Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study.
April MD, Arana A, Schauer SG, Davis WT, Oliver JJ, Fantegrossi A, Summers SM, Maddry JK, Walls RM, Brown CA 3rd; NEAR Investigators. | Acad Emerg Med. 2020 Nov;27(11):1106-1115
DOI: https://doi.org/10.1111/acem.14063
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation.

Méthode : We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality.

Résultats : There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg.

Conclusion : Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

Conclusion (proposition de traduction) : Dans l'attente de données supplémentaires, nos résultats suggèrent que les praticiens ne devraient pas nécessairement donner la priorité à la kétamine par rapport à l'étomidate en raison du risque hémodynamique chez les patients bénéficiant d'une intubation en urgence.

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study.
Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA 3rd. | Acad Emerg Med. 2020 Nov;27(11):1140-1149
DOI: https://doi.org/10.1111/acem.14070
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis.

Méthode : This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine.

Résultats : A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed.

Conclusion : Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.

Conclusion (proposition de traduction) : L'étomidate est utilisé moins fréquemment chez les patients atteints de septicémie que chez les patients non septiques, la kétamine étant l'alternative la plus fréquemment utilisée. La kétamine était associée à plus d'hypotension post-opératoire que l'étomidate. Des essais cliniques futurs sont nécessaires pour déterminer l'agent d'induction optimal chez les patients atteints de septicémie.

Beltramini A, Capitaine AG, De la Dure Molla M, Colon P, Pateron D. | Ann. Fr. Med. Urgence. 2020 Nov;10:373-390
DOI: https://doi.org/10.3166/afmu-2020-0231
Keywords: Dental traumatology; Dental infection; Emergency department; Antibiotherapy

Original article

Editorial : Les traumatismes et les douleurs dentaires sont un motif fréquent de consultation dans les structures d’urgence. Le médecin urgentiste (MU) doit examiner, poser un diagnostic et connaître le degré d’urgence avec lequel le patient doit consulter son dentiste. Ces urgences concernent autant les enfants que les adultes ; or, il existe des spécificités importantes de prise en charge en fonction de la maturation de la dent traumatisée : temporaire, permanente immature ou permanente adulte. Parmi les douleurs dentaires, le MU sera confronté aux infections dentaires, notamment les rares cas d’infections extensives, qui engagent le pronostic vital du patient. Il pourra également être sollicité pour certaines com- plications après traitement odontologique (hémorragies, douleurs inflammatoires). La connaissance des indications de l’antibiothérapie, des conseils à donner pour rassurer le patient et l’orienter vers un spécialiste en odontologie dans les bons délais conditionne le succès de la prise en charge en urgence. Un MU peut efficacement prendre en charge les urgences dentaires s’il pose un diagnostic précis après un interrogatoire et un examen méticuleux et s’il connaît les recommandations internationales.

Conclusion (proposition de traduction) : Les structures d’urgence sont fréquemment le lieu de premier recours pour les patients lors de traumatismes ou de douleurs dentaires. Bien que le MU ne soit pas spécialisé et ne puisse pas effectuer les traitements odontologiques salvateurs, une connaissance simple de la pathologie dentaire lui permet de soulager le patient et de trier efficacement les pathologies urgentes de celles qui peuvent attendre. Pour quelques traumatismes dentaires, le MU peut effectuer des gestes thérapeutiques avant d’orienter le patient vers une consultation spécialisée. Ces gestes réalisés en aigu au sein des structures d’urgence sont fondamentaux pour assurer le bon pronostic fonctionnel de la dent. Lors d’une infection dentaire, le MU doit savoir connaître les situations où la prescription d’antibiotiques est recommandée et être attentif aux signes évocateurs d’une extension locorégionale de l’infection. En cas d’aggravation des symptômes, il faut inciter le patient à consulter à nouveau dans la structure d’urgence. La douleur dentaire, motif le plus fréquent de consultation dans les structures d’urgence, doit toujours être prise en charge, chez l’adulte comme chez l’enfant. Enfin, il faudra toujours rappeler qu’aucune de ces pathologies ou aucun traumatisme n’empêche le maintien du brossage et que, bien au contraire, l’arrêt du brossage peut aggraver les symptômes et retarder la cicatrisation.

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay.
Mumma BE, Casey SD, Dang RK, Polen MK, Kaur JC, Rodrigo J, Tancredi DJ, Narverud RA, Amsterdam EA, Tran N. | Ann Emerg Med. 2020 Nov;76(5):566-579
DOI: https://doi.org/10.1016/j.annemergmed.2020.06.047
Keywords: Aucun

Cardiology

Introduction : Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States.

Méthode : We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data.

Résultats : We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT.

Conclusion : Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.

Conclusion (proposition de traduction) : Comparé à la troponine cardiaque I conventionnelle, le dosage de la troponine cardiaque T à haute sensibilité n'a entraîné aucun changement cliniquement pertinent dans les diagnostics d'infarctus du myocarde, mais beaucoup plus de diagnostics de lésion du myocarde.

Ondansetron Prescription Is Associated With Reduced Return Visits to the Pediatric Emergency Department for Children With Gastroenteritis.
Benary D, Lozano JM, Higley R, Lowe D. | Ann Emerg Med. 2020 Nov;76(5):625-634
DOI: https://doi.org/10.1016/j.annemergmed.2020.04.012
Keywords: Aucun

Pediatrics

Introduction : We determine whether an ondansetron prescription for pediatric patients with vomiting or gastroenteritis is associated with decreased return visits to the emergency department (ED), and whether alternate diagnoses are more frequent on return visits in patients prescribed ondansetron.

Méthode : This is a retrospective cohort study of patients 6 months to 18 years of age, presenting to a pediatric ED or its affiliated urgent care centers between 2012 and 2017 with an International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, 10th Revision diagnosis of gastroenteritis, gastritis, vomiting, or vomiting with diarrhea. Multivariate logistic regression analysis was used to measure the association between an ondansetron prescription and the odds of 72-hour return visits. Rates of alternate diagnoses on return visits (appendicitis, intussusception, intracranial mass, meningitis, and diabetic ketoacidosis) were compared between patients who were prescribed ondansetron for home use and those who were not.

Résultats : A total of 82,139 patients were studied, with a median age of 4 years. An ondansetron prescription was given to 13.4% of patients on discharge. The 72-hour return visit rate was 4.7%. Patients receiving an ondansetron prescription had decreased odds of 72-hour return visits (adjusted odds ratio 0.84; 95% confidence interval 0.75 to 0.93). The subgroup of patients specifically receiving a diagnosis of gastroenteritis had decreased odds of 72-hour return visits (adjusted odds ratio 0.82; 95% confidence interval 0.72 to 0.95). There was no significant difference between groups in the diagnosis of appendicitis on return visit (odds ratio 0.97; 95% confidence interval 0.37 to 2.18).

Conclusion : An ondansetron prescription is associated with reduced 72-hour ED return visit rates for children with vomiting or acute gastroenteritis and is not associated with masking alternate diagnoses.

Conclusion (proposition de traduction) : Une prescription d'ondansétron est associée à une réduction des taux de visites de retour au service des urgences de 72 heures chez les enfants souffrant de vomissements ou de gastro-entérite aiguë et n'est pas associée au masquage des diagnostics alternatifs.

Straddle versus Conventional Chest Compressions in a Confined Space; a Comparative Study.
Supatanakij P, Yuksen C, Chantawong T, Sawangwong P, Jenpanitpong C, Patchkrua J, Kanchayawong P. | Arch Acad Emerg Med. 2020 Nov 14;9(1):e4
DOI: https://doi.org/10.22037/aaem.v9i1.994  | Télécharger l'article au format  
Keywords: ambulances; cardiopulmonary resuscitation; emergency medical service; heart arrest; heart massage

Original/Research Article

Introduction : When cardiac arrest occurs in a confined space, such as in an aircraft or ambulance, kneeling by the patient's side may be difficult. Straddle chest compression is an alternative technique that can be used in a confined space. This study was performed to compare the quality of chest compressions in straddle versus conventional CPR on a manikin model.

Méthode : The participants were randomized into two groups using the sequential numbered, opaque, sealed envelope method chosen through block-of-four randomization: straddle and conventional chest compression technique. Each participant performed a maximum of 4 minutes of hands-only chest compressions, and quality parameters (compression rate and depth) were recorded from the defibrillator's monitor.

Résultats : 124 participants with mean age of 26.67 ± 6.90 years (27.58% male) were studied. There was no difference in the mean compression rate between the conventional and straddle chest compression techniques (126.18 ± 17.11 and 127.01 ± 21.01 compressions/min, respectively; p = 0.811) or their mean compression depth (43.8 ± 9.60 and 43.4 ± 9.10 mm, respectively; p = 0.830). The participants' comfort and fatigue were assessed through changes in their vital signs. In both methods, statistically significant differences were observed in vital signs before and after performing chest compression, but the differences were not clinically significant. In addition, there was no difference between the 2 groups in this regard.

Conclusion : The quality of CPR using the straddle chest compression was as good as conventional chest compression technique. No significant differences were found in the quality of chest compressions or the participants' comfort and fatigue levels.

Conclusion (proposition de traduction) : La qualité de la RCP utilisant la compression thoracique à cheval était aussi bonne que la technique de compression thoracique conventionnelle. Aucune différence significative n'a été trouvée dans la qualité des compressions thoraciques ou les niveaux de confort et de fatigue des participants.

Topical Tranexamic Acid versus Phenylephrine-lidocaine for the Treatment of Anterior Epistaxis in Patients Taking Aspirin or Clopidogrel; a Randomized Clinical Trial.
Amini K, Arabzadeh A, Jahed S, Amini P. | Arch Acad Emerg Med. 2020 Nov 19;9(1):e6
DOI: https://doi.org/10.22037/aaem.v9i1.875  | Télécharger l'article au format  
Keywords: Aspirin; Clopidogrel; Emergency Medical Services; Epistaxis; Tranexamic Acid; lidocaine drug combination; phenylephrine.

Original/Research Article

Introduction : Epistaxis is one of the most prevalent complaints in the emergency department (ED), especially in patients who take antiplatelet agents. This study aimed to compare the effect of topical use of tranexamic acid (TXA) with phenylephrine-lidocaine anterior nasal packing (PANP) in controlling epistaxis of patients who take aspirin or clopidogrel.

Méthode : This prospective, double-blind, parallel-group, randomized clinical trial was conducted to compare the effect of topical use of intravenous (IV) TXA compared with PANP on controlling anterior epistaxis in patients who take aspirin or clopidogrel.

