false positive predictions and with sensitivities 34.6-42.5%. Our results should be validated prospectively, preferably in patients where withdrawal of life-sustaining therapy is uncommon to exclude any confounding from self-fulfilling prophecies.

Conclusion (proposition de traduction) : L'algorithme ERC/ESICM et toutes ses variations multimodales exploratoires étudiées dans cette étude ont prédit de mauvais résultats sans fausses prédictions positives et avec des sensibilités de 34,6 à 42,5 %. Nos résultats devraient être validés de manière prospective, de préférence chez les patients pour lesquels l'arrêt d'une thérapeutique vitale est peu fréquent afin d'exclure toute confusion avec les pronostications qui se réalisent d'elles-mêmes.

Commentaire : Voir l'article :
Sandroni C, Grippo A, Nolan JP. ERC-ESICM guidelines for prognostication after cardiac arrest: time for an update. Intensive Care Med. 2020 Oct;46(10):1901-1903  .

Lung ultrasound predicts clinical course and outcomes in COVID-19 patients.
Lichter Y, Topilsky Y, Taieb P, Banai A, Hochstadt A, Merdler I, Gal Oz A, Vine J, Goren O, Cohen B, Sapir O, Granot Y, Mann T, Friedman S, Angel Y, Adi N, Laufer-Perl M, Ingbir M, Arbel Y, Matot I, Szekely Y. | Intensive Care Med. 2020 Oct;46(10):1873-1883
DOI: https://doi.org/10.1007/s00134-020-06212-1  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : Information regarding the use of lung ultrasound (LUS) in patients with Coronavirus disease 2019 (COVID-19) is quickly accumulating, but its use for risk stratification and outcome prediction has yet to be described. We performed the first systematic and comprehensive LUS evaluation of consecutive patients hospitalized with COVID-19 infection, in order to describe LUS findings and their association with clinical course and outcome.

Méthode : Between 21/03/2020 and 04/05/2020, 120 consecutive patients admitted to the Tel Aviv Medical Center due to COVID-19, underwent complete LUS within 24 h of admission. A second exam was performed in case of clinical deterioration. LUS score of 0 (best)—36 (worst) was assigned to each patient. LUS findings were compared with clinical data.

Résultats : The median baseline total LUS score was 15, IQR [7–20]. Baseline LUS score was 0–18 in 80 (67%) patients, and 19–36 in 40 (33%) patients. The majority had patchy pleural thickening (n = 100; 83%), or patchy subpleural consolidations (n = 93; 78%) in at least one zone. The prevalence of pleural thickening, subpleural consolidations and the total LUS score were all correlated with severity of illness on admission. Clinical deterioration was associated with increased follow-up LUS scores (p = 0.0009), mostly due to loss of aeration in anterior lung segments. The optimal cutoff point for LUS score was 18 (sensitivity = 62%, specificity = 74%). Both mortality and need for invasive mechanical ventilation were increased with baseline LUS score > 18 compared to baseline LUS score 0–18. Unadjusted hazard ratio of death for LUS score was 1.08 per point [1.02–1.16], p = 0.008; Unadjusted hazard ratio of the composite endpoint (death or need for invasive mechanical ventilation) for LUS score was 1.12 per point [1.05–1.2], p = 0.0008.

Conclusion : Hospitalized patients with COVID-19, at all clinical grades, present with pathological LUS findings. Baseline LUS score strongly correlates with the eventual need for invasive mechanical ventilation and is a strong predictor of mortality. Routine use of LUS may guide patients’ management strategies, as well as resource allocation in case of surge capacity.

Conclusion (proposition de traduction) : Les patients hospitalisés atteints de COVID-19, à tous les grades cliniques, présentent des résultats d'échographie pulmonaire pathologique. Le score échographique pulmonaire de base est fortement corrélé avec le besoin éventuel de ventilation mécanique invasive et est un puissant prédicteur de mortalité. L’utilisation systématique de l’échographie pulmonaire peut guider les stratégies de prise en charge des patients, ainsi que l’allocation des ressources en cas de surtension.

Commentaire : Correction to: Lung ultrasound predicts clinical course and outcomes in COVID-19 patients  .

Voir les articles sur le même sujet /
Zieleskiewicz L, Markarian T, Lopez A, Taguet C, Mohammedi N, Boucekine M, et al. Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia. Intensive Care Med [Internet]. 2020;46(9):1707–13  .
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  .

Lung ultrasonography as an alternative to chest computed tomography in COVID-19 pneumonia?.
Vieillard-Baron A, Goffi A, Mayo P. | Intensive Care Med. 2020 Oct;46(10):1908-1910
DOI: https://doi.org/10.1007/s00134-020-06221-0  | Télécharger l'article au format  
Keywords: Aucun

Editorial

Editorial : A letter recently published by Yang et al. in this journal raises the important question as to whether lung ultrasonography (LUS) may be an useful alternative to chest computed tomography (CT) for the evaluation of COVID-19 pneumonia [1]. The information in the study is particularly relevant to a situation in which an overwhelming volume of COVID-19 patients may exceed CT performance and processing capacity. What is new and provocative in Yang’s study is the reported higher sensitivity of LUS compared to CT for the detection of alveolar-interstitial syndrome (AIS), consolidation, and pleural effusion in patients with COVID-19 pneumonia. The authors found weak or very weak agreement between LUS and CT for alveolar-interstitial findings, consolidation, and pleural effusion, with CT not able to identify a significant proportion of these findings. This editorial comments on the controversy engendered by the letter with the intent of furthering the discussion on LUS and CT as imaging modalities for SARS-CoV-2 pneumonia.

Conclusion : Finally, this preliminary report, provocative and hypothesis-generating, needs to be confirmed (or not) in a larger population of critically ill patients, with standardized semiology. We also want to emphasize that LUS requires adequate training; and, when performed with attention to details, it can be time consuming. This could potentially prolong the period of time clinicians are exposed to SARS-CoV-2 at the bedside. These disadvantages are balanced against the ease of use of LUS, its serial repeatability, its low cost, its lack of radiation exposure, and its logical integration with other aspects of critical care ultrasonography. It remains to determine how to best combine LUS and CT for management of COVID-19.

Conclusion (proposition de traduction) : Enfin, ce rapport préliminaire, provocateur et générateur d'hypothèses, doit être confirmé (ou non) dans une population plus large de patients de réanimation, avec une sémiologie standardisée. Nous tenons également à souligner que l'échographie pulmonaire nécessite une formation adéquate; et, lorsqu'elle est effectuée avec une attention aux détails, elle peut prendre du temps. Cela pourrait prolonger la période pendant laquelle les cliniciens sont exposés au SRAS-CoV-2 au chevet du patient. Ces inconvénients sont contrebalancés par la facilité d'utilisation de l'échographie pulmonaire, sa répétabilité en série, son faible coût, son absence d'exposition aux rayonnements et son intégration logique avec d'autres aspects de l'échographie en soins intensifs. Il reste à déterminer comment combiner au mieux l'échographie pulmonaire et la tomodensitométrie pour la gestion de la COVID-19.

Commentaire : Article cité :
Yang Y, Huang Y, Gao F, Yuan L, Wang Z. Lung ultrasonography versus chest CT in COVID-19 pneumonia: a two-centered retrospective comparison study from China. Intensive Care Med. 2020 May;46(9):1761-1763  .

Internal and Emergency Medicine

Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment.
Hachimi-Idrissi S, Coffey F, Hautz WE, Leach R, Sauter TC, Sforzi I, Dobias V. | Intern Emerg Med. 2020 Oct;15(7):1125-1139
DOI: https://doi.org/10.1007/s11739-020-02477-y
Keywords: Acute pain; Analgesia; Emergency care; Emergency department; Pain assessment; Practice guideline; Pre-hospital.

Guidelines and Position papers

Editorial : Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.

Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations.
Hachimi-Idrissi S, Dobias V, Hautz WE, Leach R, Sauter TC, Sforzi I, Coffey F. | Intern Emerg Med. 2020 Oct;15(7):1141-1155
DOI: https://doi.org/10.1007/s11739-020-02411-2
Keywords: Acute pain; Analgesia; Emergency care; Emergency department; Non-pharmacological treatment; Pain management; Pharmacological treatment; Practice guideline; Pre-hospital.

Guidelines and position papers

Introduction : In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind.

Méthode : With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings.

Conclusion : This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.

Conclusion (proposition de traduction) : Cet article fournit des recommandations de traitement issues de lignes directrices récemment élaborées, basées sur une revue de la littérature, la pratique actuelle en Europe et l'expertise clinique des conseillers de l'Initiative européenne contre la douleur. Les recommandations ont été élaborées, évaluées et affinées pour les adultes et les enfants (âgés de ≥ 1 an, ≤ 15 ans), avec l'hypothèse d'une évaluation et d'une réévaluation de la douleur en temps opportun et de la possibilité de mettre en œuvre une analgésie. Pour offrir une flexibilité d'utilisation à travers l'Europe, des options sont proposées pour la sélection du traitement pharmacologique approprié.

Commentaire :  Prise en charge pharmacologique de la douleur aiguë chez l'adulte.

Prise en charge pharmacologique de la douleur aiguë chez l'enfant (de 1 à 15 ans).

Novel biomarkers to assess the risk for acute coronary syndrome: beyond troponins.
Piccioni A, Valletta F, Zanza C, Esperide A, Franceschi F. | Intern Emerg Med. 2020 Oct;15(7):1193-1199
DOI: https://doi.org/10.1007/s11739-020-02422-z
Keywords: Acute coronary syndrome; Adhesion molecules; Biomarkers; Cytokines; MicroRNAs; Mitochondrial peptides.

IM - REVIEW

Editorial : Current diagnostic biomarkers for ACS are mainly represented by troponin I and troponin T. Dosing of these two molecules often leads to false positive results, since their plasma levels can increase in several different systemic settings. Therefore, identification of new markers able to detect patients with acute coronary syndromes is an emerging priority. On this view, many studies have been performed on different microRNAs, mitochondrial peptides, inflammatory cytokines and adhesion molecules with very promising results. Besides their introduction in screening programs, further studies are now needed in the acute setting, beyond or in association with troponin levels. This will help to better discriminate the real occurrence of an ACS in many patients accessing the emergency department for chest pain.

Conclusion : In conclusion, we currently need to exert a more precise assessment of cardiovascular risk and to identify biomarkers more precise that troponins for a fast and safe rule out of patients presenting in emergency department with chest pain. There are now several potential novel biomarkers able to early detect patients at a high risk to develop acute coronary syndromes, beyond troponins. Besides their introduction in screening programs, further studies are now needed to test their predictive value in the acute setting, beyond or in association with Tn levels. This will help to better identify patients with acute coronary syndromes accessing the emergency department.

Conclusion (proposition de traduction) : En conclusion, il nous faut actuellement réaliser une évaluation plus précise du risque cardiovasculaire et identifier des biomarqueurs plus précis que les troponines pour une élimination rapide et sûre des patients se présentant aux urgences avec des douleurs thoraciques. Il existe maintenant plusieurs nouveaux biomarqueurs potentiels capables de détecter précocement les patients à haut risque de développer des syndromes coronariens aigus, au-delà des troponines. Outre leur introduction dans les programmes de dépistage, des études complémentaires sont désormais nécessaires pour tester leur valeur prédictive en situation aiguë, au-delà ou en association avec les taux de troponine. Cela aidera à mieux identifier les patients atteints de syndromes coronariens aigus qui sont admis au service des urgences.

Commentaire : Dans cette revue, sont présentés les nouveaux biomarqueurs, tels que : les microARN (Mir), les peptides mitochondriaux, les cytokines inflammatoires et les molécules d'adhésion.

The assessment of dermatological emergencies in the emergency department via telemedicine is safe: a prospective pilot study.
Villa L, Matz O, Olaciregui Dague K, Kluwig D, Rossaint R, Brokmann JC. | Intern Emerg Med. 2020 Oct;15(7):1275-1279
DOI: https://doi.org/10.1007/s11739-020-02323-1
Keywords: Dermatology; Emergency medicine; Telemedicine.

EM - ORIGINAL

Introduction : The aim of the study was to examine the feasibility and safety of telemedicine for dermatological emergency patients in the emergency department.

Méthode : This observational study was monocentric, open, prospective and two-arm randomized [control group (n = 50) and teledermatology group (n = 50)]. The control group was conventionally recruited directly by a dermatologist.

Résultats : In the teledermatology group patients, images of the skin lesions and clinical parameters were transferred to a tablet PC (personal computer) by an emergency physician and telemedically assessed by a dermatologist without patient contact. Subsequently, the dermatologist, who was previously telemedically contacted, then personally examined the patient in the emergency department. The treatment time between the control group and the teledermatology group was also recorded and compared. The agreement in suspected diagnosis between teledermatological evaluation and clinical evaluation of the same physician in the teledermatology group was 100%. The treatment time [mean (minutes) ± standard deviation] of the control group was 151 ± 71, that of the teledermatology group was 43 ± 38 (p < 0.001).

Conclusion : The use of emergency telemedicine is safe and effective and provides a viable alternative for clinical care of emergency patients.

Conclusion (proposition de traduction) : L'utilisation de la télémédecine d'urgence est sûre et efficace et constitue une alternative viable pour les soins cliniques des patients d'urgence.

Journal of the American College of Emergency Physicians Open

Cardiologists appropriately exclude resuscitated out-of-hospital cardiac arrests from emergency coronary angiography.
Wittwer MR, Zeitz C, Wu S, Mishra K, Rajendran S, Beltrame JF, Arstall MA. | J Am Coll Emerg Physicians Open. 2020 Oct 20;1(6):1177-1184
DOI: https://doi.org/10.1002/emp2.12276  | Télécharger l'article au format  
Keywords: coronary angiography; out‐of‐hospital cardiac arrest; percutaneous coronary intervention.

ORIGINAL RESEARCH

Introduction : Emergency coronary angiography after resuscitated out-of-hospital cardiac arrest as a selective or non-selective diagnostic procedure with or without intervention continues to be the subject of debate. This study sought to determine if cardiologists reliably select patients using clinical judgement for emergency coronary angiography without missing acutely ischemic cases requiring revascularization.

Méthode : Presenting clinical details and ECGs (within 2 hours) from 52 consecutive out-of-hospital cardiac arrest patients who underwent non-selective coronary angiography were compiled retrospectively. Three out-of-hospital cardiac arrest-experienced interventional cardiologists, blinded to patient outcome, independently determined working diagnosis, and decision for emergency coronary angiography using clinical judgement. Sensitivity of the cardiologists' decision was assessed with respect to the outcome of acute revascularization. Inter-rater differences, consensus in clinical assessment, and influence of working diagnosis were also investigated.

Résultats : Sensitivity of individual cardiologist's decision for emergency coronary angiography with respect to acute revascularization was very high (adjusted overall sensitivity = 95.8%, 95% CI = 89-100, cardiologist range = 93%-100%), and perfect for the consensus of 2 or more cardiologists (100%, 95% CI = 79.4-100). There was no statistical difference in the sensitivity of this decision between cardiologists (P < 0.05), and inter-rater agreement was moderate (78% overall agreement, Κ = 0.56).

Conclusion : Experienced cardiologists recommend emergency coronary angiography in all resuscitated out-of-hospital cardiac arrest requiring acute revascularization and appropriately excluded one-third of patients. Rather than advocating a non-selective, or conversely, a restrictive strategy with respect to coronary angiography after out-of-hospital cardiac arrest, the findings support an individualized approach by a multidisciplinary emergency team that includes experienced cardiologists. The results should be confirmed in a larger prospective study.

Conclusion (proposition de traduction) : Les cardiologues expérimentés recommandent une coronarographie d'urgence dans tous les arrêts cardiaques réanimés hors de l'hôpital nécessitant une revascularisation aiguë et ont exclu de manière appropriée un tiers des patients. Plutôt que de préconiser une stratégie non sélective, ou inversement, restrictive en ce qui concerne l'angiographie coronarienne après un arrêt cardiaque hors de l'hôpital, les résultats soutiennent une approche individualisée par une équipe d'urgence multidisciplinaire qui comprend des cardiologues expérimentés. Les résultats devraient être confirmés dans une étude prospective plus large.

Journal of Trauma and Acute Care Surgery

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis.
Knapp J, Häske D, Böttiger BW, Limacher A, Stalder O, Schmid A, Schulz S, Bernhard M. | J Trauma Acute Care Surg. 2019 Oct;87(4):978-989
DOI: https://doi.org/10.1097/ta.0000000000002444
Keywords: Aucun

SYSTEMATIC REVIEWS

Introduction : As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

Méthode : PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

Résultats : There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

Conclusion : Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

Conclusion (proposition de traduction) : La prise en charge préhospitalière des patients gravement blessés par les équipes des systèmes médicaux d'urgence comprenant un médecin semble être associée à une mortalité plus faible. Après avoir exclu le facteur de confusion du transport par hélicoptère, nous avons montré une tendance non significative vers une mortalité plus faible.

Pediatric Emergency Care

Timing of Antibiotic Administration in Pediatric Sepsis.
Creedon JK, Vargas S, Asaro LA, Wypij D, Paul R, Melendez E. | Pediatr Emerg Care. 2020 Oct;36(10):464-467
DOI: https://doi.org/10.1097/pec.0000000000001663
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : Antibiotic administration within 1 hour of hypotension has been shown to reduce mortality. It is unknown whether antibiotics before hypotension in children who eventually meet criteria for septic shock improves outcomes. This study assesses whether antibiotic timing from the time of meeting criteria for sepsis in children with septic shock impacts morbidity and mortality.

Méthode : This is a retrospective study of children 18 years or younger presenting to a tertiary free-standing children's hospital emergency department with sepsis that subsequently progressed to septic shock and were admitted to an intensive care unit from 2008 to 2012. The time when the patient met criteria for sepsis to the time of first antibiotic administration was assessed and correlated with patient morbidity and mortality.

Résultats : Among 135 children (median age, 13.1 years), 34 (25%) were previously healthy, whereas 49 (36%) had 2 or more medical comorbidities. Twenty-seven children (20%) had positive blood cultures, 17 (13%) had positive urine cultures, and 34 (25%) had chest x-ray findings that were interpreted as pneumonia. Among the 42 (31%) with antibiotics within 1 hour from criteria for sepsis, there was higher mortality (4/42 vs 0/93, P = 0.009), more organ dysfunction, longer time on a vasoactive infusion, and increased intensive care unit and hospital lengths of stay (all P < 0.05).

Conclusion : Children with criteria for sepsis who subsequently progressed to septic shock who received antibiotics within 1 hour of meeting sepsis criteria had increased mortality, length of stay, and organ dysfunction.

Conclusion (proposition de traduction) : Les enfants avec des critères de septicémie qui ont évolué vers un choc septique et qui ont reçu des antibiotiques dans l'heure qui a suivi l'apparition des critères de septicémie ont vu leur mortalité, la durée de leur séjour et la défaillance de leurs organes augmenter.

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use.
Hildenbrand AK, Kassam-Adams N, Barakat LP, Kohser KL, Ciesla JA, Delahanty DL, Fein JA, Ragsdale LB, Marsac ML. | Pediatr Emerg Care. 2020 Oct;36(10):e549-e557
DOI: https://doi.org/10.1097/PEC.0000000000001404
Keywords: Aucun

ORIGINAL ARTICLES

Introduction : After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

Méthode : Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

Résultats : Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

Conclusion : Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.

Conclusion (proposition de traduction) : La douleur pendant l'hospitalisation peut augmenter la sensibilité aux symptômes de stress post-traumatique persistant au-delà de l'influence d'autres facteurs de risque empiriques. Les résultats suggèrent que l'évaluation de la douleur peut être un complément utile aux outils de dépistage des symptômes de stress post-traumatique pédiatriques et soulignent la nécessité de recherches supplémentaires sur les approches de prévention secondaire pharmacologique. Étant donné qu'un contrôle inadéquat de la douleur et des symptômes de stress post-traumatique persistants entravent chacun le rétablissement et le fonctionnement à long terme, une meilleure compréhension des interactions entre la douleur aiguë et les symptômes de stress post-traumatique après une blessure est essentielle pour améliorer les efforts de dépistage, de prévention et d'intervention précoce.

Comparison of 4 Pediatric Intraosseous Access Devices: A Randomized Simulation Study.
Szarpak L, Ladny JR, Dabrowski M, Ladny M, Smereka J, Ahuja S, Ruetzler K. | Pediatr Emerg Care. 2020 Oct;36(10):e568-e572
DOI: https://doi.org/10.1097/pec.0000000000001587
Keywords: Aucun

Original article

Introduction : Obtaining intravascular access can be challenging or even impossible in several clinical situations. As an alternative, medications and fluids can be administered via the intraosseous (IO) route, which is a well-tolerated and established alternative, especially in the emergency setting.

Méthode : Seventy-five novice physicians participated in this randomized simulation study. After a single educational session and 6 months without any clinical application, participants were asked to identify the correct puncture site and obtain IO access using 3 widely used mechanical devices (BIG Pediatric, Arrow EZ-IO, NIO Pediatric) and a manual device (Jamshidi needle) on a pediatric manikin and turkey bone, respectively.

Résultats : Sixty-eight participants correctly identified the puncture site and performed IO cannulations. First placement attempt success rate was similar with mechanical devices (NIO Pediatric, 100%; Arrow EZ-IO, 97%; and BIG Pediatric, 90%), whereas was only 43% using the manual Jamshidi device. Also, procedure time was much faster using mechanical devices (ranging between 18 and 23 seconds) compared with the manual Jamshidi device (34 seconds).

Conclusion : Although the efficacy of devices was demonstrated in simulated environment in novice users, further studies are needed to assess the efficacy and safety of devices in clinical comparative settings. With more experienced users, the success rate may differ considerably as compared with naive users.

Conclusion (proposition de traduction) : Bien que l'efficacité des dispositifs ait été démontrée dans un environnement simulé chez des utilisateurs novices, d'autres études sont nécessaires pour évaluer l'efficacité et la sécurité des dispositifs dans des contextes cliniques comparatifs. Avec des utilisateurs plus expérimentés, le taux de réussite peut différer considérablement par rapport aux utilisateurs naïfs.