Résultats : One hundred patients with the mean age of 59.24 ± 7.75 (45 - 75) years were studied (52% male). Two groups were similar in terms of age (p=0.81) and sex (p=0.23) distribution, diabetes mellitus (p=0.54), and hypertension (p = 0.037). The mean time to stop bleeding was 6.70 ± 2.35 minutes in the TXA group and 11.50±3.64 minutes in the PANP group (p=0.002). Bleeding recurrence occurred in 3 (6%) cases of the TXA group and 10 (20%) cases of the PANP group (p =0.03). Time to discharge from ED in the TXA group was significantly lower than the PANP group (p<0.001). The absolute risk reduction (ARR), relative risk reduction, and number needed to harm of treatment with TXA for anterior nasal bleeding were 14.00% (95%CI: 1.11 - 26.89), 17.50% (95%CI: 0.60 - 37.27), and 7.14 (95%CI: 3.71 -90.43), respectively.

Conclusion : Topical TXA is an appropriate treatment option in bleeding cessation, and reducing re-bleeding and duration of hospital stay in patients with epistaxis who take antiplatelet agents.

Conclusion (proposition de traduction) : L'acide tranexamique topique est une option de traitement appropriée pour l'arrêt des saignements et la réduction des saignements répétés et de la durée du séjour à l'hôpital chez les patients présentant un épistaxis et qui prennent des traitements antiagrégants plaquettaires.

Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury.
Harper JA, Klassen TP, Balshaw R, Dyck J, Osmond MH; Pediatric Emergency Research Canada Head Injury Study Group. | CJEM. 2020 9:1-9
DOI: https://doi.org/10.1017/cem.2020.378
Keywords: Computed tomography; head injury; pediatric; prospective; vomiting.

Republication

Introduction : Vomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury.

Méthode : This secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0-16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models.

Résultats : A total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7-3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5-7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9-3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors.

Conclusion : Recurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.

Conclusion (proposition de traduction) : Les vomissements récurrents (≥ quatre épisodes) étaient un facteur de risque significatif de lésions intracrâniennes chez les enfants après un traumatisme crânien mineur. La probabilité de blessure intracrânienne augmentait avec le nombre d'épisodes de vomissements et si elle était accompagnée d'autres facteurs à haut risque, tels que des signes de fracture du crâne ou une altération du niveau de conscience.

Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis.
Fuller G, Sabir L, Evans R, Bradbury D, Kuczawski M, Mason SM. | Emerg Med J. 2020 Nov;37(11):666-673
DOI: https://doi.org/10.1136/emermed-2019-209307  | Télécharger l'article au format  
Keywords: CT/MRI; clinical; head; imaging; research; trauma.

Original research

Introduction : Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group.

Méthode : An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies.

Résultats : 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%).

Conclusion : The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.

Conclusion (proposition de traduction) : Le risque d'événement indésirable après un traumatisme crânien léger chez les patients prenant des anticoagulants oraux directs (AOD) semble faible. Ces résultats soutiendraient la prise de décision partagée entre le patient et le clinicien, plutôt que l'imagerie de routine, après un traumatisme crânien mineur lors de la prise d'anticoagulants oraux directs.

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study.
Price J, Sandbach DD, Ercole A, Wilson A, Barnard EBG. | Emerg Med J. 2020 Nov;37(11):674-679
DOI: https://doi.org/10.1136/emermed-2019-209077  | Télécharger l'article au format  
Keywords: anaesthesia; head; prehospital care; trauma.

Original research

Introduction : In the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO₂) of 4.0-4.5 kPa (30.0-33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO₂), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO₂-PaCO₂ gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO₂-PaCO₂ gradient of TBI patients at hospital arrival.

Méthode : A retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R²). A Bland-Altman plot was used to test for paired ETCO₂ and PaCO₂ agreement and reported with 95% CI. ETCO₂-PaCO₂ gradient data were compared with a two-tailed, unpaired, t-test.

Résultats : 107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO₂-PaCO₂ gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R²=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and -0.2 (95% CI -0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R²=0.13, p=0.10), and this cohort had a larger ETCO2-PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg).

Conclusion : There is only moderate correlation of ETCO₂ and PaCO₂ at hospital arrival in patients with serious TBI. The mean ETCO₂-PaCO₂ gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO₂ targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO₂ measurement.

Conclusion (proposition de traduction) : Il n'y a qu'une corrélation modérée entre l'ETCO₂ et la PaCO₂ à l'arrivée à l'hôpital chez les patients présentant un TC grave. Le gradient moyen ETCO₂-PaCO₂ était de 1,7 (± 1,0) kPa (12,8 mm Hg). Des cibles ETCO₂ inférieures à celles recommandées précédemment peuvent être sûres et appropriées, et la mesure de la PaCO₂ préhospitalière peut jouer un rôle.

Identification of very low-risk acute chest pain patients without troponin testing.
Smith LM, Ashburn NP, Snavely AC, Stopyra JP, Lenoir KM, Wells BJ, Hiestand BC, Herrington DM, Miller CD, Mahler SA. | Emerg Med J. 2020 Nov;37(11):690-695
DOI: https://doi.org/10.1136/emermed-2020-209698
Keywords: ECG; acute coronary syndrome; cardiac care, acute coronary syndrome; cardiac care, acute myocardal infarct; cardiac care, diagnosis.

Original research

Introduction : The HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of <1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with <1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.

Méthode : A secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of <1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of <1 was determined using Net Reclassification Improvement Index (NRI).

Résultats : Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR <1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR <1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI -0.7 to 2.4%).

Conclusion : These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%.

Conclusion (proposition de traduction) : Ces données suggèrent que les patients avec des scores HEAR de 0 et 1 représentent un groupe à très faible risque qui peut ne pas nécessiter de dosage de la troponine pour obtenir un taux d'événements cardiaques indésirables majeurs (MACE) manqué < 1 %.

BET 1: Can acute shoulder dislocations be reduced using intra-articular local anaesthetic infiltration as an alternative to intravenous analgesia with or without sedation?.
Penn DM, Williams O. | Emerg Med J. 2020 Nov;37(11):725-728
DOI: https://doi.org/10.1136/emermed-2020-210736.2
Keywords: Aucun

BEST EVIDENCE TOPIC REPORTS

Editorial : A short cut review was carried out to establish whether intra-articular injection of local anaesthetic is an effective alternative to intravenous analgesia with or without sedation to facilitate reduction of acute shoulder dislocations. Eleven studies were considered relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these studies are tabulated. The clinical bottom line is that intra-articular injection of local anaesthetic is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations.

Conclusion : Intra-articular lidocaine (IAL) is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations. Compared with intravenous analgesia with or without sedation, IAL offers a cheaper and less resource dependent alternative, facilitating quicker emergency department discharge. It is associated with fewer complications, and patients experience a similar level of procedural pain. IAL should, therefore, be considered as an analgesic strategy, particularly in patients deemed as a high anaesthetic risk.

Conclusion (proposition de traduction) : L'administration de lidocaïne intra-articulaire (IAL) est une méthode sûre et efficace pour fournir une analgésie procédurale pour la réduction des luxations aiguës de l'épaule. Par rapport à l'analgésie intraveineuse avec ou sans sédation, l'IAL offre une alternative moins chère et moins dépendante des ressources, facilitant une sortie plus rapide des services d'urgence. Elle est associée à moins de complications et les patients éprouvent un niveau similaire de douleur procédurale. L'IAL doit donc être considérée comme une stratégie analgésique, en particulier chez les patients considérés comme présentant un risque anesthésique élevé.

Commentaire :  Le patient est en position demi-assise.
Palpation de l’extrémité crâniale de la cavité glénoïdale de l’acromion et de la tête humérale. Le repère du point de ponction est à 2 cm sous le bord acromial antérolatéral au niveau du sillon latéral formé par l’absence de la tête humérale avec une approche dorsale ou latérale.
Réalisation d’un bouton cutané avec 1 ml de lidocaïne à 1 % puis introduction de l’aiguille intramusculaire jusqu’à la garde dans un plan perpendiculaire en direction de la cavité glénoïdale.
Après franchissement de la capsule, réalisation du test d’aspiration et injection lente intra-articulaire en trente secondes approximativement des 19 ml de lidocaïne restante. L’injection doit être facile, sans résistance.
La réduction de la luxation était tentée au minimum 15 minutes après l’injection intra-articulaire.

La dose limite maximale administrable en injection unique varie de 200 mg à 400 mg (4 mg/Kg à 6 mg/Kg) pour les solutions non adrénalinées, à 500 mg (7 mg/Kg) en solution adrénalinée.
En pratique, chez l’adulte, on retient les posologies maximales de 400 mg pour la lidocaïne.
Un flacon ou une ampoule de 20 mL contient 200 mg de chlorhydrate de lidocaïne à 1 % ou 10 mg/mL.

Technical factors associated with first-pass success during endotracheal intubation in children: analysis of videolaryngoscopy recordings.
Miller KA, Monuteaux MC, Nagler J. | Emerg Med J. 2020 Nov 10:emermed-2020-209700
DOI: https://doi.org/10.1136/emermed-2020-209700
Keywords: airway; anaesthesia - rsi; paediatric emergency medicine; paediatric resuscitation; paediatrics; resuscitation.

RSI

Introduction : First-pass success (FPS) during intubation is associated with lower morbidity for paediatric patients. Using videolaryngoscopy (VL) recordings, we reviewed technical aspects of intubation, including factors associated with FPS in children.

Méthode : We performed a retrospective study of intubation attempts performed using video-assisted laryngoscopy in a paediatric ED between January 2014 and December 2018. Data were abstracted from a quality assurance database, the electronic medical record and VL recordings. Our primary outcome was FPS. Intubation practices were analysed using descriptive statistics. Patient and procedural characteristics associated with FPS in univariate testing and clinical factors identified from the literature were included as covariates in a multivariable logistic regression. An exploratory analysis examined the relationship between position of the glottic opening on the video screen and FPS.

Résultats : Intubation was performed during 237 patient encounters, with 231 using video-assisted laryngoscopy. Data from complete video recordings were available for 129 attempts (59%); an additional 31 (13%) had partial recordings. Overall, 173 (73%) of first attempts were successful. Adjusting for patient age, placing the blade tip into the vallecula adjusted OR ((aOR) 7.2 (95% CI 1.7 to 30.1)) and obtaining a grade 1 or 2a-modified Cormack-Lehane glottic view on the videolaryngoscope screen (aOR 6.1 (95% CI 1.5 to 25.7) relative to grade 2b) were associated with increased FPS in the subset of patients with complete recordings. Exploratory analysis suggested that FPS is highest (81%) and duration is shortest when the glottic opening is located in the second quintile of the video screen.

Conclusion : Placement of the blade tip into the vallecula regardless of blade type, sufficient glottic visualisation and locating the glottic opening within the second quintile of the video screen were associated with FPS using video-assisted laryngoscopy in the paediatric ED.

Conclusion (proposition de traduction) : Le logement de la pointe de la lame dans la vallécule quel que soit le type de lame, une visualisation glottique suffisante et la localisation de l'ouverture glottique dans le deuxième quintile de l'écran vidéo ont été associés au succès du premier essai en utilisant la laryngoscopie vidéo-assistée dans le service des urgences pédiatriques.