Tourniquets in Major Extremity Trauma.
Fuchs S | Pediatr Emerg Care. 2020 Oct;36(10):489-494
DOI: https://doi.org/10.1097/pec.0000000000002226
Keywords: Aucun

CME Review Article

Editorial : Much has been learned about hemorrhage control using tourniquets from wartime experiences, and recent mass casualty events. The use of tourniquets for extremity hemorrhage is a lifesaving skill for all providers to learn.

Conclusion : The use of tourniquets for extremity hemorrhage is a lifesaving skill. Physicians should know the indications and application of a tourniquet. They can also educate others, including the public, with Stop The Bleed program from the American College of Surgeons, Committee on Trauma.

Conclusion (proposition de traduction) : L'utilisation de garrots dans l'hémorragie des extrémités est une compétence vitale. Les médecins doivent connaître les indications et les modalités d'application d'un garrot. Ils peuvent également former les autres, y compris le public, avec le programme Stop The Bleed de l'American College of Surgeons, Committee on Trauma.

A Novel Pediatric Multisystem Inflammatory Syndrome During the COVID-19 Pandemic.
Del Greco G, Brady K, Clark B, Park H. | Pediatr Emerg Care. 2020 Oct;36(10):500-504
DOI: https://doi.org/10.1097/pec.0000000000002229
Keywords: Aucun

Special Features - Case Reports

Editorial : In late March and early April, New York City was an epicenter of the COVID-19 pandemic. Citizens were ordered to stay at home to flatten the curve. The adult population was affected with a severe respiratory illness as well as acute kidney injury, cardiomyopathy, arrhythmia, and thromboembolism. Although children were not affected in the same manner, weeks after the peak, reports from other countries emerged about cases of pediatric patients presenting with a novel inflammatory syndrome. We present 4 patients along with their emergency department course, so providers will have a better understanding of the identification and workup of these patients. Currently, it is unclear when this inflammatory syndrome develops in respect to a COVID-19 infection. The clinical features of this syndrome seem to overlap between Kawasaki disease, toxic shock syndrome, and myocarditis. All patients presenting to our emergency department had fever, variable rash, abdominal pain, vomiting, and/or diarrhea. Patients remained persistently tachycardic and febrile despite being given proper doses of antipyretics. Severity of presentations varied among the 4 cases. All 4 patients were found to have antibodies to COVID-19. All patients required admission, but 2 required the pediatric intensive care unit for cardiac and/or respiratory support or closer monitoring. Upon follow-up on our patients, it seems that most patients are recovering with treatment, and overall, there is a low reported mortality rate.

Conclusion : All patients should be admitted to a facility with the availability of pediatric intensivists, pediatric cardiology, pediatric rheumatology, and pediatric infectious disease expertise. Upon follow-up on our patients and discussions with PICU providers, it seems that most patients are recovering with treatment, and overall, there is a low reported mortality rate.

Conclusion (proposition de traduction) : Tous les patients doivent être admis dans un établissement disposant d'une expertise en réanimation pédiatrique, en cardiologie pédiatrique, en rhumatologie pédiatrique et en maladies infectieuses pédiatriques. Lors du suivi de nos patients et des discussions avec les intensivistes, il semble que la plupart des patients se rétablissent grâce au traitement et, dans l'ensemble, le taux de mortalité rapporté est faible.

Prehospital and Disaster Medicine

Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin.
Perlmutter MC, Cohen MW, Stratton NS, Conterato M. | Prehosp Disaster Med. 2020 Oct 7:1-6
DOI: https://doi.org/10.1017/s1049023x20001193
Keywords: Emergency Medical Services; cardiac; edema; heart failure; nitroglycerin; pulmonary edema; systolic.

First View

Introduction : The study describes the implementation of a prehospital treatment algorithm that included intravenous (IV) bolus (IVB) nitroglycerin (NTG) followed by maintenance infusion for the treatment of acute pulmonary edema (APE) in a single, high-volume Emergency Medical Services (EMS) system.

Méthode : This is a retrospective chart review of patients who received IVB NTG for APE in a large EMS system in Minnesota and Wisconsin (USA). Inclusion criteria for treatment included a diagnosis of APE, systolic blood pressure ≥120mmHg, and oxygen saturation (SpO2) ≤93% following 800mcg of sublingual NTG. Patients received a 400mcg IVB of NTG, repeated every two minutes as needed, and subsequent infusion at 80mcg/min for transport times ≥10 minutes.

Résultats : Forty-four patients were treated with IVB NTG. The median total bolus dose was 400mcg. Twenty patients were treated with NTG infusion following IVB NTG. The median infusion rate was 80mcg/min. For all patients, the initial median blood pressure was 191/113mmHg. Five minutes following IVB NTG, it was 160/94mmHg, and on arrival to the emergency department (ED) it was 152/90mmHg. Five minutes after the initial dose of IVB NTG, median SpO2 increased to 92% from an initial reading of 88% and was 94% at hospital arrival. One episode of transient hypotension occurred during EMS transport.

Conclusion : Patients treated with IVB NTG for APE had reduction in blood pressure and improvement in SpO2 compared to their original presentation. Prehospital treatment of APE with IVB appears to be feasible and safe. A randomized trial is needed to confirm these findings.

Conclusion (proposition de traduction) : Les patients traités par de la nitroglycérine en bolus pour un œdème pulmonaire aigu ont présenté une réduction de la pression artérielle et une amélioration de la SpO2 par rapport à leur présentation clinique initiale. Le traitement préhospitalier de l'œdème pulmonaire aigu par bolus semble faisable et sûr. Un essai randomisé est nécessaire pour confirmer ces résultats.

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport.
Patrick C, Ward B, Anderson J, Fioretti J, Rogers Keene K, Oubre C, Cash RE, Panchal AR, Dickson R. | Prehosp Disaster Med. 2020 Oct;35(5):495-500
DOI: https://doi.org/10.1017/s1049023x20000886
Keywords: Emergency Medical Services; epinephrine; hypotension; prehospital; shock.

Original Research

Introduction : The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.

Méthode : This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record.

Résultats : Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.

Conclusion : These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

Conclusion (proposition de traduction) : Ces données préliminaires suggèrent que l'administration d'adrénaline en bolus peut être efficace pour améliorer rapidement une hypotension en milieu préhospitalier avec une incidence minimale d'événements indésirables. L'utilisation paramédicale d'adrénaline en bolus a augmenté avec succès la pression artérielle systolique et la moyenne sans effets secondaires cliniquement significatifs. Des études prospectives avec des échantillons de plus grande taille sont nécessaires pour étudier plus en détail les effets de l'adrénaline en bolus en préhospitalier sur la morbidité et la mortalité des patients.

A Comparison of Non-Invasive Blood Pressure Measurement Strategies with Intra-Arterial Measurement.
Rebesco MR, Pinkston MC, Smyrnios NA, Weisberg SN. | Prehosp Disaster Med. 2020 Oct;35(5):516-523
DOI: https://doi.org/10.1017/s1049023x20000916
Keywords: arterial pressure; blood pressure; blood pressure monitor; sphygmomanometer.

Original research

Introduction : It is difficult to obtain an accurate blood pressure (BP) measurement, especially in the prehospital environment. It is not known fully how various BP measurement techniques differ from one another.
Study objective: The study hypothesized that there are differences in the accuracy of various non-invasive blood pressure (NIBP) measurement strategies as compared to the gold standard of intra-arterial (IA) measurement.

Méthode : The study enrolled adult intensive care unit (ICU) patients with radial IA catheters placed to measure radial intra-arterial blood pressure (RIBP) as a part of their standard care at a large, urban, tertiary-care Level I trauma center. Systolic blood pressure (SBP) was taken by three different NIBP techniques (oscillometric, auscultated, and palpated) and compared to RIBP measurements. Data were analyzed using the paired t-test with dependent samples to detect differences between RIBP measurements and each NIBP method. The primary outcome was the difference in RIBP and NIBP measurement. There was also a predetermined subgroup analysis based on gender, body mass index (BMI), primary diagnosis requiring IA line placement, and current vasoactive medication use.

Résultats : Forty-four patients were enrolled to detect a predetermined clinically significant difference of 5mmHg in SBP. The patient population was 63.6% male and 36.4% female with an average age of 58.4 years old. The most common primary diagnoses were septic shock (47.7%), stroke (13.6%), and increased intracranial pressure (ICP; 13.6%). Most patients were receiving some form of sedation (63.4%), while 50.0% were receiving vasopressor medication and 31.8% were receiving anti-hypertensive medication. When compared to RIBP values, only the palpated SBP values had a clinically significant difference (9.88mmHg less than RIBP; P < .001). When compared to RIBP, the oscillometric and auscultated SBP readings showed statistically but not clinically significant lower values. The palpated method also showed a clinically significant lower SBP reading than the oscillometric method (5.48mmHg; P < .001) and the auscultated method (5.06mmHg; P < .001). There was no significant difference between the oscillometric and auscultated methods (0.42mmHg; P = .73).

Conclusion : Overall, NIBPs significantly under-estimated RIBP measurements. Palpated BP measurements were consistently lower than RIBP, which was statistically and clinically significant. These results raise concern about the accuracy of palpated BP and its pervasive use in prehospital care. The data also suggested that auscultated and oscillometric BP may provide similar measurements.

Conclusion (proposition de traduction) : Dans l'ensemble, les pressions sanguines non invasives ont sous-estimé de manière significative les mesures de la pression sanguine radiale intra-artérielle. Les mesures de la pression artérielle palpatoire étaient systématiquement inférieures à la pression artérielle radiale intra-artérielle, ce qui était statistiquement et cliniquement significatif. Ces résultats suscitent des inquiétudes quant à la précision de la pression artérielle palpée et à son utilisation généralisée dans les soins préhospitaliers. Les données ont également suggéré que la pression artérielle auscultatoire et oscillométrique pourrait fournir des mesures similaires.

Diagnostic Performance of Prehospital Point-of-Care Troponin Tests to Rule Out Acute Myocardial Infarction: A Systematic Review.
Alghamdi A, Alotaibi A, Alharbi M, Reynard C, Body R. | Prehosp Disaster Med. 2020 Oct;35(5):567-573
DOI: https://doi.org/10.1017/s1049023x20000850
Keywords: biomarkers; chest pain; myocardial infarction; paramedic.

Systematic Review

Introduction : Chest pain is one of the most common reasons for 999 calls and transfers to the emergency department (ED). In these patients, acute myocardial infarction (AMI) is often the diagnosis that clinicians are seeking to exclude. However, only a minority of those patients have AMI, causing a substantial financial burden to health services. Cardiac troponin (cTn) is the reference standard biomarker for the diagnosis of AMI. Several commercially available point-of-care (POC) cTn assays are portable and could feasibly be used in an ambulance. The aim of this paper is to systematically review existing evidence for the use of POC cTn assays in the prehospital setting to rule out AMI.

Méthode : A systematic search was conducted on EMBASE, MEDLINE, and CINAHL Plus databases, reference lists, and relevant grey literature, including combinations of the relevant terms. Papers published in English language since the year 2000 were eligible for inclusion. A narrative synthesis of the evidence was then undertaken.