How to ventilate obstructive and asthmatic patients.
Demoule A, Brochard L, Dres M, Heunks L, Jubran A, Laghi F, Mekontso-Dessap A, Nava S, Ouanes-Besbes L, Peñuelas O, Piquilloud L, Vassilakopoulos T, Mancebo J.. | Intensive Care Med. 2020 Nov 9
DOI: https://doi.org/10.1007/s00134-020-06291-0
Keywords: Asthma; Chronic obstructive pulmonary disease; Intrisic positive end-expiratory pressure (PEEP); Mechanical ventilation; Non-invasive ventilation; Weaning

Review

Editorial : Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed.

Conclusion : Mechanical ventilation is the cornerstone of the management of COPD and asthma patients presenting with life-threatening respiratory failure. Although NIV prevents the majority of patients with COPD exacerbation from subsequently needing invasive ventilation, future efforts should focus on improving the efficacy of NIV and on evaluation of the high-flow nasal cannula technique. Invasive mechanical ventilation is reserved for patients who fail NIV and are subsequently intubated. The major goal during invasive mechanical ventilation is to limit hyperinflation; this is achieved through reduced minute ventilation, low tidal volumes and prolonged expiratory time. Normalization of blood gas is a secondary therapeutic goal. A low level of external PEEP may be applied to patients triggering their ventilator. Mechanical ventilation of asthma patients follows the same rules except that the use of NIV is not presently recommended despite promising recent data. Weaning should be performed as expeditiously as possible with a daily screening test followed by a trial of spontaneous breathing. In selected patients, prophylactic post-extubation NIV prevents post-extubation acute respiratory failure and subsequent reintubation. High-flow nasal cannula seems as efficient as NIV to prevent reintubation and the combination of NIV and high-flow nasal cannula may be even more efficient. Finally, tracheostomy should be the subject of a multidisciplinary discussion.

Conclusion (proposition de traduction) : La ventilation mécanique est la pierre angulaire de la prise en charge des patients atteints de BPCO et d'asthme présentant une décompensation respiratoire potentiellement mortelle. Bien que la VNI empêche la majorité des patients présentant une exacerbation de la BPCO d'avoir ensuite besoin d'une ventilation invasive, les efforts futurs devraient se concentrer sur l'amélioration de l'efficacité de la VNI et sur l'évaluation de la technique de l'oxygénothérapie nasale à haut débit (ndlr : Optiflow). La ventilation mécanique invasive est réservée aux échecs de la VNI chez des patients qui sont ensuite intubés. L'objectif principal de la ventilation mécanique invasive est de limiter l'hyperinflation ; ceci est obtenu grâce à une ventilation minute réduite, de faibles volumes courants et un temps expiration prolongé. La normalisation des gaz du sang est un objectif thérapeutique secondaire. Un faible niveau de PEP externe peut être appliqué aux patients qui peuvent déclencher leur cycle respiratoire. La ventilation mécanique des patients asthmatiques suit les mêmes règles, sauf que l'utilisation de la VNI n'est pas actuellement recommandée malgré des données récentes prometteuses. Le sevrage doit être effectué le plus rapidement possible avec un test de dépistage quotidien suivi d'un essai de respiration spontanée. Chez certains patients, la VNI prophylactique post-extubation prévient l'insuffisance respiratoire aiguë post-extubation et la réintubation ultérieure. L'oxygénothérapie nasale à haut débit (ndlr : Optiflow) semble aussi efficace que la VNI pour empêcher la réintubation et la combinaison de la VNI et de l'oxygénothérapie nasale à haut débit peut être encore plus efficace. Enfin, la décision de trachéotomie devrait faire l'objet d'une concertation multidisciplinaire.

Neuromuscular blockade in patients with ARDS: a rapid practice guideline.
Alhazzani W, Belley-Cote E, Møller MH, Angus DC, Papazian L, Arabi YM, Citerio G, Connolly B, Denehy L, Fox-Robichaud A, Hough CL, Laake JH, Machado FR, Ostermann M, Piraino T, Sharif S, Szczeklik W, Young PJ, Gouskos A, Kiedrowski K, Burns KEA. | Intensive Care Med. 2020 Nov;46(11):1977-1986
DOI: https://doi.org/10.1007/s00134-020-06227-8  | Télécharger l'article au format  
Keywords: ARDS; Neuromuscular blockade; Rapid guidelines.

Review

Editorial : The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) is to formulate an evidence-based guidance for the use of neuromuscular blocking agents (NMBA) in adults with acute respiratory distress syndrome (ARDS). The panel comprised 20 international clinical experts from 12 countries, and 2 patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines and followed a strict conflict of interest policy. We convened panelists through teleconferences and web-based discussions. Guideline experts from the guidelines in intensive care, development, and evaluation Group provided methodological support. Two content experts provided input and shared their expertise with the panel but did not participate in drafting the final recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence and grade recommendations and suggestions. We used the evidence to decision framework to generate recommendations. The panel provided input on guideline implementation and monitoring, and suggested future research priorities. The overall certainty in the evidence was low. The ICM-RPG panel issued one recommendation and two suggestions regarding the use of NMBAs in adults with ARDS. Current evidence does not support the early routine use of an NMBA infusion in adults with ARDS of any severity. It favours avoiding a continuous infusion of NMBA for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning, and require neuromuscular blockade, an infusion of an NMBA for 48 h is a reasonable option.

Conclusion : In this Intensive Care Medicine Rapid Practice Guideline, the panel issued one recommendation and two suggestions regarding the use of neuromuscular blocking agent in ARDS. The current evidence does not support the early routine use of neuromuscular blocking agent infusion in all adults with ARDS. It favours avoiding an neuromuscular blocking agent infusion for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning and require neuromuscular blockade, an infusion of an neuromuscular blocking agent is a reasonable option.

Conclusion (proposition de traduction) : Dans ce guide de pratique rapide de médecine de soins intensifs, le groupe a émis une recommandation et deux suggestions concernant l'utilisation d'un acurare dans le SDRA. Les preuves actuelles ne soutiennent pas l'utilisation systématique précoce de la perfusion d'un curare chez tous les adultes atteints de SDRA. Elle permet d'éviter une perfusion d'un curare chez les patients ventilés selon une stratégie de sédation plus légère. Cependant, pour les patients qui nécessitent une sédation profonde pour faciliter la ventilation protectrice des poumons ou le positionnement sur le ventre et qui nécessitent un blocage neuromusculaire, une perfusion d'un curare est une option raisonnable.

Combination therapy of vitamin C and thiamine for septic shock: a multi-centre, double-blinded randomized, controlled study.
Hwang SY, Ryoo SM, Park JE, Jo YH, Jang DH, Suh GJ, Kim T, Kim YJ, Kim S, Cho H, Jo IJ, Chung SP, Choi SH, Shin TG, Kim WY; Korean Shock Society (KoSS). | Intensive Care Med. 2020 Nov;46(11):2015-2025
DOI: https://doi.org/10.1007/s00134-020-06191-3  | Télécharger l'article au format  
Keywords: Resuscitation; Sepsis; Septic shock; Thiamine; Vitamin C.

Original

Introduction : To evaluate the effects of early combination therapy with intravenous vitamin C and thiamine on recovery from organ failure in patients with septic shock.

Méthode : The ascorbic acid and thiamine effect in septic shock (ATESS) trial was a multi-centre, double-blind, randomized, controlled trial conducted in four academic emergency departments, enrolling adult patients with septic shock from December 2018 through January 2020. Patients were randomly assigned in a 1:1 ratio to either the treatment group [intravenous vitamin C (50 mg/kg, maximum single dose 3 g) and thiamine (200 mg) administration every 12 h for a total of 48 h] or the placebo group (identical volume of 0.9% saline with the same protocol). The primary outcome was Δ Sequential Organ Failure Assessment (SOFA) score (SOFA score at enrolment-SOFA score after 72 h). Eighteen secondary outcomes were predefined, including shock reversal and 28-day mortality.

Résultats : A total of 111 patients were enrolled, of which 53 were assigned to the treatment group and 58 were assigned to the placebo group. There was no significant difference in ΔSOFA scores between the treatment group and the placebo group [3, interquartile range (IQR) - 1 to 5 vs. 3, IQR 0-4, respectively, p = 0.96]. Predefined secondary outcomes were also not significantly different between the groups.

Conclusion : In this study, vitamin C and thiamine administration in the early phase of septic shock did not improve organ function compared with placebo, despite improvements in vitamin C and thiamine levels.

Conclusion (proposition de traduction) : Dans cette étude, l'administration de vitamine C et de thiamine dans la phase précoce du choc septique n'a pas amélioré la fonction des organes par rapport au placebo, malgré des améliorations des taux de vitamine C et de thiamine.

Vitamin C and thiamine for sepsis: time to go back to fundamental principles.
Fujii T, Fowler R, Vincent JL. | Intensive Care Med. 2020 Nov;46(11):2061-2063
DOI: https://doi.org/10.1007/s00134-020-06242-9
Keywords: Aucun

Editorial

Editorial : Vitamin C plays a vital role in human physiology. For decades, intriguing research has highlighted the possi- bility of acute effects of vitamin C deficiency in patients with sepsis. Vitamin C is a mediator of endothelial function through its co-factor role with many enzymes (including one that catalyses the conversion of dopamine to noradrenaline). Vitamin C also works as an antioxidant by scavenging free radicals. In animal models of sepsis, exogenous vitamin C increases perfused capillary density and arteriolar vasoconstrictor responsiveness, implying its possible role in treating vasoplegic status in sepsis.

Conclusion : Until larger sample sizes improve the precision of an effect size across populations and sub-populations of septic patients, the results of the ATESS trial and others counsel us to remain focused on the fundamental prin- ciples in treating sepsis—prompt and measured resusci- tation that includes early appropriate empiric antibiotics and source control—while subjecting new therapies to methodologically rigorous clinical trials.

Conclusion (proposition de traduction) : Jusqu'à ce que des échantillons plus importants améliorent la précision de la taille d'un effet dans les populations et sous-populations de patients septiques, les résultats de l'essai ATESS et d'autres nous conseillent de rester concentrés sur les principes fondamentaux du traitement de la septicémie - une réanimation rapide et mesurée cela inclut des antibiotiques probabilistes appropriés précoces et un contrôle de la source de la contamination - tout en soumettant les nouvelles thérapies à des essais cliniques méthodologiquement rigoureux.