Résultats : The initial search and cross-referencing revealed a total of 350 papers, of which 243 were excluded. Seven papers were included in the systematic literature review.

Conclusion : Current evidence does not support the use of POC troponin assays to exclude AMI due to issues with diagnostic accuracy and insufficient high-quality evidence.

Conclusion (proposition de traduction) : Les preuves actuelles ne soutiennent pas l'utilisation du dosages de la troponine au point d'intervention pour exclure l'infarctus aigu du myocarde en raison de problèmes de précision diagnostique et de preuves insuffisantes de haute qualité.

Prehospital Emergency Care

Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest.
Hubble MW, Van Vleet L, Taylor S, Bachman M, Williams JG, Vipperman R, Renkiewicz GK. | Prehosp Emerg Care. 2020 Oct 28:1-9
DOI: https://doi.org/10.1080/10903127.2020.1828518
Keywords: capnography; cardiac arrest; cardiopulmonary resuscitation; defibrillation; ventricular fibrillation.

Article

Introduction : The likelihood of survival from ventricular fibrillation (VF) declines 7%-10% per minute until successful defibrillation. When VF duration is prolonged, immediate defibrillation of the ischemic myocardium is less likely to result in ROSC, and repeated unsuccessful defibrillations are associated with post-resuscitation myocardial dysfunction. Thus, the timing of defibrillation should be based upon the probability of shock success-a function of VF duration. Unfortunately, VF duration is often unknown in out-of-hospital cardiac arrest (OHCA) and a better predictor of shock success is needed.
Objective: To assess the ability of end-tidal carbon dioxide (EtCO2) to predict successful defibrillation in OHCA.

Méthode : This retrospective study included adult patients among four EMS systems who experienced non-traumatic OHCA from August, 2015-July, 2017 and received one or more defibrillations. First and succedent shocks were analyzed separately. First shocks represented EMS-attempted defibrillation of patients who had not received a prior AED shock, whereas succedent shocks included all shocks subsequent to the first. Logistic regression provided odds ratios (OR) for first shocks resulting in ROSC, while a generalized estimating equation was used to analyze succedent shocks.

Résultats : Among 324 patients, 869 shocks were delivered by EMS (153 first and 716 succedent shocks). Layperson CPR was performed in 48.1% of cases and 21.6% received an AED shock before EMS arrival. First defibrillation ROSC was more likely with layperson CPR (OR = 4.41;p = 0.01) and increasing EtCO2 (OR = 1.03/mmHg;p = 0.01). No other variables were statistically significant. Notably, only one patient with EtCO2 < 20 mmHg was successfully defibrillated on the first shock. The probability of ROSC was higher with increasing values of EtCO2 when layperson CPR was provided, yet remained relatively unchanged across all values of EtCO2 ≥ 20 mmHg without layperson CPR. The optimal threshold first shock EtCO2 was 27 and 32 mmHg for those with/without layperson CPR, respectively. EtCO2 was not a predictor of ROSC for succedent shocks.

Conclusion : An optimal defibrillation threshold EtCO2 of 27 and 32 mmHg was observed for patients with and without layperson CPR, respectively. Further studies are warranted to verify these results and to evaluate the clinical effect of delaying defibrillation in favor of chest compressions until these values are attained.

Conclusion (proposition de traduction) : Un seuil d'EtCO2 de 27 et 32 mmHg pour réaliser une défibrillation optimale a été observé pour les patients avec et sans RCP par un témoin non professionnel, respectivement. Des études supplémentaires sont justifiées pour vérifier ces résultats et évaluer l'effet clinique du report de la défibrillation en faveur des compressions thoraciques jusqu'à ce que ces valeurs soient atteintes.

Ketamine for Prehospital Pain Management Does Not Prolong Emergency Department Length of Stay.
Robinson EJ, Watanabe BL, Brown LH. | Prehosp Emerg Care. 2020 Oct 12:1-8
DOI: https://doi.org/10.1080/10903127.2020.1819493
Keywords: emergency medical services; ketamine; pain management.

Article

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 en préhospitalier, par rapport à la morphine ou au fentanyl, pour la prise en charge des affections douloureuses non cardiorespiratoires isolées.

Ventilation in Simulated Out-of-Hospital Cardiac Arrest Resuscitation Rarely Meets Guidelines.
Neth MR, Benoit JL, Stolz U, McMullan J. | Prehosp Emerg Care. 2020 Oct 6:1-9
DOI: https://doi.org/10.1080/10903127.2020.1822481
Keywords: EMT; assessment; minute ventilation; out-of-hospital cardiac arrest; prehospital; simulation; tidal volume; ventilation rate.

Article

Introduction : The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend ventilation rates of eight to ten breaths per minute or two ventilations every 30 compressions, and tidal volumes between 500-600 ml. However, compliance with these guidelines is mainly unknown. The objective of this study is to estimate the proportion of simulated adult OHCA cases that meet guideline-based ventilation targets.

Méthode : We conducted a blinded prospective observational study of standardized simulated cases of EMS-witnessed adult OHCA. During scheduled training sessions, resuscitations were performed by high-quality CPR trained EMS teams composed of four on-duty, full-time EMT/Paramedics from a large urban fire-based EMS agency. A high-fidelity simulation center allowed complete audio and video monitoring from a control room. Rescuers were unaware of the study, or that ventilation practices were being observed. All interventions, including airway and ventilation strategies, were at the discretion of the clinical team. A calibrated Laerdal SimMan 3 G manikin and associated Laerdal Debrief Viewer software recorded ventilation rate, tidal volume, and minute ventilation. Simulations achieving median ventilation rate 7-10 breaths/min, tidal volume 500-600 ml, and minute ventilation 3.5-6 liters/min were considered meeting guideline-based targets.

Résultats : A total of 106 EMS teams were included in the study. Only 3/106 [2.8% (95% CI: 0.6-8.0)] of the EMS teams demonstrated ventilation characteristics meeting all guideline-based targets. The median ventilation rate was 5.8 breaths/min (IQR 4.4-7.7 breaths/min) with 26/106 [24.5% (95% CI: 17.2-33.7)] between 7-10 breaths/min. The median tidal volume was 413.5 ml (IQR 280.5-555.4 ml), with 18/106 [17.0% (95% CI: 10.9-25.5)] between 500-600 ml. The median minute ventilation was 2.4 L/min (IQR 1.2-3.6 L/min) with 16/106 [15.1% (95% CI: 9.4-23.3)] between 3.5-6.0 L/min.

Conclusion : During simulated adult OHCA resuscitation attempts, ventilation practices rarely met guideline-based targets, despite being performed by well-trained EMS providers. Methods should be developed to monitor and ensure high-quality ventilation during actual OHCA resuscitation attempts.

Conclusion (proposition de traduction) : Au cours des tentatives de simulation de réanimation d'un arrêt cardiaque extra-hospitalier de l'adulte, les pratiques de ventilation ont rarement atteint les objectifs proposées par les lignes directrices, bien qu'elles aient été effectuées par des prestataires de soins d'urgence bien formés. Des méthodes doivent être développées pour surveiller et assurer une ventilation de haute qualité pendant les tentatives de réanimation extra-hospitalières.

Resuscitation

The optimal surface for delivery of CPR: A systematic review and meta-analysis.
Holt J, Ward A, Mohamed TY, Chukowry P, Grolmusova N, Couper K, Morley P, Perkins GD. | Resuscitation. 2020 Oct;155:159-164
DOI: https://doi.org/10.1016/j.resuscitation.2020.07.020
Keywords: Backboard; Cardiac arrest; Chest compressions; Mattress; Systematic review.

Reviews

Introduction : To determine the effect of CPR delivery surface (e.g. firm mattress, floor, backboard) on patient outcomes and CPR delivery.

Méthode : We searched Medline, Cochrane Library and Web of Science for studies published since 2009 that evaluated the effect of CPR delivery surface in adults and children on patient outcomes and quality of CPR. We included randomised controlled trials only. We identified pre-2010 studies from the 2010 ILCOR evaluation of this topic. Two reviewers independently screened titles/ abstracts and full-text papers, extracted data and assessed risk of bias. Evidence certainty for each outcome was evaluated using GRADE methodology. Where appropriate, we pooled data in a meta-analysis, using a random-effects model.

Résultats : Database searches identified 2701 citations. We included seven studies published since 2009. We analysed these studies together with the four studies included in the previous ILCOR review. All included studies were randomised controlled trials in manikins. Certainty of evidence was very low. Increasing mattress stiffness or moving the manikin from the bed to the floor did not improve compression depth. Use of a backboard marginally improved compression depth (mean difference 3 mm (95% CI 1-4).

Conclusion : The use of a backboard led to a small increase in chest compression depth in manikin trials. Different mattress types or delivery of CPR on the floor did not affect chest compression depth.

Conclusion (proposition de traduction) : L’utilisation d’une planche dorsale a entraîné une légère augmentation de la profondeur de compression thoracique lors des essais sur mannequin. Les différents types de matelas ou la réalisation de la RCP au sol n’ont pas affecté la profondeur de compression thoracique.

Epinephrine treatment but not time to ROSC is associated with intestinal injury in patients with cardiac arrest.
Krychtiuk KA, Richter B, Lenz M, Hohensinner PJ, Huber K, Hengstenberg C, Wojta J, Heinz G, Speidl WS. | Resuscitation. 2020 Oct;155:32-38
DOI: https://doi.org/10.1016/j.resuscitation.2020.05.046
Keywords: Cardiac arrest; Epinephrine; Intestinal fatty acid binding protein; iFABP.

Clinical Papers

Introduction : Current guidelines suggest the use of epinephrine in patients with cardiac arrest (CA). However, evidence for increased survival in good neurological condition is lacking. In experimental settings, epinephrine-induced impairment of microvascular flow was shown. The aim of our study was to analyze the association between epinephrine treatment and intestinal injury in patients after CA.

Méthode : We have included 52 patients with return of spontaneous circulation (ROSC) after CA admitted to our medical intensive care unit (ICU). Blood was taken on admission and levels of circulating intestinal fatty acid binding protein (iFABP) were analyzed.

Résultats : Patients were 64 (49.8-73.8) years old and predominantly male (76.9%). After six months, 50% of patients died and 38.5% of patients had a cerebral performance category (CPC)-score of 1-2. iFABP levels were lower in survivors (234 IQR 90-399 pg/mL) as compared to non-survivors (283, IQR 86-11500 pg/mL; p < 0.05). Plasma levels of iFABP were not associated with time to ROSC but correlated with epinephrine-dose (R = 0.32; p < 0.05). 40% of patients receiving ≥3 mg of epinephrine as compared to 10.5% of patients treated with <3 mg (p < 0.05) developed iFABP plasma levels >1500 pg/mL, which was associated with dramatically increased mortality (HR4.87, 95%CI 1.95-12.1; p < 0.001). iFABP levels predicted mortality independent from time to ROSC and the disease severity score SAPS II. In contrast to mortality, iFABP plasma levels were not associated with neurological outcome.

Conclusion : In this small, single centre study, cumulative dose of epinephrine used in cardiac arrest patients was associated with an increase in biomarker indicative of intestinal injury and 6-month mortality.

Conclusion (proposition de traduction) : Dans cette petite étude monocentrique, la dose cumulative d'adrénaline utilisée chez les patients en arrêt cardiaque a été associée à une augmentation du biomarqueur indiquant une lésion intestinale et une mortalité à 6 mois.

Effects of real-time feedback on cardiopulmonary resuscitation quality on outcomes in adult patients with cardiac arrest: A systematic review and meta-analysis.
Wang SA, Su CP, Fan HY, Hou WH, Chen YC. | Resuscitation. 2020 Oct;155:82-90
DOI: https://doi.org/10.1016/j.resuscitation.2020.07.024
Keywords: Cardiopulmonary resuscitation; Feedback; Real-time; Return of spontaneous circulation; Survival.

Reviews

Introduction : To investigate the relationship between the implementation of real-time audiovisual cardiopulmonary resuscitation (CPR) feedback devices with cardiac arrest patient outcomes, such as return of spontaneous circulation (ROSC), short-term survival, and neurological outcome.

Méthode : We systematically searched PubMed, Embase, and the Cochrane CENTRAL from inception date until April 30, 2020, for eligible randomized and nonrandomized studies. Pooled odds ratio (OR) for each binary outcome was calculated using R system. The primary patient outcome was ROSC. The secondary outcomes were short-term survival and favorable neurological outcomes (cerebral performance category scores: 1 or 2).

Résultats : We identified 11 studies (8 nonrandomized and 3 randomized studies) including 4851 patients. Seven studies documented patients with out-of-hospital cardiac arrest and four studies documented patients with in-hospital cardiac arrest. The pooled results did not confirm the effectiveness of CPR feedback device, possibly because of the high heterogeneity in ROSC (OR: 1.42, 95% CI: 1.03-1.94, I2: 80%, tau2: 0.1875, heterogeneity test p < 0.01) and survival-to-discharge (OR: 1.27, 95% CI: 0.74-2.18, I2: 86%, tau2: 0.4048, heterogeneity test p < 0.01). The subgroup analysis results revealed that heterogeneity was due to the types of devices used. Patient outcomes were more favorable in studies investigating portable devices than in studies investigating automated external defibrillator (AED)-associated devices.

Conclusion : Whether real-time CPR feedback devices can improve patient outcomes (ROSC and short-term survival) depend on the type of device used. Portable devices led to better outcomes than did AED-associated devices. Future studies comparing different types of devices are required to reach robust conclusion.

Conclusion (proposition de traduction) : Le fait que les appareils de rétroaction de la RCP en temps réel puissent améliorer les résultats des patients (RACS et survie à court terme) dépend du type d'appareil utilisé. Les appareils portables ont donné de meilleurs résultats que les appareils associés aux DAE. Des études futures comparant différents types d'appareils sont nécessaires pour parvenir à une conclusion solide.

Association between sex and mortality in adults with in-hospital and out-of-hospital cardiac arrest: A systematic review and meta-analysis.
Parikh PB, Hassan L, Qadeer A, Patel JK. | Resuscitation. 2020 Oct;155:119-124
DOI: https://doi.org/10.1016/j.resuscitation.2020.07.031
Keywords: Cardiac arrest; Female; Gender; In-hospital cardiac arrest; Male; Men; Mortality; Out-of-hospital cardiac arrest; Outcomes; Sex; Survival; Women.

Review

Introduction : Conflicting data exists regarding the association between sex and mortality in adults with in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA). We therefore conducted a meta-analysis to investigate the association between sex and mortality in adults with IHCA and OHCA.

Méthode : We systematically searched MEDLINE and Cochrane databases to identify studies reporting sex-specific mortality in adults following IHCA or OHCA from inception to April 2020. Data were pooled using random-effects models. The primary outcome of interest was in-hospital (or 30-day) all-cause mortality.

Résultats : We included 21 observational studies with a total of 1,029,978 adult patients - 622,085 men and 407,893 women. Seven studies included patients only with IHCA and 14 studies included patients only with OHCA. Female sex was associated with significantly higher mortality following OHCA [odds ratio (OR) 1.56, 95% confidence interval (CI) 1.32-1.84, p < 0.001) and a trend toward higher mortality following IHCA (OR 1.10, 95%CI 1.00-1.20, p = 0.052).

Conclusion : In adults with cardiac arrest, female sex was associated with significantly higher mortality following OHCA and a trend toward higher mortality following IHCA.

Conclusion (proposition de traduction) : Chez l'adultes en arrêt cardiaque, le sexe féminin était associé à une mortalité significativement plus élevée après un arrêt cardiaque extra-hospitalier et à une tendance à une mortalité plus élevée chez les adultes ayant en arrêt cardiaque inra-hospitalier.

Double (dual) sequential defibrillation for refractory ventricular fibrillation cardiac arrest: A systematic review.
Deakin CD, Morley P, Soar J, Drennan IR. | Resuscitation. 2020 Oct;155:24-31
DOI: https://doi.org/10.1016/j.resuscitation.2020.06.008  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Double sequential defibrillation; Emergency medical services; Out-of-hospital cardiac arrest; Ventricular fibrillation.

Reviews

Introduction : Cardiac arrests associated with shockable rhythms such as ventricular fibrillation or pulseless VT (VF/pVT) are associated with improved outcomes from cardiac arrest. The more defibrillation attempts required to terminate VF/pVT, the lower the survival. Double sequential defibrillation (DSD) has been used for refractory VF/pVT cardiac arrest despite limited evidence examining this practice. We performed a systematic review to summarize the evidence related to the use of DSD during cardiac arrest.

Méthode : This review was performed according to PRISMA and registered on PROSPERO (ID: CRD42020152575). We searched Embase, Pubmed, and the Cochrane library from inception to 28 February 2020. We included adult patients with VF/pVT in any setting. We excluded case studies, case series with less than five patients, conference abstracts, simulation studies, and protocols for clinical trials. We predefined our outcomes of interest as neurological outcome, survival to hospital discharge, survival to hospital admission, return of spontaneous circulation (ROSC), and termination of VF/pVT. Risk of bias was examined using ROBINS-I or ROB-2 and certainty of studies were reported according to GRADE methodology.

Résultats : Overall, 314 studies were identified during the initial search. One hundred and thirty studies were screened during title and abstract stage and 10 studies underwent full manuscript screening, nine included in the final analysis. Included studies were cohort studies (n = 4), case series (n = 3), case-control study (n = 1) and a prospective pilot clinical trial (n-1). All studies were considered to have serious or critical risk of bias and no meta-analysis was performed. Overall, we did not find any differences in terms of neurological outcome, survival to hospital discharge, survival to hospital admission, ROSC, or termination of VF/pVT between DSD and a standard defibrillation strategy.

Conclusion : The use of double sequential defibrillation was not associated with improved outcomes from out-of-hospital cardiac arrest, however the current literature has a number of limitations to interpretation. Further high-quality evidence is needed to answer this important question.

Conclusion (proposition de traduction) : L'utilisation de la double défibrillation séquentielle n'a pas été associée à une amélioration des résultats dans l'arrêt cardiaque extra-hospitalier, mais la littérature actuelle présente un certain nombre de limites d'interprétation. Des preuves supplémentaires de haute qualité sont nécessaires pour répondre à cette question importante.

Is your unconscious patient in cardiac arrest? A New protocol for telephonic diagnosis by emergency medical call-takers: A national study.
Mao DR, Ee AZQ, Leong PWK, Leong BS, Arulanandam S, Ng M, Ng YY, Siddiqui FJ, Ong MEH. | Resuscitation. 2020 Oct;155:199-206
DOI: https://doi.org/10.1016/j.resuscitation.2020.08.009
Keywords: Cardiac arrest; Dispatcher-assisted cardiopulmonary resuscitation; Telephonic diagnosis; Unconscious.

Clinical paper

Introduction : Worldwide, call-taker recognition of out-of-hospital cardiac arrests (CA) suffers from poor accuracy, leading to missed opportunities for dispatcher-assisted cardiopulmonary resuscitation (DACPR) in CA patients and inappropriate DACPR in non-CA patients. Diagnostic protocols typically ask 2 questions in sequence: 'Is the patient conscious?' and 'Is the patient breathing normally?' As part of quality improvement efforts, our national emergency medical call centre changed the breathing question to an instruction for callers to place their hand onto the patient's abdomen to evaluate for the presence of breathing.

Méthode : We performed a prospective before-and-after study of all unconscious cases from the national call centre database over a 31-day period in 2018. Cases were placed in 2 groups: 1) 'Before' group (standard protocol) where call-takers asked 'Is the patient breathing normally?' and 2) 'After' group (modified protocol) where callers were instructed to place their hand on the patient's abdomen. In an intention-to-treat analysis, the accuracy, sensitivity and specificity of both protocols for determining CA were compared.

Résultats : 1557 calls presented with unconsciousness, of which 513 cases were included. 231 cases were in the 'Before' group and 282 cases were in the 'After' group. The 'After' showed superior accuracy (84.4% vs 67.5%), sensitivity (75.0% vs 40.4%) and specificity (87.9% vs 75.4%) when compared to the standard protocol. Adherence in the 'Before' group to the standard protocol was 100%. However, adherence in the 'After' group to the modified protocol was 50.4%. Per protocol analysis comparing the modified protocol with the standard protocol showed vastly improved accuracy (96.5% vs 69.3%), sensitivity (94.1% vs 39.0%) and specificity (97.8% vs 77.2%) of the modified protocol. In patients with true cardiac arrest, the median time to 1st compression was 32.5 s longer in the modified protocol group when compared to the standard protocol group, approaching significance (199.5 s vs 167.0 s, p = 0.059). Median time to recognize CA was similar in both groups.

Conclusion : Dispatch assessment using the hand on abdomen method appeared feasible but uptake by dispatch staff was moderate. Diagnostic performance of this method should be verified in randomised trials.

Conclusion (proposition de traduction) : L’évaluation à l’aide de la méthode « main sur l’abdomen  » semblait faisable, mais la participation par les professionnels était modérée. Les performances diagnostiques de cette méthode doivent être vérifiées dans des essais randomisés.

The relationship between no-flow interval and survival with favourable neurological outcome in out-of-hospital cardiac arrest: Implications for outcomes and ECPR eligibility.
Guy A, Kawano T, Besserer F, Scheuermeyer F, Kanji HD, Christenson J, Grunau B. | Resuscitation. 2020 Oct;155:219-225
DOI: https://doi.org/10.1016/j.resuscitation.2020.06.009
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Emergency medical services; Extracorporeal life support; Resuscitation.

Clinical paper

Introduction : The "no flow" interval is the time from out-of-hospital cardiac arrest (OHCA) to cardiopulmonary resuscitation (CPR). Its prognostic value is important to define for prehospital resuscitation decisions, post-resuscitation care and prognostication, and extracorporeal cardiopulmonary resuscitation (ECPR) candidacy assessment.