The association of treatment with hydroxychloroquine and hospital mortality in COVID-19 patients.
Ayerbe L, Risco-Risco C, Ayis S. | Intern Emerg Med. 2020 Nov;15(8):1501-1506
DOI: https://doi.org/10.1007/s11739-020-02505-x  | Télécharger l'article au format  
Keywords: Aucun

IM - ORIGINAL

Editorial : This study investigates the association between the treatment with hydroxychloroquine and mortality in patients admitted with COVID-19. Routinely recorded, clinical data, up to the 24th of April 2020, from the 2075 patients with COVID-19, admitted in 17 hospitals in Spain between the 1st of March and the 20th of April 2020 were used. The following variables were extracted for this study: age, gender, temperature, and saturation of oxygen on admission, treatment with hydroxychloroquine, azithromycin, heparin, steroids, tocilizumab, a combination of lopinavir with ritonavir, and oseltamivir, together with data on mortality. Multivariable logistic regression models were used to investigate the associations. At the time of collecting the data, 301 patients had died, 1449 had been discharged home from the hospitals, 240 were still admitted, and 85 had been transferred to hospitals not included in the study. Median follow-up time was 8 (IQR 5-12) days. Hydroxychloroquine had been used in 1857 patients. Hydroxychloroquine was associated with lower mortality when the model was adjusted for age and gender, with OR (95% CI): 0.44 (0.29-0.67). This association remained significant when saturation of oxygen < 90% and temperature > 37 °C were added to de model with OR 0.45 (0.30-0.68) p < 0.001, and also when all the other drugs, and time of admission, were included as covariates. The association between hydroxychloroquine and lower mortality observed in this study can be acknowledged by clinicians in hospitals and in the community. Randomized-controlled trials to assess the causal effects of hydroxychloroquine in different therapeutic regimes are required.

Conclusion : Further randomized controlled trials, observational studies, and summaries of both types of evidence to assess the associations between hydroxychloroquine and survival are necessary. Future studies could also address at what dosage, and in what phase of the disease, does hydroxychloroquine lead to the best possible outcome, for patients with different past medical histories. The interven- tional evidence on the management of COVID-19 is still limited. Therefore, clinicians could acknowledge the results presented in this study. The positive effect of hydroxychloroquine seems consistent and its use could be considered in clinical set- tings. Hydroxychloroquine is easy to administer, and its use in ambulatory patients, to reduce symptoms, prevent admissions, decrease mortality, and the transmission of the disease, could also be considered by clinicians and future researchers.

Conclusion (proposition de traduction) : D'autres essais contrôlés randomisés, des études d'observation et des résumés des deux types de preuves pour évaluer les associations entre l'hydroxychloroquine et la survie sont nécessaires. Des études futures pourraient également porter sur la posologie et dans quelle phase de la maladie l'hydroxychloroquine conduit-elle au meilleur résultat possible, pour des patients ayant des antécédents médicaux différents. Les preuves interventionnelles sur la prise en charge du COVID-19 sont encore limitées. Par conséquent, les cliniciens pourraient reconnaître les résultats présentés dans cette étude. L'effet positif de l'hydroxychloroquine semble constant et son utilisation pourrait être envisagée en milieu clinique. L'hydroxychloroquine est facile à administrer et son utilisation chez les patients ambulatoires, pour réduire les symptômes, prévenir les admissions, diminuer la mortalité et la transmission de la maladie, pourrait également être envisagée par les cliniciens et les futurs chercheurs.

Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19.
Piazza G, Campia U, Hurwitz S, Snyder JE, Rizzo SM, Pfeferman MB, Morrison RB, Leiva O, Fanikos J, Nauffal V, Almarzooq Z, Goldhaber SZ. | J Am Coll Cardiol. 2020 Nov 3;76(18):2060-2072
DOI: https://doi.org/10.1016/j.jacc.2020.08.070  | Télécharger l'article au format  
Keywords: COVID-19; anticoagulation; cardiovascular disease; coronavirus; deep venous thrombosis; myocardial infarction; pulmonary embolism; stroke; thromboembolism.

Original Investigation

Introduction : Cardiovascular complications, including myocardial infarction, ischemic stroke, and pulmonary embolism, represent an important source of adverse outcomes in coronavirus disease-2019 (COVID-19).
Objectives : To assess the frequency of arterial and venous thromboembolic disease, risk factors, prevention and management patterns, and outcomes in patients with COVID-19, the authors designed a multicenter, observational cohort study.

Méthode : We analyzed a retrospective cohort of 1,114 patients with COVID-19 diagnosed through our Mass General Brigham integrated health network. The total cohort was analyzed by site of care: intensive care (n = 170); hospitalized nonintensive care (n = 229); and outpatient (n = 715). The primary study outcome was a composite of adjudicated major arterial or venous thromboembolism.

Résultats : Patients with COVID-19 were 22.3% Hispanic/Latinx and 44.2% non-White. Cardiovascular risk factors of hypertension (35.8%), hyperlipidemia (28.6%), and diabetes (18.0%) were common. Prophylactic anticoagulation was prescribed in 89.4% of patients with COVID-19 in the intensive care cohort and 84.7% of those in the hospitalized nonintensive care setting. Frequencies of major arterial or venous thromboembolism, major cardiovascular adverse events, and symptomatic venous thromboembolism were highest in the intensive care cohort (35.3%, 45.9%, and 27.0 %, respectively) followed by the hospitalized nonintensive care cohort (2.6%, 6.1%, and 2.2%, respectively) and the outpatient cohort (0% for all).

Conclusion : Major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism occurred with high frequency in patients with COVID-19, especially in the intensive care setting, despite a high utilization rate of thromboprophylaxis.

Conclusion (proposition de traduction) : Une thrombose artérielle ou thromboembolie veineuse majeure, des événements cardiovasculaires indésirables majeurs et une thromboembolie veineuse symptomatique sont survenus avec une fréquence élevée chez les patients atteints de COVID-19, en particulier dans le cadre des soins intensifs, malgré un taux d'utilisation élevé de la thromboprophylaxie.

Commentaire : Lire l'analyse de l'article dans :
McBane RD 2nd. Thromboembolism and the Pandemic. J Am Coll Cardiol. 2020 Nov 3;76(18):2073-2075  .

Ticagrelor or Prasugrel in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes.
Valina C, Neumann FJ, Menichelli M, Mayer K, Wöhrle J, Bernlochner I, Aytekin A, Richardt G, Witzenbichler B, Sibbing D, Cassese S, Angiolillo DJ, Kufner S, Liebetrau C, Hamm CW, Xhepa E, Hapfelmeier A, Sager HB, Wustrow I, Joner M, Trenk D, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A.. | J Am Coll Cardiol. 2020 Nov 24;76(21):2436-2446
DOI: https://doi.org/10.1016/j.jacc.2020.09.584
Keywords: mortality; non-ST-segment elevation acute coronary syndrome; percutaneous coronary intervention; prasugrel; ticagrelor.

Original Investigation

Introduction : Current guidelines recommend intensified platelet inhibition by prasugrel or ticagrelor in patients with unstable angina (UA) or non-ST-segment elevation (NSTE) myocardial infarction (MI). Objectives: This study sought to investigate the benefits and risks of ticagrelor as compared with prasugrel in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and planned invasive management.

Méthode : This post hoc analysis combines the pre-specified subgroups of UA and NSTEMI of the randomized ISAR-REACT 5 trial. It included 1,179 patients assigned to ticagrelor and 1,186 assigned to prasugrel. Ticagrelor was started immediately after randomization and prasugrel after coronary angiography. The primary endpoint was a composite of death, MI, or stroke during 1-year follow-up, and the safety endpoint was Bleeding Academic Research Consortium class 3-5.

Résultats : The primary endpoint was reached in 101 (8.7%) patients in the ticagrelor and in 73 (6.3%) patients in the prasugrel group (hazard ratio [HR]: 1.41; 95% confidence interval [CI]: 1.04 to 1.90). The HR for all-cause death was 1.43 (95% CI: 0.93 to 2.21) and that for MI 1.43 (95% CI: 0.94 to 2.19). The safety endpoint occurred in 49 (5.2%) patients in the ticagrelor and in 41 (4.7%) patients in the prasugrel group (HR: 1.09; 95% CI: 0.72 to 1.65). Landmark analysis revealed persistence of the efficacy advantage with prasugrel after the first month.

Conclusion : In patients with NSTE-ACS, we found that prasugrel was superior to ticagrelor in reducing the combined 1-year risk of death, MI, and stroke without increasing the risk of bleeding. Due to the post hoc nature of the analysis, these findings need confirmation by further studies.

Conclusion (proposition de traduction) : Chez les patients présentant un syndrome coronarien aigu sans élévation du segment ST, nous avons constaté que le prasugrel (Effient^®) était supérieur au ticagrélor pour réduire le risque combiné de décès, d'infarctus du myocarde et d'accident vasculaire cérébral à 1 an sans augmenter le risque de saignement. En raison de la nature post hoc de l'analyse, ces résultats doivent être confirmés par d'autres études.

Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial.
Schuh S, Sweeney J, Rumantir M, Coates AL, Willan AR, Stephens D, Atenafu EG, Finkelstein Y, Thompson G, Zemek R, Plint AC, Gravel J, Ducharme FM, Johnson DW, Black K, Curtis S, Beer D, Klassen TP, Nicksy D, Freedman SB; Pediatric Emergency Research Canada (PERC) Network. | JAMA. 2020 Nov 24;324(20):2038-2047
DOI: https://doi.org/10.1001/jama.2020.19839
Keywords: Aucun

Original Investigation

Introduction : While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown.
Objective: To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy.
Design, setting, and participants: A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed.
Interventions: Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408).

Méthode : The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes.

Résultats : Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%).

Conclusion : Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma.

Conclusion (proposition de traduction) : Chez les enfants présentant un asthme aigu réfractaire au service des urgences, le magnésium nébulisé avec l'albutérol, comparé au placebo avec l'albutérol, n'a pas diminué de manière significative le taux d'hospitalisation pour asthme dans les 24 heures. Les résultats ne soutiennent pas l'utilisation de magnésium nébulisé avec l'albutérol chez les enfants souffrant d'asthme aigu réfractaire.

Endoscopic Findings Associated With Button Battery Ingestion in Children: Do We Need to Change the Protocol for Managing Gastric Location?.
Ríos G, Rodríguez L, Lucero Y, Miquel I, Arancibia ME, Alliende F. | Pediatr Emerg Care. 2020 Nov;36(11):523-526
DOI: https://doi.org/10.1097/pec.0000000000001415
Keywords: Aucun

Original Article

Introduction : Ingested button batteries (BB) can cause corrosive damage of digestive mucosa within minutes. Immediate endoscopic removal of esophageal BB has been clearly established, but the management of BB located in the stomach is still controversial.
Aim: To describe demographic, clinical, radiologic, and endoscopic characteristics of a series of pediatric patients evaluated for BB ingestion.

Méthode : Retrospective analysis of clinical charts belonging to children younger than 15 years, who underwent endoscopic removal of BB at Clínica Alemana of Santiago, between November 2007 and November 2011.

Résultats : Twenty-five patients subjected to upper endoscopy were analyzed; median age, 31 months; 15 were male (60%), and 11 patients (46%) were symptomatic after ingestion. The BB ingestion was confirmed by radiograph. Endoscopy revealed 10 patients with BB in the esophagus, 12 patients in the stomach and 3 distal to duodenum. Range time between ingestion and endoscopy was 2 to 10 hours for esophageal BB and 2 hours to 3 days for gastric BB. Eight of the 22 BBs removed had a diameter of 20 mm or greater, 6 of them were located in the esophagus and 2 in stomach. The BB color changes were observed in 14 of the 22 BBs. Breakage of battery edges was present in 11 of the 22 batteries. All patients with esophageal BB and 6 of those 12 with gastric BB presented mucosal damage.