Méthode : We examined bystander-witnessed OHCAs without bystander CPR from two Resuscitation Outcomes Consortium datasets. We used modified Poisson regression to model the relationship between the no-flow interval (9-1-1 call to professional resuscitation) and favourable neurological outcome (Modified Rankin Score ≤ 3) at hospital discharge. Furthermore, we identified the no-flow interval beyond which no patients had a favourable outcome. We analysed a subgroup to simulate ECPR-treated patients (witnessed arrest, age < 65, non-asystole initial rhythm, and >30 min until return of circulation).

Résultats : Of 43,593 cases, we included 7299; 616 (8.4%) had favourable neurological outcomes. Increasing no-flow interval was inversely associated with favourable neurological outcomes (adjusted relative risk 0.87, 95% CI 0.85-0.90); the adjusted probability of a favourable neurological outcome decreased by 13% (95% CI 10-15%) per minute. No patients (0/7299, 0%; 1-sided 97.5% CI 0-0.051%) had both a no-flow interval >20 min and a favourable neurological outcome. In the hypothetical ECPR group, 0/152 (0%; 1-sided 97.5% CI 0-2.4%) had both a no-flow interval >10 min and a favourable neurological outcome.

Conclusion : The probability of a favourable neurological outcome in OHCA decreases by 13% for every additional minute of no-flow time until high-quality CPR, with the possibility of favourable outcomes up to 20 min.

Conclusion (proposition de traduction) : La probabilité d'un résultat neurologique favorable dans l'arrêt cardiaque extra-hospitalier diminue de 13 % pour chaque minute supplémentaire de temps sans circulation jusqu'à la mise en oeuvre d'une RCP de haute qualité, avec la possibilité de résultats favorables jusqu'à 20 min.

The American Journal of Emergency Medicine

Retrospective analysis of the hemodynamic consequences of prehospital supplemental oxygen in acute stroke.
Dylla L, Cushman JT, Abar B, Benesch C, Jones CMC, O'Banion MK, Adler DH M. | Am J Emerg Med. 2020 Oct;38(10):2125-2129
DOI: https://doi.org/10.1016/j.ajem.2020.07.021
Keywords: Acute ischemic stroke; Hyperoxia; Prehospital.

Original Contribution

Introduction : Hyperoxia, the delivery of high levels of supplemental oxygen (sO2) despite normoxia, may increase cerebral oxygenation to penumbral tissue and improve stroke outcomes. However, it may also alter peripheral hemodynamic profiles with potential negative effects on cerebral blood flow (CBF). This study examines the hemodynamic consequences of prehospital sO2 in stroke.

Méthode : A retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017 was conducted using demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects' medical records. Outcomes were compared across three groups based on prehospital oxygen saturation and sO2 administration. Chi-square, ANOVA, and multivariable linear regression were used to determine if sO2 was associated with differences in peripheral hemodynamic profiles.

Résultats : All subjects had similar initial EMS vitals except for oxygen saturation. However, both univariate and multivariable analysis revealed that hyperoxia subjects had slightly lower average ED mean arterial pressures (MAP) compared to normoxia (Cohen's d = 0.313).

Conclusion : Prehospital-initiated hyperoxia for acute stroke is associated with a small, but significant decrease in average ED MAP, without changes in heart rate, compared to normoxia. While limited by the inability to link changes in peripheral hemodynamical profiles directly to changes in CBF, this study suggests that hyperoxia may result in a relative hypotension. Further studies are needed to determine if this small change in peripheral vascular resistance translates into a clinically significant reduced CBF.

Conclusion (proposition de traduction) : L'hyperoxie préhospitalière dans accident vasculaire cérébral à la phase aigüe est associée à une diminution faible, mais significative, de la pression artérielle moyenne (PAM) au service des urgences, sans modification de la fréquence cardiaque, par rapport à la normoxie.
Bien que limitée par l'incapacité de lier directement les modifications des profils hémodynamiques périphériques aux modifications du flux sanguin cérébral, cette étude suggère que l'hyperoxie peut entraîner une hypotension relative. Des études supplémentaires sont nécessaires pour déterminer si ce petit changement de la résistance vasculaire périphérique se traduit par une réduction du débit sanguin cérébral cliniquement significatif.

Predictive performance of SOFA and qSOFA for in-hospital mortality in severe novel coronavirus disease.
Liu S, Yao N, Qiu Y, He C. | Am J Emerg Med. 2020 Oct;38(10):2074-2080
DOI: https://doi.org/10.1016/j.ajem.2020.07.019  | Télécharger l'article au format  
Keywords: Mortality; Novel coronavirus disease; Quick sequential organ failure assessment; Sequential organ failure assessment.

Original Contribution

Introduction : The assessment of illness severity at admission can contribute to decreased mortality in patients with the coronavirus disease (COVID-19). This study was conducted to evaluate the effectiveness of the Sequential Organ Failure Assessment (SOFA) and Quick Sequential Organ Failure Assessment (qSOFA) scoring systems at admission for the prediction of mortality risk in COVID-19 patients.

Méthode : We included 140 critically ill COVID-19 patients. Data on demographics, clinical characteristics, and laboratory findings at admission were used to calculate SOFA and qSOFA against the in-hospital outcomes (survival or death) that were ascertained from the medical records. The predictive accuracy of both scoring systems was evaluated by the receiver operating characteristic (ROC) curve analysis.

Résultats : The area under the ROC curve for SOFA in predicting mortality was 0.890 (95% CI: 0.826-0.955), which was higher than that of qSOFA (0.742, 95% CI 0.657-0.816). An optimal cutoff of ≥3 for SOFA had sensitivity, specificity, positive predictive value, and negative predictive value of 90.00%, 83.18%, 50.00%, and 97.80%, respectively.

Conclusion : This novel report indicates that SOFA could function as an effective adjunctive risk-stratification tool at admission for critical COVID-19 patients. The performance of qSOFA is accepted but inferior to that of SOFA.

Conclusion (proposition de traduction) : Cette nouvelle étude indique que le score SOFA pourrait fonctionner comme un outil complémentaire efficace de stratification du risque à l'admission pour les patients critiques atteinte de la COVID-19. Les performances du qSOFA sont acceptables mais inférieures à celles du score SOFA.

Commentaire : Voir l'article :
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1038  .

Pulmonary embolism in COVID-19: Clinical characteristics and cardiac implications.
Kho J, Ioannou A, Van den Abbeele K, Mandal AKJ, Missouris CG. | Am J Emerg Med. 2020 Oct;38(10):2142-2146
DOI: https://doi.org/10.1016/j.ajem.2020.07.054  | Télécharger l'article au format  
Keywords: COVID-19; Coagulopathy; Coronavirus; Pulmonary embolism; Venous thromboembolism.

Brief Reports

Introduction : The thrombogenic potential of Covid-19 is increasingly recognised. We aim to assess the characteristics of COVID-19 patients diagnosed with pulmonary embolism (PE).

Méthode : We conducted a single centre, retrospective observational cohort study of COVID-19 patients admitted between 1st March and 30th April 2020 subsequently diagnosed with PE following computed tomography pulmonary angiogram (CTPA). Patient demographics, comorbidities, presenting complaints and inpatient investigations were recorded.

Résultats : We identified 15 COVID-19 patients diagnosed with PE (median age = 58 years [IQR = 23], 87% male). 2 died (13%), both male patients >70 years. Most common symptoms were dyspnoea (N = 10, 67%) and fever (N = 7, 47%). 12 (80%) reported 7 days or more of non-resolving symptoms prior to admission. 7 (47%) required continuous positive airway pressure (CPAP), 2 (13%) of which were subsequently intubated. All patients had significantly raised D-dimer levels, lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin and prothrombin times. The distribution of PEs correlated with the pattern of consolidation observed on CTPA in 9 (60%) patients; the majority being peripheral or subsegmental (N = 14, 93%) and only 1 central PE. 10 (67%) had an abnormal resting electrocardiogram (ECG), the commonest finding being sinus tachycardia. 6 (40%) who underwent transthoracic echocardiography (TTE) had structurally and functionally normal right hearts.

Conclusion : Our study suggests that patients who demonstrate acute deterioration, a protracted course of illness with non-resolving symptoms, worsening dyspnoea, persistent oxygen requirements or significantly raised D-dimer levels should be investigated for PE, particularly in the context of COVID-19 infection. Transthoracic echocardiography and to a lesser degree the ECG are unreliable predictors of PE within this context.

Conclusion (proposition de traduction) : Notre étude suggère que les patients qui présentent une détérioration aiguë, une évolution prolongée de la maladie avec des symptômes non résolus, une dyspnée aggravée, des besoins persistants en oxygène ou des niveaux de D-dimères significativement élevés devraient être étudiés pour la PE, en particulier dans le contexte d'une infection au COVID-19. L'échocardiographie transthoracique et dans une moindre mesure l'ECG ne sont pas des prédicteurs fiables de l'EP dans ce contexte.

COVID-19 respiratory support in the emergency department setting.
Montrief T, Ramzy M, Long B, Gottlieb M, Hercz D. | Am J Emerg Med. 2020 Oct;38(10):2160-2168
DOI: https://doi.org/10.1016/j.ajem.2020.08.001  | Télécharger l'article au format  
Keywords: Airway; COVID-19; Coronavirus; Emergency medicine; Intensive care; Intubation; SARS-CoV-2.

Reviews

Introduction : Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), may result in severe complications, multiorgan dysfunction, acute respiratory failure, and death. SARS-CoV-2 is highly contagious and places healthcare workers at significant risk, especially during aerosol-generating procedures, including airway management.

Méthode : This narrative review outlines the underlying respiratory pathophysiology of patients with COVID-19 and discusses approaches to airway management in the emergency department (ED) based on current literature.

Résultats : Patients presenting with SARS-CoV-2 infection are at high risk for acute respiratory failure requiring airway management. Among hospitalized patients, 10-20% require intensive care unit admission, and 3-10% require intubation and mechanical ventilation. While providing respiratory support for these patients, proper infection control measures, including adherence to personal protective equipment policies, are necessary to prevent nosocomial transmission to healthcare workers. A structured approach to respiratory failure in these patients includes the use of exogenous oxygen via nasal cannula or non-rebreather, as well as titrated high-flow nasal cannula and non-invasive ventilation. This review offers several guiding principles and resources designed to be adapted in conjunction with local workplace policies for patients requiring respiratory support.

Conclusion : While the fundamental principles of acute respiratory failure management are similar between COVID-19 and non-COVID-19 patients, there are some notable differences, including a focus on provider safety. This review provides an approach to airway management and respiratory support in the patient with COVID-19.

Conclusion (proposition de traduction) : Bien que les principes fondamentaux de la gestion de l’insuffisance respiratoire aiguë soient semblables entre les patients atteints de la COVID-19 et ceux qui ne sont pas atteints de la COVID-19, il existe certaines différences notables, notamment l’accent mis sur la sécurité des fournisseurs de soins. Cet revue de la littérature fournit une approche de la gestion des voies respiratoires et de l'assistance respiratoire chez le patient atteint de la COVID-19.

Amiodarone and/or lidocaine for cardiac arrest: A Bayesian network meta-analysis.
Zhao H, Fan K, Feng G. | Am J Emerg Med. 2020 Oct;38(10):2185-2193
DOI: https://doi.org/10.1016/j.ajem.2020.06.074
Keywords: Amiodarone; Amiodarone plus lidocaine; Cardiac arrest; Lidocaine.

Reviews

Introduction : Although available studies have not demonstrated that antiarrhythmic drugs could increase long-term survival or survival with favorable neurological outcome, some studies have shown that the rate of hospital admission is higher with amiodarone or lidocaine than with placebo. To study the effects of antiarrhythmic drugs during cardiac arrest, a meta-analysis was conducted to assess the efficacy of amiodarone and/or lidocaine.

Méthode : We searched studies from inception until Jan 21, 2020. The primary endpoint was survival to hospital discharge in cardiac arrest, and the secondary endpoints were survival to hospital admission/24 h and favorable neurological outcome.

Résultats : A total of 9 studies were included. In head-to-head studies, amiodarone (odds ratio [OR] 2.96, 95% credible interval [CrI] 1.02-8.53) and lidocaine (OR 3.12, 95% CrI 1.08-9.98) had superior effects on survival to hospital admission/24 h compared to the combination of the two drugs. In terms of survival to hospital discharge, amiodarone (OR 1.18, 95% CrI 1.03-1.35) and lidocaine (OR 1.22, 95% CrI 1.06-1.41) were more effective than placebo. Amiodarone (OR 1.20, 95% CrI 1.02-1.41) was significantly better than placebo in favorable neurological outcome. However, there was no significant difference in other pairwise comparisons. The surface under cumulative ranking curve (SUCRA) revealed that lidocaine was the most effective therapy for survival to hospital admission (84.1%) and discharge (88.4%), while amiodarone was associated with a more favorable neurological outcome (88.2%).

Conclusion : Lidocaine had the best effect on both survival to hospital admission and discharge, while amiodarone was associated with a more favorable neurological outcome.

Conclusion (proposition de traduction) : La lidocaïne a eu le meilleur effet tant sur la survie à l’admission qu'à la sortie de l'hôpital, tandis que l’amiodarone a été associée à un résultat neurologique plus favorable.

Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS.
Lentz S, Roginski MA, Montrief T, Ramzy M, Gottlieb M, Long B. | Am J Emerg Med. 2020 Oct;38(10):2194-2202
DOI: https://doi.org/10.1016/j.ajem.2020.06.082  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; COVID-19; Lung protective strategy; Mechanical ventilation; Respiratory failure; SARS-CoV-2.

Reviews

Introduction : Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging viral pathogen that causes the novel coronavirus disease of 2019 (COVID-19) and may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation in the most severe cases.

Méthode : This narrative review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.

Discussion : In severe cases, COVID-19 leads to hypoxemic respiratory failure that may meet criteria for acute respiratory distress syndrome (ARDS). The mainstay of treatment for ARDS includes a lung protective ventilation strategy with low tidal volumes (4-8 mL/kg predicted body weight), adequate positive end-expiratory pressure (PEEP), and maintaining a plateau pressure of < 30 cm H2O. While further COVID-19 specific studies are needed, current management should focus on supportive care, preventing further lung injury from mechanical ventilation, and treating the underlying cause.

Conclusion : This review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.

Conclusion (proposition de traduction) : Cette revue fournit des recommandations fondées sur les preuves pour le traitement de l'insuffisance respiratoire liée à la COVID-19 nécessitant une ventilation mécanique invasive.

The Journal of Emergency Medicine

Association of Pain Location With Computed Tomography Abnormalities in Emergeny Department Patients With Abdominal Pain.
Morley EJ, Bracey A, Reiter M, Thode HC Jr, Singer AJ. | J Emerg Med. 2020 Oct;59(4):485-490
DOI: https://doi.org/10.1016/j.jemermed.2020.06.002
Keywords: abdominal pain; appendicitis; computed tomography; diverticulitis; physical examination

Original Contribution

Introduction : Over the last decade the usage of computed tomography (CT) imaging has risen dramatically in emergency department (ED) patients with abdominal pain. Recognizing the potential disadvantages of overuse of CT imaging, efforts are being made to reduce imaging.

Méthode : This is a prospective, observational registry of ED patients with abdominal pain, performed in an academic, suburban ED with an annual census of 110,000. Presence of clinically significant CT abnormalities (e.g., appendicitis, diverticulitis, bowel obstruction) were recorded along with clinical variables including laboratory values, vital signs, reported location of pain, location of tenderness on examination, and physician pretest probability.

Résultats : A convenience sample of 1154 patients was enrolled. Of all patients, 273 cases (24%) had abnormal CT results, including appendicitis (n = 95), diverticulitis (n = 133), and bowel obstruction (n = 49). Right upper quadrant pain was negatively associated with abnormal CT (p = 0.02). Clinician gestalt was highly specific, but lacked sensitivity for the diagnosis of appendicitis, diverticulitis, and obstruction. Twenty-four percent of patients diagnosed with appendicitis had no right lower quadrant pain or tenderness, and 7% of patients with diverticulitis had no left lower quadrant pain or tenderness.

Conclusion : Localization of abdominal pain by history or physical examination is not sufficient to accurately diagnose intra-abdominal pathology, especially cases of acute appendicitis, diverticulitis, or intestinal obstruction.

Conclusion (proposition de traduction) : La localisation des douleurs abdominales par l'anamnèse ou l'examen physique n'est pas suffisante pour diagnostiquer avec précision la pathologie intra-abdominale, en particulier les cas d'appendicite aiguë, de diverticulite ou d'occlusion intestinale.

Double Defibrillation for Refractory In- and Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.
Miraglia D, Miguel LA, Alonso W. | J Emerg Med. 2020 Oct;59(4):521-541
DOI: https://doi.org/10.1016/j.jemermed.2020.06.024
Keywords: Aucun

Research article

A Comparison of Etomidate, Ketamine, and Methohexital in Emergency Department Rapid Sequence Intubation.
Farrell NMa P, Killius K, Kue R, Langlois BK, Nelson KP, Golenia P. | J Emerg Med. 2020 Oct;59(4):508-514
DOI: https://doi.org/10.1016/j.jemermed.2020.06.054
Keywords: emergency department; etomidate; ketamine; methohexital; rapid sequence intubation

Brief Reports

Introduction : Rapid sequence intubation (RSI) is routinely used for emergent airway management in the emergency department (ED). It involves the use of induction, and paralytic agents help facilitate endotracheal tube placement.Objective: In response to a previous national drug shortage resulting in the use of alternative induction agents for RSI, we describe the effectiveness and safety of ED RSI with ketamine or methohexital compared with etomidate.

Méthode : We conducted a retrospective, single-center observational study from March 1-August 31, 2012 describing RSI with etomidate, ketamine, and methohexital. All adult patients undergoing RSI in the ED who received etomidate prior to its shortage and methohexital or ketamine during the shortage were included.

Résultats : The study included 47, 9, and 26 patients in the etomidate, ketamine, and methohexital groups, respectively. Successful intubation on the first attempt occurred in 74.5%, 55.6%, and 73.1% of the etomidate, ketamine, and methohexital groups, respectively. The mean number of intubation attempts and time to intubation seemed to be similar in all groups. At least three intubation attempts were required in 22.2% and 7.7% of the ketamine and methohexital groups, respectively, compared with none in the etomidate group. Two aspirations were observed in the etomidate group.

Conclusion : Methohexital and etomidate had similar rates of successful intubation on the first attempt and seem to be more effective than ketamine. Etomidate may reduce the need for three or more intubation attempts. Larger, prospective studies are needed to determine if ketamine or methohexital are more effective than etomidate for RSI.

Conclusion (proposition de traduction) : Le méthohexital et l'étomidate ont eu des taux similaires d'intubation réussie à la première tentative et semblent être plus efficaces que la kétamine. L'étomidate peut réduire la nécessité de trois tentatives d'intubation ou plus. Des études prospectives plus importantes sont nécessaires pour déterminer si la kétamine ou le méthohexital sont plus efficaces que l'étomidate pour l'intubation en séquence rapide.

Commentaire : Remarque :
Le méthohexital sodique ou méthohexitone (Briétal) des Laboratoires Lilly est un barbiturique intraveineux de courte durée d'action et à début d'action rapide, il a été découvert et développé en 1956. Il permettait des gestes courts de 5 à 7 minutes, il pouvait y avoir des réinjections.
Il est similaire dans ses effets au thiopental sodique. Il a été détrôné par le propofol.

A Time-Dependent Propensity Score Matching Approach to Assess Epinephrine Use on Patients Survival Within Out-of-Hospital Cardiac Arrest Care.
Baert V, Hubert H, Chouihed T, Claustre C, Wiel É, Escutnaire J, Jaeger D, Vilhelm C, Segal N, Adnet F, Gueugniaud PY, Tazarourte K, Mebazaa A, Fraticelli L, El Khoury C; RéAC Research Group. | J Emerg Med. 2020 Oct;59(4):542-552
DOI: https://doi.org/10.1016/j.jemermed.2020.06.016
Keywords: epinephrine; out-of-hospital cardiac arrest; resuscitation; time-dependent propensity score.

Selected Topics: Prehospital Care

Introduction : Epinephrine effectiveness and safety are still questioned. It is well known that the effect of epinephrine varies depending on patients' rhythm and time to injection. Objective: We aimed to assess the association between epinephrine use during out-of-hospital cardiac arrest (OHCA) care and patient 30-day (D30) survival.

Méthode : Between 2011 and 2017, 27,008 OHCA patients were included from the French OHCA registry. We adjusted populations using a time-dependent propensity score matching. Analyses were stratified according to patient's first rhythm. After matching, 2837 pairs of patients with a shockable rhythm were created and 20,950 with a nonshockable rhythm.

Résultats : Whatever the patient's rhythm (shockable or nonshockable), epinephrine use was associated with less D30 survival (odds ratio [OR] 0.508; 95% confidence interval [CI] 0.440-0.586] and OR 0.645; 95% CI 0.549-0.759, respectively). In shockable rhythms, on all outcomes, epinephrine use was deleterious. In nonshockable rhythms, no difference was observed regarding return of spontaneous circulation and survival at hospital admission. However, epinephrine use was associated with worse neurological prognosis (OR 0.646; 95% CI 0.549-0.759).

Conclusion : In shockable and nonshockable rhythms, epinephrine does not seem to have any benefit on D30 survival. These results underscore the need to perform further studies to define the optimal conditions for using epinephrine in patients with OHCA.

Conclusion (proposition de traduction) : Dans les rythmes choquables et non choquables, l'adrénaline ne semble pas avoir de bénéfice sur la survie à 30 jours. Ces résultats soulignent la nécessité de mener des études complémentaires pour définir les conditions optimales d'utilisation de l'adrénaline chez les patients en arrêt cardiaque extra-hospitalier.

The Effect of Lights and Sirens on Critical Care Transport Time.
Jansson PS, Richards JB, Frakes MA, Cohen JE, Wilcox SR. | J Emerg Med. 2020 Oct;59(4):553-560
DOI: https://doi.org/10.1016/j.jemermed.2020.06.066
Keywords: critical care transportation; ground transportation; interfacility transportation; lights and sirens; transport time.

Research article - Critical Care

Introduction : In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation. Objective: The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport.

Méthode : We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for L&S were assessed and the transport times with and without L&S were compared using distance matching for common transport routes. Median times were compared for temporal subgroups.