Conclusion : Esophageal BB cause damage within hours. The BB located in the stomach may also cause damage early. Extraction of gastric BB before 48 hours should be considered.

Conclusion (proposition de traduction) : Les piles bouton en position œsophagienne causent des dommages en quelques heures. Les piles boutons situées dans l'estomac peuvent également causer des dommages précoces. L'extraction des piles boutons gastriques avant 48 heures doit être envisagée.

Ocular Injury Presenting to a Level-III Pediatric Trauma Center.
Schneider K, Nguyen-Tran H, Segura BJ, Areaux RG, Nerheim D, Louie JP. | Pediatr Emerg Care. 2020 Nov;36(11):e606-e609
DOI: https://doi.org/10.1097/pec.0000000000001524
Keywords: Aucun

Original article

Introduction : The purpose of this study is to describe pediatric ocular injuries presenting to a level-III pediatric trauma center and emergency department.

Méthode : We performed a retrospective study and identified children from January 1, 2011, to January 1, 2016. Charts were reviewed for any subject, age from newborn to younger than 18 years, based on International Classification of Diseases, ninth and tenth revision, codes for any ocular injury. Data abstraction included age, sex, means of arrival, eye involved, mechanism of injury, type of ocular injury, imaging studies obtained, procedures performed, location of definitive repair (in the operating room or emergency department), and subspecialty services involved.

Résultats : In the 5-year period, we describe 356 injuries among 278 children. Males had a slightly higher rate of presentation than females (156 and 122, respectively). Forty-three children (15.46%) required repair in the operating room. Dog bites comprised of 7.19% children with outpatient follow-up, one patient (0.36%) eventually developed anophthalmia, and 30 children (10.79%) had long-term ophthalmological sequelae (ie, glaucoma and blindness).

Conclusion : At our institution, a level-III trauma center, we evaluated and managed approximately 1 ocular injury case per week and children required surgical repair in the operating room at a higher rate than higher-level trauma centers. Injuries secondary to dog bites remain a clinically significant etiology.

Conclusion (proposition de traduction) : ans notre établissement, un centre de traumatologie de niveau III, nous avons évalué et pris en charge environ 1 cas de lésion oculaire par semaine et les enfants nécessitaient une réparation chirurgicale en salle d'opération à un taux plus élevé que les centres de traumatologie de niveau supérieur. Les blessures secondaires aux morsures de chien restent une étiologie cliniquement significative.

The Association of Glasgow Coma Scale Score With Clinically Important Traumatic Brain Injuries in Children.
Johnson MA, Nishijima DK, Kuppermann N. | Pediatr Emerg Care. 2020 Nov;36(11):e610-e613
DOI: https://doi.org/10.1097/pec.0000000000001701
Keywords: Aucun

Original article

Introduction : An accurate understanding of the incidence of clinically important traumatic brain injuries (ciTBIs) based on presenting Glasgow Coma Scale (GCS) scores in pediatric patients is required to formulate a pretest probability of disease to guide testing and treatment. Our objective was to determine the prevalence of ciTBI and neurosurgical intervention for each GCS score (range 3-15) in children presenting after blunt head trauma.

Méthode : This was a secondary analysis of prospectively collected observational data from 25 pediatric emergency departments in the Pediatric Emergency Care Applied Research Network. Patients younger than 18 years with nontrivial blunt head injury were included.

Résultats : A total of 43,379 children with complete GCS scores were included in the analysis. Seven hundred sixty-three children had ciTBIs (1.8%) and 200 underwent neurosurgery (0.5%). Children with GCS scores of 4 had the highest incidence of ciTBI (21/22, 95.5%) and neurosurgical intervention (16/22, 72.2%). A nearly linear decrease in the prevalence of ciTBI from a GCS score of 4 to a score of 15 was observed (R = 0.92). Of 1341 children, 107 (8.0%) presenting with GCS scores of 14 were found to have ciTBIs and 17 (1.3%) underwent neurosurgical intervention.

Conclusion : A nearly linear relationship exists between the initial GCS score and ciTBI in children with blunt head trauma. The highest prevalence of ciTBI and neurosurgical intervention occurred in children with GCS scores of 4. Children presenting with GCS scores of 14 had a nonnegligible prevalence of ciTBI. These findings are critical to providers caring for children with blunt head trauma to accurately formulate pretest probabilities of ciTBI.

Conclusion (proposition de traduction) : Il existe une relation presque linéaire entre le score initial de Glasgow et les lésions cérébrales traumatiques cliniquement importantes chez les enfants souffrant d'un traumatisme crânien contondant. La prévalence la plus élevée de lésions cérébrales traumatiques cliniquement importantes et d'intervention neurochirurgicale est survenue chez les enfants avec des scores de Glasgow Coma Scale de 4. Les enfants présentant des scores Glasgow Coma Scale de 14 avaient une prévalence non négligeable de lésions cérébrales traumatiques cliniquement importantes. Ces résultats sont essentiels pour les prestataires qui s'occupent d'enfants souffrant d'un traumatisme crânien contondant pour formuler avec précision les probabilités de prétest de lésions cérébrales traumatiques importantes sur le plan clinique.

Pediatric Transport Practices Among Prehospital Providers.
Fidacaro GA Jr, Jones CW, Drago LA. | Pediatr Emerg Care. 2020 Nov;36(11):e632-e635
DOI: https://doi.org/10.1097/pec.0000000000001564
Keywords: Aucun

Original article

Introduction : There are nearly 1000 annual ambulance crashes within the United States involving pediatric patients. In 2012 National Highway Traffic Safety Administration/US Department of Transportation released Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. The aim of our study was to measure emergency medical services (EMS) providers' knowledge and opinions of how to safely transport pediatric patients. In addition, we aimed to gather information on barriers to safe pediatric transport.

Méthode : Members of 1 urban and 2 suburban EMS agencies completed an anonymous survey that assessed level of training, years of experience, exposure to pediatric patients, knowledge of best practices, and opinions about barriers to safe transport of pediatric patients.

Résultats : A total of 114 EMS providers answered the survey. Sixty-three percent were basic life support providers who had more than 10 years of experience in EMS. Ninety-six percent reported that they transported 0 to 5 pediatric patients per week. Twenty percent reported being trained on pediatric safe transport practices. Thirty-two percent of providers reported that personnel did not drive faster when transporting a sick pediatric patient. Eighty-six percent reported that it was unsafe to transport a child on a parent's lap, but 27% reported that it was appropriate to transport a newborn on the stretcher with mom. Thirty-eight percent were comfortable identifying proper restraint system/seat for pediatric patients, and only 35% were comfortable installing/using these devices. Provider-reported barriers to safe transport were identified.

Conclusion : ur survey demonstrates that despite published best practices for the safe transport of children, many providers are unfamiliar with the safest way to transport these patients. In addition, we identified several existing barriers that may contribute to unsafe practices.

Conclusion (proposition de traduction) : Notre enquête démontre qu'en dépit des meilleures pratiques publiées pour le transport sûr des enfants, de nombreux prestataires ne connaissent pas le moyen le plus sûr de transporter ces patients. De plus, nous avons identifié plusieurs obstacles existants qui peuvent contribuer à des pratiques dangereuses.

Current Approach to the Evaluation and Management of Incomplete Kawasaki Disease in the Emergency Department.
Morishita KA, Goldman RD. | Pediatr Emerg Care. 2020 Nov;36(11):537-541
DOI: https://doi.org/10.1097/pec.0000000000002259
Keywords: Aucun

CME Review Article

Editorial : Kawasaki disease (KD) is one of the most common vasculitides of childhood and frequently presents to the emergency department. Although the diagnosis of KD is based on clinical criteria, children who do not fulfill the criteria but have sufficient supportive features of KD are diagnosed as having incomplete KD and warrant the same course of therapy as children with classic KD. The diagnosis of incomplete KD is challenging and requires a high index of suspicion. The purpose of this article is to review presenting features of incomplete KD and the diagnostic approach and management of children in the emergency department.

Conclusion :  The diagnosis of incomplete KD should be considered in the ED in any infant or child with prolonged unexplained fever, fewer than 4 of the principal clinical findings, and compatible laboratory and/or echocardiographic findings.

Conclusion (proposition de traduction) : Le diagnostic de maladie de Kawasaki incomplète doit être évoqué au service des urgences chez tout nourrisson ou enfant présentant une fièvre prolongée inexpliquée, moins de 4 des principaux signes cliniques et des résultats de laboratoire et/ou échocardiographiques compatibles.

Neurological outcome of chest compression-only bystander CPR in asphyxial and non-asphyxial out-of-hospital cardiac arrest: an observational study.
Javaudin F, Raiffort J, Desce N, Baert V, Hubert H, Montassier E, Le Cornec C, Lascarrou JB, Le Bastard Q; GR-RéAC. | Prehosp Emerg Care. 2020 Nov 18:1-13
DOI: https://doi.org/10.1080/10903127.2020.1852354  | Télécharger l'article au format  
Keywords: Basic life support; Cardiopulmonary resuscitation; Chest compression-only; Mouth-to-mouth resuscitation; Out-of-hospital cardiac arrest.

Article

Introduction : According to guidelines and bystander skill, two different methods of cardiopulmonary resuscitation (CPR) are feasible: standard CPR (S-CPR) with mouth-to-mouth ventilations and chest compression-only CPR (CO-CPR) without rescue breathing. CO-CPR appears to be most effective for cardiac causes, but there is a lack of evidence for asphyxial causes of out-of-hospital cardiac arrest (OHCA). Thus, the aim of our study was to compare CO-CPR versus S-CPR in adult OHCA from medical etiologies and assess neurologic outcome in asphyxial and non-asphyxial causes.

Méthode : Using the French National OHCA Registry (RéAC), we performed a multicenter retrospective study over a five-year period (2013 to 2017). All adult-witnessed OHCA who had benefited from either S-CPR or CO-CPR by bystanders were included. Non-medical causes as well as professional rescuers as witnesses were excluded. The primary end point was 30-day neurological outcome in a weighted population for all medical causes, and then for asphyxial, non-asphyxial and cardiac causes.

Résultats : Of the 8 541 subjects included for all medical causes, 6 742 had a non-asphyxial etiology, including 5 904 of cardiac causes, and 1 799 had an asphyxial OHCA. Among all subjects, 8.6%; 95% CI [8.1-9.3] had a good neurological outcome (i.e. cerebral performance category of 1 or 2). Bystanders who performed S-CPR began more often immediately (89.0%; 95% CI [87.3-90.5] versus 78.2%; 95% CI [77.2-79.2]) and in younger subjects (64.1 years versus 65.7; p < 0.001). In the weighted population, subjects receiving bystander-initiated CO-CPR had an adjusted relative risk (aRR) of 1.04; 95% CI [0.79-1.38] of having a good neurological outcome at 30 days for all medical causes, 1.28; 95% CI [0.92-1.77] for asphyxial etiologies, 1.08; 95% CI [0.80-1.46] for non-asphyxial etiologies and 1.09; 95% CI [0.93-1.28] for cardiac-related OHCA.