Résultats : L&S were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p < 0.001). The timing of the transport was not associated with L&S use. For all transports, there was a significant decrease in the transport time using L&S, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without L&S (33 vs. 41 min; p < 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports.

Conclusion : The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours.

Conclusion (proposition de traduction) : L'utilisation du gyrophare et du deux-tons pendant le transport de soins intensifs entre les établissements a été associée à une réduction de temps statistiquement significative dans cette analyse rétrospective urbaine à un seul système. Bien que l'utilisation du gyrophare et du deux-tons n'ait pas été associée aux transports aux heures de pointe, la plus grande réduction de temps était associée au transport des gyrophare et du deux-tons pendant ces heures.

High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II.
Lentz S, Grossman A, Koyfman A, Long B. | J Emerg Med. 2020 Oct;59(4):573-585
DOI: https://doi.org/10.1016/j.jemermed.2020.05.009
Keywords: airway; aortic stenosis; cardiac tamponade; elevated intracranial pressure; morbid obesity; postintubation cardiac arrest; pregnancy; trauma; upper gastrointestinal bleed.

Research article - Techniques and Procedures

Introduction : Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series.

Méthode : This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department.

Résultats : Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise.

Conclusion : This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.

Conclusion (proposition de traduction) : Cette revue descriptive examine les trucs et astuces, les plus courantes, des intubations physiologiques à risque élevé, en mettant l’accent sur le clinicien d’urgence.

Commentaire : Retrouvez la première partie :
Lentz S, Grossman A, Koyfman A, Long B. High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches. J Emerg Med. 2020 Jul;59(1):84-95  .

Best Practice Recommendations for Point-of-Care Lung Ultrasound in Patients with Suspected COVID-19.
Duggan NM, Shokoohi H, Liteplo AS, Huang C, Goldsmith AJ. | J Emerg Med. 2020 Oct;59(4):515-520
DOI: https://doi.org/10.1016/j.jemermed.2020.06.033  | Télécharger l'article au format  
Keywords: COVID-19; POCUS; coronavirus; lung; safety; ultrasound.

Clinical Review

Introduction : Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected coronavirus disease (COVID)-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk free.

Méthode : Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 that maximizes clinical utility and provider safety.

Discussion : In COVID-19 lung, POCUS findings are predominantly located in the posterior and lateral lung zones bilaterally. A six-zone scanning protocol that prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning, which can reduce risk to health care workers performing POCUS.

Conclusion : Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here, which target clinical utility and decreased nosocomial disease spread, must be prioritized.

Conclusion (proposition de traduction) : L'échographie pulmonaire au point d'intervention peut offrir des données cliniques précieuses lors de l'évaluation des patients atteints de la COVID-19. Les protocoles d'analyse tels que celui présenté ici, qui visent l'utilité clinique et la diminution de la propagation de la maladie nosocomiale, doivent être priorisés.

Double Defibrillation for Refractory In- and Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.
Miraglia D, Miguel LA, Alonso W. | J Emerg Med. 2020 Oct;59(4):521-541
DOI: https://doi.org/10.1016/j.jemermed.2020.06.024
Keywords: double defibrillation; double sequential defibrillation; double simultaneous defibrillation; dual defibrillation; in-hospital cardiac arrest; out-of-hospital cardiac arrest; refractory ventricular fibrillation.

Research article

Introduction : Double/dual defibrillation (DD) has been proposed as an alternative treatment for refractory ventricular fibrillation (VF). This topic has been poorly researched and data on survival rates are limited.

Objective: This systematic review and meta-analysis evaluates whether DD improves outcomes among patients with refractory VF in- and out-of-hospital cardiac arrest compared with standard defibrillation.

Méthode : A literature search was conducted on July 20, 2019 using MEDLINE via PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews. We gave all results as a pooled odds ratio (OR) and 95% confidence interval (CI). Heterogeneity was assessed by calculating the I2 statistic and was deemed significant for a p value of < 0.10 or I2 ≥ 50%. The quality of evidence was evaluated according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

Résultats : We included 27 records, of which 4 cohort studies totaling 1061 patients were included in the quantitative analysis. Of these, 20.5% (n = 217) received the intervention. DD had no effect on return of spontaneous circulation (OR 0.68; 95% CI 0.44-1.04; I2 = 41%, p = 0.08) (GRADE: Very low), survival to admission (OR 0.77; 95% CI 0.51-1.17; I2 = 18%, p = 0.22) (GRADE: Very low), or survival to discharge (OR 0.66; 95% CI 0.38-1.15; I2 = 0%, p = 0.14) (GRADE: Very low).

Conclusion : DD did not improve any outcomes of interest. Therefore, it is imperative that a well-designed study in this area be conducted. Ideally, conducting a randomized controlled trial in this population should be attempted to obtain a higher level of scientific evidence.

Conclusion (proposition de traduction) : La double défibrillation n'a amélioré aucun résultat d'intérêt. Par conséquent, il est impératif qu'une étude bien conçue dans ce domaine soit menée. Idéalement, la conduite d'un essai contrôlé randomisé dans cette population devrait être tentée pour obtenir un niveau plus élevé de preuves scientifiques.

Commentaire : Les lignes directrices 2020 de l'AHA  , considèrent que sur la base des preuves les plus récente, l'utilisation systématique de la double défibrillation séquentielle n'est pas recommandée.

The Journal of the American Medical Association

Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy.
Bodilsen J, Mariager T, Vestergaard HH, Christiansen MH, Kunwald M, Lüttichau HR, Kristensen BT, Bjarkam CR, Nielsen H. | JAMA. 2020 Oct 13;324(14):1419-1428
DOI: https://doi.org/10.1001/jama.2020.14895
Keywords: Aucun

Original Investigation

Introduction : Coagulopathy may deter physicians from performing a lumbar puncture.
Objective: To determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy. Design, setting, and participants: Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.
Exposures: Coagulopathy at the time of lumbar puncture.

Méthode : Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.

Résultats : A total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%).

Conclusion : In this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.

Conclusion (proposition de traduction) : Dans cette étude de cohorte danoise, le risque d'hématome périmédullaire après ponction lombaire était de 0,20 % chez les patients sans coagulopathie et de 0,23 % chez ceux atteints de coagulopathie. Bien que ces résultats puissent éclairer la prise de décision concernant la ponction lombaire en décrivant les taux dans cet échantillon, les taux observés peuvent refléter un biais dû au fait que les médecins sélectionnent des patients à risque relativement faible de ponction lombaire.

The New England Journal of Medicine

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.
CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NI, Odom SR, Sanchez SE, Drake FT, Fischkoff K, Johnson J, Patton JH, Evans H, Cuschieri J, Sabbatini AK, Faine BA, Skeete DA, Liang MK, Sohn V, McGrane K, Kutcher ME, Chung B, Carter DW, Ayoung-Chee P, Chiang W, Rushing A, Steinberg S, Foster CS, Schaetzel SM, Price TP, Mandell KA, Ferrigno L, Salzberg M, DeUgarte DA, Kaji AH, Moran GJ, Saltzman D, Alam HB, Park PK, Kao LS, Thompson CM, Self WH, Yu JT, . | N Engl J Med. 2020 Oct 5
DOI: https://doi.org/10.1056/nejmoa2014320
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis.

Méthode : We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith.

Résultats : In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).

Conclusion : For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.

Conclusion (proposition de traduction) : Pour le traitement de l'appendicite, les antibiotiques n'étaient pas inférieurs à l'appendicectomie sur la base des résultats d'une mesure standard de l'état de santé. Dans le groupe antibiotiques, près de 3 participants sur 10 ont subi une appendicectomie à 90 jours. Les participants avec un appendicolithe étaient plus à risque d'appendicectomie et de complications que ceux sans appendicolithe.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Appendicite aiguë : antibiotiques versus appendicectomie.  . Rédigé par le Dr Jean-Pierre Bru, le 13 octobre 2020.

Early Rhythm-Control Therapy in Patients with Atrial Fibrillation.
Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, Fetsch T, van Gelder IC, Haase D, Haegeli LM, Hamann F, Heidbüchel H, Hindricks G, Kautzner J, Kuck KH, Mont L, Ng GA, Rekosz J, Schoen N, Schotten U, Suling A, Taggeselle J, Themistoclakis S, Vettorazzi E, Vardas P, Wegscheider K, Willems S, Crijns HJGM, Breithardt G; EAST-AFNET 4 Trial Investigators. | N Engl J Med. 2020 Oct 1;383(14):1305-1316
DOI: https://doi.org/10.1056/nejmoa2019422
Keywords: Aucun

Original article

Introduction : Despite improvements in the management of atrial fibrillation, patients with this condition remain at increased risk for cardiovascular complications. It is unclear whether early rhythm-control therapy can reduce this risk.

Méthode : In this international, investigator-initiated, parallel-group, open, blinded-outcome-assessment trial, we randomly assigned patients who had early atrial fibrillation (diagnosed ≤1 year before enrollment) and cardiovascular conditions to receive either early rhythm control or usual care. Early rhythm control included treatment with antiarrhythmic drugs or atrial fibrillation ablation after randomization. Usual care limited rhythm control to the management of atrial fibrillation-related symptoms. The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome; the second primary outcome was the number of nights spent in the hospital per year. The primary safety outcome was a composite of death, stroke, or serious adverse events related to rhythm-control therapy. Secondary outcomes, including symptoms and left ventricular function, were also evaluated.

Résultats : In 135 centers, 2789 patients with early atrial fibrillation (median time since diagnosis, 36 days) underwent randomization. The trial was stopped for efficacy at the third interim analysis after a median of 5.1 years of follow-up per patient. A first-primary-outcome event occurred in 249 of the patients assigned to early rhythm control (3.9 per 100 person-years) and in 316 patients assigned to usual care (5.0 per 100 person-years) (hazard ratio, 0.79; 96% confidence interval, 0.66 to 0.94; P = 0.005). The mean (±SD) number of nights spent in the hospital did not differ significantly between the groups (5.8±21.9 and 5.1±15.5 days per year, respectively; P = 0.23). The percentage of patients with a primary safety outcome event did not differ significantly between the groups; serious adverse events related to rhythm-control therapy occurred in 4.9% of the patients assigned to early rhythm control and 1.4% of the patients assigned to usual care. Symptoms and left ventricular function at 2 years did not differ significantly between the groups.

Conclusion : Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions.

Conclusion (proposition de traduction) : Le contrôle précoce du rythme cardiaque a été associé à un risque plus faible d’effets indésirables cardiovasculaires que les soins habituels chez les patients présentant une fibrillation auriculaire précoce et des affections cardiovasculaires.

Commentaire : La recommandation sur la prise en charge de la fibrillation atriale en médecin d'urgence propose le contrôle de la fréquence plutôt que du rythme.
Taboulet P, Duchenne J, Lefort H, Zanker C, Jabre P, Davy JM, Le Heuezy JY, Ganansia O et les membres de la commission des référentiels de la SFMU. Prise en charge de la fibrillation atriale en médecine d’urgence. SFMU 2015. Ann. Fr. Med. Urgence 5, 260–279 (2015)  .


Mois d'octobre 2020