Conclusion : We observed no significant difference in neurological outcome when lay bystanders of adult OHCA initiated CO-CPR or S-CPR, whether the cause was asphyxial or not.

Conclusion (proposition de traduction) : Nous n'avons observé aucune différence significative dans le résultat neurologique lorsque des témoins non professionnels d'un arrêt cardiaque adulte extra-hospitalier ont initié une RCP par compression thoracique uniquement ou une RCP standard, que la cause soit asphyxique ou non.

The neurologic impact of epinephrine during cardiac arrest: Much to learn.
Kilbaugh TJ , Morgan RW, Berg RA . | Resuscitation. 2020 Nov;156:263-264
DOI: https://doi.org/10.1016/j.resuscitation.2020.07.017
Keywords: Aucun

Original article

Editorial : Epinephrine is administered hundreds of thousands of times annually during the course of CPR for in- and out-of-hospital cardiac arrest. Recommended regardless of age, comorbidities, arrest location, etiology, or rhythm, it is the pharmacologic cornerstone of cardiac arrest care, and has been for nearly 60 years. Despite its ubiquity and decades of research, epinephrine’s utility in achieving the principal goal of resuscitation – neurologically intact survival – remains controversial.

Conclusion : In summary, the authors should be congratulated on an excellent study that enhances our understanding of the effect of epinephrine during CPR, but once again each new answer raises several new questions. It is certain that the ‘right’ answers regarding epinephrine’s benefit or harm on the brain as well as the dose and interval at which it should be administered varies from patient to patient (and animal to animal). To effectively study the impact of our resuscitation therapies on the brain and to best guide such therapies at the bedside, we need high-fidelity, minimally invasive biomarkers of cerebral blood flow, metabolism, and injury. Innovative bioengineering and molecular science will develop the next generation of large animal pre-clinical studies that will lay the foundation for informed clinical trials aimed at individual physiology prior to, during, and after cardiac arrest. This will allow us to not only save our patients’ lives, but to save their futures.

Conclusion (proposition de traduction) : En résumé, il faut féliciter les auteurs pour leur excellente étude qui améliore notre compréhension de l’effet de l’adrénaline dans la RCP, mais encore une fois, chaque nouvelle réponse soulève plusieurs nouvelles questions. Il est certain que les « bonnes » réponses concernant les bienfaits ou les dommages de l’adrénaline sur le cerveau ainsi que la dose et l’intervalle à laquelle elle doit être administrée varient d’un patient à l’autre (et d’un animal à l’autre). Pour étudier efficacement l’impact de nos traitements de réanimation sur le cerveau et pour guider au mieux ces traitement au lit du malade, nous avons besoin de biomarqueurs à haute fidélité et faiblement invasif sur le flux sanguin cérébral, du métabolisme et des blessures. La bioingénierie et la science moléculaire innovatrices permettront de mettre au point la prochaine génération d’études précliniques sur de grands animaux qui jetteront les bases d’essais cliniques éclairés axés sur la physiologie individuelle avant, pendant et après l’arrêt cardiaque. Cela nous permettra non seulement de sauver la vie de nos patients, mais aussi de sauver leur avenir.

Commentaire : Voir l'article de Putzer G. :
Putzer G, Martini J, Spraider P, et al. Effects of different adrenaline doses on cerebral oxygenation and cerebral metabolism during cardiopulmonary resuscitation in pigs. Resuscitation. 2020 Jul 8:S0300-9572(20)30260-4  .

The impact of ventilation rate on end-tidal carbon dioxide level during manual cardiopulmonary resuscitation.
Ruiz de Gauna S, Gutiérrez JJ, Ruiz J, Leturiondo M, Azcarate I, González-Otero DM, Corcuera C, Russell JK, Daya MR. | Resuscitation. 2020 Nov;156:215-222
DOI: https://doi.org/10.1016/j.resuscitation.2020.06.007
Keywords: Advanced life support (ALS); Cardiopulmonary resuscitation (CPR); End-tidal carbon dioxide (ETCO(2)); Out-of-hospital cardiac arrest (OHCA); Ventilation; Ventilation rate; Waveform capnography.

Clinical paper

Introduction : Ventilation rate is a confounding factor for interpretation of end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR). The aim of our study was to model the effect of ventilation rate on ETCO2 during manual CPR in adult out-of-hospital cardiac arrest (OHCA).

Méthode : We conducted a retrospective analysis of OHCA monitor-defibrillator files with concurrent capnogram, compression depth, transthoracic impedance and ECG. We annotated pairs of capnogram segments presenting differences in average ventilation rate and average ETCO2 value but with other influencing factors (e.g. compression rate and depth) presenting similar values within the pair. ETCO2 variation as a function of ventilation rate was adjusted through curve fitting using non-linear least squares as a measure of goodness of fit.

Résultats : A total of 141 pairs of segments from 102 patients were annotated. Each pair provided a single data point for curve fitting. The best goodness of fit yielded a coefficient of determination R2 of 0.93. Our model described that ETCO2 decays exponentially with increasing ventilation rate. The model showed no differences attributable to the airway type (endotracheal tube or supraglottic King-LT-D).

Conclusion : Capnogram interpretation during CPR is challenging since many factors influence ETCO2. For adequate interpretation, we need to know the effect of each factor on ETCO2. Our model allows quantifying the effect of ventilation rate on ETCO2 variation. Our findings could contribute to better interpretation of ETCO2 during CPR.

Conclusion (proposition de traduction) : L'interprétation de la capnographie pendant la RCP est difficile car de nombreux facteurs influencent l'ETCO2. Pour une interprétation adéquate, nous devons connaître l'effet de chaque facteur sur l'ETCO2. Notre modèle permet de quantifier l'effet de la fréquence ventilatoire sur la variation de l'ETCO2. Nos résultats pourraient contribuer à une meilleure interprétation de l'ETCO2 pendant la RCP.

Circadian variation of in-hospital cardiac arrest.
Tripathi A, Girotra S, Toft LEB; American Heart Association's Get With the Guidelines-Resuscitation Investigators.. | Resuscitation. 2020 Nov;156:19-26
DOI: https://doi.org/10.1016/j.resuscitation.2020.08.014
Keywords: Asystole; Circadian variation; In-hospital cardiac arrest; Pulseless electrical activity; Ventricular fibrillation; Ventricular tachycardia.

Clinical paper

Introduction : Out of hospital cardiac arrests, especially those due to ventricular tachyarrhythmias, have higher incidence in the morning. It is unknown whether in-hospital cardiac arrests follow a similar pattern.
Aim of the study: The purpose of this study was to analyze the circadian variation of in-hospital cardiac arrest incidence.

Méthode : This retrospective review of data from the multicenter Get With The Guidelines-Resuscitation registry between 2000 and 2014 used multivariable hierarchical logistic regression analysis to examine circadian rhythm of in-hospital cardiac arrest over a 24-h cycle, stratified by initial shockable versus non-shockable rhythm.

Résultats : Among 154,038 patients, initial rhythm was recorded as asystole or pulseless electrical activity (non-shockable) in 124,918 (81%), and ventricular fibrillation or ventricular tachycardia (shockable) in 29,120 (19%). Among non-shockable events, the highest relative proportion occurred during 0400-0759 (17.9%), followed by 0000-0359 (17.1%). For shockable rhythms the greatest relative proportion occurred between 2000-2359 (17.0%), followed by 1200-1559 (16.9%). Multivariable analysis showed that the relative risk of non-shockable compared to shockable arrest was slightly higher from midnight through 0359 (aOR 1.13; 95% CI 1.06-1.20, p < 0.001) and from 0400 through 0759 h (aOR 1.14; 95% CI 1.07-1.22, p < 0.001). Although statistically significant, the magnitude of difference in incidence by time of day was small in both groups.

Conclusion : Although small differences in the relative frequency of in-hospital cardiac arrest (both shockable and non-shockable rhythms) were noted during different time intervals, in-hospital cardiac arrest occurs with nearly equal frequency throughout the day. Our findings have important implications for hospital staffing models to ensure that quality of resuscitation care is consistent regardless of time.

Conclusion (proposition de traduction) : Bien que de petites différences dans la fréquence relative des arrêts cardiaques à l'hôpital (rythmes choquables et non choquables) aient été notées à différents intervalles de temps, l'arrêt cardiaque à l'hôpital se produit à une fréquence presque égale tout au long de la journée. Nos résultats ont des implications importantes pour les modèles de dotation en personnel hospitalier afin de garantir que la qualité des soins de réanimation soit constante quelle que soit l'heure.

Predicting intensive care unit admission and death for COVID-19 patients in the emergency department using early warning scores.
Covino M, Sandroni C, Santoro M, Sabia L, Simeoni B, Bocci MG, Ojetti V, Candelli M, Antonelli M, Gasbarrini A, Franceschi F. . | Resuscitation. 2020 Nov;156:84-91
DOI: https://doi.org/10.1016/j.resuscitation.2020.08.124
Keywords: COVID-19; Early warning scores; MEWS; NEWS; NEWS2; REMS; qSOFA.

Clinical paper

Introduction : To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED).

Méthode : In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated.

Résultats : We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes.

Conclusion : In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration.

Conclusion (proposition de traduction) : Dans notre cohorte monocentrique de patients COVID-19, NEWS et REMS mesurés à l'arrivée aux urgences étaient les prédicteurs les plus sensibles de l'admission ou du décès à l'USI à 7 jours. L'EWS pourrait être utile pour identifier les patients présentant un faible risque de détérioration clinique.

Commentaire : Retrouver le calcul et l'interprétation du score NEWS sur la page score de mon site Internet   et le calcul en ligne sur la site MDCalc  .

The NACA score as a predictor of ventricular cardiac arrhythmias - A retrospective six-year study.
Leszczyński P, Mioduski M, Gałązkowski R. | Am J Emerg Med. 2020 Nov;38(11):2249-2253
DOI: https://doi.org/10.1016/j.ajem.2019.12.044  | Télécharger l'article au format  
Keywords: Arrhythmia; Cardiovascular risk factors; Emergency medicine; Transport - emergency.

Original Contribution

Introduction : Helicopter Emergency Medical Service (HEMS) conducts the evaluation of a patient's condition using NACA score before transporting the patient to hospital. The conditions inside the rescue helicopter limit or even make it impossible to conduct some medical procedures. An appropriate classification of the patient may lead to a lower possibility of occurrence of adverse events during the flight. The aim of the research was to evaluate the correlation of NACA score with the cardiac arrhythmia that may be life threatening.

Méthode : A retrospective observational study included a group of 47,131 patients, who were transported by HEMS services between 2012 and 2017. The research was conducted using the analysis of variance ANOVA running a post hoc test. In order to calculate the correlation of variables, Kruskal-Wallis and r-Pearson tests were carried out, interpreting the results according to J. Gilville's scale. The significance level was set at α = 0,05.

Résultats : The average number of points using NACA score for the studied group was 4,06 (SD ± 1,38). Twelve heart rhythms were selected while evaluating correlations using NACA score. There was a significant relation between the ECG variable and NACA score (p = 0,003). There was a very strong correlation between NACA score and the following: VF/pVT (r-Pearson = 0,856; p = 0,006), PEA (r-Pearson = 0,810; p = 0,015) and Asystole (r-Pearson = 0,728; p = 0,026).

Conclusion : NACA score allows to predict the risk of occurrence of ventricular arrhythmia of the myocardium as well as cardiac arrest. The possibility of occurrence of a life-threatening rhythm is significantly higher in patients classified as NACA IV or higher.

Conclusion (proposition de traduction) : Le score NACA (Comité consultatif national de l'aéronautique) permet de prédire le risque de survenue d'arythmie ventriculaire ainsi que le risque d'arrêt cardiaque. La possible apparition d'un rythme potentiellement mortel est significativement plus élevée chez les patients classés comme NACA IV ou plus (sur VII).

Commentaire :  Score NACA (National Advisory Committee for Aeronautics)

Weight-based versus non-weight-based diltiazem dosing in the setting of atrial fibrillation with rapid ventricular response.
Ward SM, Radke J, Calhoun C, Caporossi J, Hall GA, Matuskowitz AJ, Weeda ER, Weant KA. | Am J Emerg Med. 2020 Nov;38(11):2271-2276
DOI: https://doi.org/10.1016/j.ajem.2019.09.020
Keywords: Atrial fibrillation; Diltiazem; Emergency medicine; Obesity; Pharmacy; Rate control.

Original contribution

Introduction : There is conflicting evidence to support the superiority of weight-based (WB) dosing of intravenous (IV) diltiazem over non-weight-based (NWB) dosing strategies in the management of atrial fibrillation (AFib) with rapid ventricular response (RVR).

Méthode : A retrospective review evaluated patients presenting to the emergency department (ED) in AFib with RVR and receiving IV diltiazem from 2015 to 2018. Those receiving a NWB dose were compared with those receiving a WB dose based on actual body weight (ABW). Secondary analyses evaluated safety profiles of the regimens and compared response in groups defined by ABW or ideal body weight (IBW).

Résultats : A total of 371 patients were included in the analysis. No significant difference was observed in achieving a therapeutic response (66.5% vs. 73.1%, p = 0.18) or adverse events between the groups. Patients receiving a WB dose were significantly more likely to have a HR < 100 bpm than those receiving a NWB dose (40.9% vs. 53.5%, p = 0.01). When groups were defined by IBW, WB dosing was associated with a significantly higher incidence of achieving a therapeutic response (62.7% vs. 74.3%, p = 0.02).

Conclusion : In patients presenting with AF with RVR, there was no significant difference in achieving a therapeutic response between the two strategies. A WB dosing approach did result in a greater proportion of patients with a HR < 100 bpm. The utilization of IBW for WB dosing may result in an increased achievement of a therapeutic response.

Conclusion (proposition de traduction) : Chez les patients présentant une FA avec une réponse ventriculaire rapide, il n’y avait aucune différence significative dans l'obtention d’une réponse thérapeutique entre les deux stratégies. Une approche basée sur le poids a donné lieu à une plus grande proportion de patients ayant une fréquence cardiaque de 100 bpm. L’utilisation du poids corporel idéal pour le dosage basé sur le poids permet une amélioration de la réponse thérapeutique.

Prehospital supplemental oxygen for acute stroke - A retrospective analysis.
Dylla L, Adler DH, Abar B, Benesch C, Jones CMC, Kerry O'Banion M, Cushman JT. | Am J Emerg Med. 2020 Nov;38(11):2324-2328
DOI: https://doi.org/10.1016/j.ajem.2019.11.002
Keywords: Acute Ischemic Stroke; Hyperoxia; Prehospital.

Original contribution

Introduction : Brief early administration of supplemental oxygen (sO2) to create hyperoxia may increase oxygenation to penumbral tissue and improve stroke outcomes. Hyperoxia may also result in respiratory compromise and vasoconstriction leading to worse outcomes. This study examines the effects of prehospital sO2 in stroke.

Méthode : This is 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. Demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects' medical records were compared across three groups based on prehospital oxygen saturation and sO2 administration. Chi-square, ANOVA, and multivariate logistic regression were used to determine if sO2 status was associated with neurological outcomes or respiratory complications.

Résultats : 1352 eligible patients were identified. 62.7% (n = 848) did not receive sO2 ("controls"), 10.7% (n = 144) received sO2 due to hypoxia ("hypoxia"), and 26.6% (n = 360) received sO2 despite normoxia ("hyperoxia"). The groups represented a continuum from more severe deficits (hypoxia) to less severe deficits (controls): mean prehospital GCS (hypoxia -12, hyperoxia - 2, controls - 14 p ≤ 0.001), mean initial NIHSS (hypoxia - 15, hyperoxia - 13, controls - 8 p < 0.001). After controlling for potential confounders, all groups had similar rates of respiratory complications and favorable neurological outcomes.

Conclusion : Hyperoxic subjects had no significant increase in respiratory complications, nor did they differ in neurologic outcomes at discharge when controlling for confounders. While limited by the retrospective nature, this suggests brief, early sO2 for stroke may be safe to evaluate prospectively.

Conclusion (proposition de traduction) : Les sujets hyperoxiques n'avaient pas d'augmentation significative des complications respiratoires ni des résultats neurologiques à la sortie lors du contrôle des facteurs de confusion. Bien que limité par la nature rétrospective, cela suggère que la supplémentation précoce et brève en oxygène dans l'AVC peut être sans danger dans le cadre d'une évaluation prospective.

Commentaire : Voir les articles :
• Dylla L, Cushman JT, Abar B, Benesch C, Jones CMC, O'Banion MK, Adler DH. Retrospective analysis of the hemodynamic consequences of prehospital supplemental oxygen in acute stroke. Am J Emerg Med. 2020 Oct;38(10):2125-2129  .
• Akca O, Nichols J, Stewart B, Elliott C, Remmel K, Lenhardt R. Association of Early Oxygenation Levels with Mortality in Acute Ischemic Stroke - A Retrospective Cohort Study. J Stroke Cerebrovasc Dis. 2020 Feb;29(2):104556  .
• Roffe C, Nevatte T, Sim J, Bishop J, Ives N, Ferdinand P, Gray R; Stroke Oxygen Study Investigators and the Stroke OxygenStudy Collaborative Group. Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial. JAMA. 2017 Sep 26;318(12):1125-1135. doi: 10.1001/jama.2017.11463  .
• L'oxygénothérapie systématique n'est pas recommandée, sauf si la saturation est inférieure à 95 % (accord professionnel). Accident vasculaire cérébral : prise en charge précoce (alerte, phase préhospitalière, phase hospitalière initiale, indications de la thrombolyse). Recommandation de bonne pratique, mai 2009  .

Rapid correction of hyperkalemia is associated with reduced mortality in ED patients.
Singer AJ, Thode HC Jr, Peacock WF. | Am J Emerg Med. 2020 Nov;38(11):2361-2364
DOI: https://doi.org/10.1016/j.ajem.2019.12.012
Keywords: Emergency department; Hyperkalemia; Mortality.

Original article

Introduction : Hyperkalemia (HK) is common and associated with mortality. Our purpose was to determine if the rapid correction of elevated serum potassium level (K+) was associated with reduced mortality in emergency department (ED) patients.
Methods: Design: We reviewed the electronic medical records (EMR) of ED patients with HK (K+ ≥ 5.5 mEq/L) from 10/2016-10/2017.
Setting: Large, academic ED.

Méthode : Adult ED patients presenting with hyperkalemia. Main outcomes and measures: The main outcome was in-hospital mortality. We compared outcomes of patients whose K⁺ normalized (dropped below 5.5 mEq/L) with those whose K⁺ did not normalize using chi-square and multivariate analyses to determine the associations between predictor variables and outcomes.

Résultats : From 114,977 ED visits, 1033 patients (0.9%, 95%CI 0.85-0.95%) had HK. Their mean (SD) age was 60 (26) years and 58% were male. Of these, 884 had a second K⁺ measured within a median (IQR) of 5 (3-8) hours. Mortality and admission rates were higher in patients with HK vs. those with normal K⁺ (8.5% vs. 0.8%, P < 0.001 and 80% vs. 39%, P < 0.001, respectively). Mortality was lower in patients whose HK normalized compared with those whose K+ remained elevated (6.3% vs. 12.7%, P = 0.001). After adjusting for age, creatinine, comorbidities, and initial K⁺, normalization of K⁺ was associated with reduced mortality (OR 0.47, 95%CI 0.28 to 0.80).

Conclusion : Normalization of K⁺ during the ED stay in patients with HK is associated with a 50% mortality reduction. Efforts to rapidly identify and treat HK in the ED are needed.

Conclusion (proposition de traduction) : La normalisation du K⁺ pendant la consultation aux urgences chez les patients présentants une hyperkaliémie est associée à une réduction de la mortalité de 50 %. Des efforts pour identifier et traiter rapidement l'hyperkaliémie au service des urgences sont nécessaires.

Plastic blanket drowning kit: A protection barrier to immediate resuscitation at the beach in the Covid-19 era. A pilot study.
Barcala-Furelos R, Szpilman D, Abelairas-Gómez C, Alonso-Calvete A, Domínguez-Graña M, Martínez-Isasi S, Palacios-Aguilar J, Rodríguez-Núñez A. | Am J Emerg Med. 2020 Nov;38(11):2395-2399
DOI: https://doi.org/10.1016/j.ajem.2020.08.101  | Télécharger l'article au format  
Keywords: COVID-19; Drowning; Lifeguard; Non-invasive ventilation; Resuscitation.

Brief Report

Introduction : Introducing a new, simple and inexpensive portable equipment for lifeguards, consisting of a pre-assembled full-size plastic blanket with a mask and HEPA filter, which could offer significant time-saving advantages to reduce COVID-19 risk transmission in the first few minutes of CPR after water rescue, avoiding the negative impact of delayed ventilation.

Méthode : A pilot study was carried out to determine the feasibility of the pre-assembled kit of face-mask and HEPA filter adapted on a pre-set plastic-blanket. The first step consisted of washing hands, putting on safety glasses and gloves as the first personal protection equipment (PPE) and then covering the victim with an assembled plastic blanket. The second step consisted of 10 min of cardiopulmonary resuscitation (CPR) with PPE and plastic blanket, following the technical recommendations for ventilation during COVID-19.

Résultats : Ten rescuers took part in the pilot study. The average time to wear PPE and place the pre-assembly kit on the victim was 82 s [IC 58-105]. After 10 min the quality of the resuscitation (QCPR) was 91% [87-94]. Quality chest compressions (CC) were 22% better than ventilations (V). Most of the rescuers (60%) thought that placing the plastic blanket on the victim on the beach was somewhat simple or very simple.

Conclusion : Resuscitation techniques in COVID-19 era at the beach have added complexities for the correct use of PPE. Plastic blanket plus basic ventilations equipment resource could be a new alternative to be considered for lifeguards to keep ventilation on use while reducing risk transmission.

Conclusion (proposition de traduction) : Les techniques de réanimation à la plage à l’ère de la COVID-19 ont compliqué l’utilisation correcte des équipements de protection individuelle. Une couverture en plastique et un équipement de ventilation de base pourraient constituer une nouvelle solution à envisager pour les sauveteurs afin de maintenir la ventilation efficace tout en réduisant la transmission des risques.

Commentaire : Données supplémentaires

SARS-CoV-2 pharmacologic therapies and their safety/effectiveness according to level of evidence.
Baroutjian A, Sanchez C, Boneva D, McKenney M, Elkbuli A. | Am J Emerg Med. 2020 Nov;38(11):2405-2415
DOI: https://doi.org/10.1016/j.ajem.2020.08.091  | Télécharger l'article au format  
Keywords: COVID-19 clinical outcomes; COVID-19 pharmacologic treatments; Drug effectiveness; Drug safety; SARS-CoV-2.

Review

Introduction : There is a pressing need for COVID-19 transmission control and effective treatments. We aim to evaluate the safety and effectiveness of SARS-CoV-2 pharmacologic therapies as of August 2, 2020 according to study level of evidence.

Méthode : PubMed, ScienceDirect, Cochrane Library, JAMA Network and PNAS were searched. The following keywords were used: ((COVID-19) OR (SARS-CoV-2)) AND ((((((therapeutics) OR (treatment)) OR (vaccine)) OR (hydroxychloroquine)) OR (antiviral)) OR (prognosis)). Results included peer-reviewed studies published in English.

Résultats : 15 peer-reviewed articles met study inclusion criteria, of which 14 were RCTs and one was a systematic review with meta-analysis. The following pharmacologic therapies were evaluated: chloroquine (CQ), hydroxychloroquine (HCQ), antivirals therapies, plasma therapy, anti-inflammatories, and a vaccine.

Conclusion : According to level 1 evidence reviewed here, the most effective SARS-Co-V-2 pharmacologic treatments include remdesivir for mild to severe disease, and a triple regimen therapy consisting of lopinavir-ritonavir, ribavirin and interferon beta-1b for mild to moderate disease. Also, dexamethasone significantly reduced mortality in those requiring respiratory support. However, there is still a great need for detailed level 1 evidence on pharmacologic therapies.

Conclusion (proposition de traduction) : Selon les données de niveau 1 examinées ici, les traitements pharmacologiques contre le SRAS-Co-V-2 les plus efficaces comprennent le remdesivir pour les maladies bénignes à graves et la trithérapie comprenant le lopinavir-ritonavir, la ribavirine et l'interféron bêta-1b pour les maladies bénignes à graves. En outre, la dexaméthasone a considérablement réduit la mortalité chez les personnes nécessitant une assistance respiratoire. Cependant, il existe encore un grand besoin de preuves détaillées de niveau 1 sur les traitements pharmacologiques.

Identifying cardiogenic shock in the emergency department.
Daly M, Long B, Koyfman A, Lentz S. | Am J Emerg Med. 2020 Nov;38(11):2425-2433
DOI: https://doi.org/10.1016/j.ajem.2020.09.045
Keywords: Cardiogenic shock; Cardiology; Heart failure; Myocardial infarction.

Review

Introduction : Cardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states (i.e. sepsis), poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters. Despite advances in interventions, mortality in patients with cardiogenic shock remains high. Emergency clinicians must be ready to recognize and start appropriate therapy for cardiogenic shock early.

Méthode : This review will discuss the clinical evaluation and diagnosis of cardiogenic shock in the emergency department with a focus on the emergency clinician.

Discussion : The most common cause of cardiogenic shock is a myocardial infarction, though many causes exist. It is classically diagnosed by invasive hemodynamic measures, but the diagnosis can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound. Early recognition and stabilization improve morbidity and mortality. This review will focus on identification of cardiogenic shock through clinical examination, laboratory studies, and point-of-care ultrasound.

Conclusion : The emergency clinician should use the clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock. Cardiogenic shock has the potential for significant morbidity and mortality if not recognized early.

Conclusion (proposition de traduction) : Le clinicien d'urgence doit utiliser l'examen clinique, les examens de laboratoire, l'électrocardiogramme et l'échographie au point d'intervention pour faciliter l’identification du choc cardiogénique. Le choc cardiogénique peut entraîner une morbidité et une mortalité importantes s’il n’est pas reconnu tôt.

Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis.
Tran QK, Mester G, Bzhilyanskaya V, Afridi LZ, Andhavarapu S, Alam Z, Widjaja A, Andersen B, Matta A, Pourmand A. | Am J Emerg Med. 2020 Nov;38(11):2434-2443
DOI: https://doi.org/10.1016/j.ajem.2020.09.047
Keywords: Adverse events; Central venous catheters; Complications; Peripheral intravenous catheters; Vasoactive medication; Vasopressors.

Review

Introduction : Vasopressors are mainstay treatment for patients in shock and are usually infused through central venous catheters (CVCs). However, CVCs are associated with risk of infection or delay from the needs of confirmation of placement. Infusing vasopressor through peripheral venous catheter (PIVs) could be an alternative in the Emergency Departments (ED) but data regarding complications is inconclusive. We performed a random-effects meta-analysis to assess literature involving prevalence of complications from infusing vasopressors via PIVs.

Méthode : We searched PubMed, EMBASE and Scopus databases from beginnings to 02/02/2020 to identify relevant randomized control trials, cohort, case-control studies. We excluded case reports. Authors assessed studies' quality with Newcastle-Ottawa Scale and Cochrane Risk of Bias tool. Kappa score was used to assess interrater agreement. Outcome was complications as direct results from infusing vasopressors through PIVs.

Résultats : We identified 325 articles and included 9 studies after reviewing 16 full text articles. Our analysis included 1835 patients whose mean age was 63 (Standard Deviation 12) years and 48% was female. There were 122 (7%) complications, of which 117 (96%) were minor. The meta-analysis with random effects showed the pooled prevalence of complications as 0.086 (95%CI 0.031-0.21). Studies reporting infusion safety guidelines had significantly lower prevalence of complications (0.029, 95%CI 0.018-0.045), compared to those not reporting a safety guideline (0.12, 95%CI 0.038-0.30, p = 0.024).

Conclusion : There was low prevalence of complications as a direct result from infusing vasopressors through PIVs. Studies with safety guidelines were associated with significantly lower prevalence of complications. Further studies are needed to confirm our observations.

Conclusion (proposition de traduction) : La prévalence des complications découlant directement de la perfusion de vasopresseurs par VVP était faible. Les études comportant des lignes directrices sur l’innocuité étaient associées à une prévalence significativement plus faible des complications. D’autres études sont nécessaires pour confirmer nos observations.

Non-respiratory presentations of COVID-19, a clinical review.
Tran QK, Mester G, Bzhilyanskaya V, Afridi LZ, Andhavarapu S, Alam Z, Widjaja A, Andersen B, Matta A, Pourmand A. | Am J Emerg Med. 2020 Nov;38(11):2434-2443
DOI: https://doi.org/10.1016/j.ajem.2020.09.047  | Télécharger l'article au format  
Keywords: COVID-19; Dermatology; Gastrointestinal; Hematology; Nephrology; Neurology; Psychiatry; SARS-CoV-2.

Review

Introduction : Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) is a highly infectious viral syndrome currently threatening millions of people worldwide. It is widely recognized as a disease of the pulmonary system, presenting with fever, cough, and shortness of breath. However, a number of extrapulmonary manifestations have been described in the literature.

Méthode : In this review, we seek to provide a comprehensive summary of the hematologic, gastroenterological, renal, dermatologic, neurologic, and psychiatric manifestations of COVID-19.

Résultats : Hematological presentations of COVID-19 include laboratory abnormalities such as decreased total lymphocyte count, prolonged prothrombin time (PT), elevated d-dimer, and increased lactate dehydrogenase (LDH). Several of these findings are associated with increased mortality among infected patients. The most common gastrointestinal symptoms include nausea, vomiting, diarrhea, and abdominal pain. Furthermore, presence of viral RNA in patient stool suggests the possibility of additional testing modalities for COVID-19. Nephrological findings such as proteinuria, hematuria, and elevated BUN and creatinine levels have been observed. Additionally, several studies demonstrated that patients with COVID-19 who developed acute kidney injury (AKI) had a greater risk of mortality. The virus can also present with cutaneous symptoms such as erythematous rashes, urticaria, and chicken pox-like lesions. Neuropsychiatric symptoms have been described in the literature, and patients can exhibit findings consistent with viral encephalitis, cerebral vascular disease, peripheral nerve disorders, and psychosis.

Conclusion : Although COVID-19 does usually present primarily with respiratory symptoms, the extra-pulmonary manifestations of the virus are unpredictable and varied. Better understanding and awareness of these symptoms can lead to more efficient diagnosis, rapid treatment, isolation, and decreased spread of the disease.

Conclusion (proposition de traduction) : Bien que la COVID-19 présente habituellement principalement des symptômes respiratoires, les manifestations extra-pulmonaires du virus sont imprévisibles et variées. Une meilleure compréhension et une meilleure sensibilisation à ces symptômes peuvent mener à un diagnostic plus efficace, à un traitement rapide, à l’isolement et à une diminution de la propagation de la maladie.

Time to Loss of Preoxygenation in Emergency Department Patients.
Mosier J, Reardon RF, DeVries PA, Stang JL, Nelsen A, Prekker ME, Driver BE. | J Emerg Med. 2020 Nov;59(5):637-642
DOI: https://doi.org/10.1016/j.jemermed.2020.06.064
Keywords: airway management; denitrogenation; emergency department; intubation; oxygen; preoxygenation.

Brief Reports

Introduction : In patients requiring emergency rapid sequence intubation (RSI), 100% oxygen is often delivered for preoxygenation to replace alveolar nitrogen with oxygen. Sometimes, however, preoxygenation devices are prematurely removed from the patient prior to the onset of apnea, which can lead to rapid loss of preoxygenation.
Objective: We sought to determine the elapsed time, on average, between removing the oxygen source and the loss of preoxygenation among non-critically ill patients in the emergency department (ED).

Méthode : We conducted a prospective, crossover study of non-critically ill patients in the ED. Each patient received two identical preoxygenation trials for 4 min using a non-rebreather mask with oxygen flow at flush rate and a nasal cannula with oxygen flow at 10 L/min. After each preoxygenation trial, patients underwent two trials in random order while continuing spontaneous breathing: 1) removal of both oxygen sources and 2) removal of non-rebreather mask with nasal cannula left in place. We defined loss of preoxygenation as an end-tidal oxygen (exhaled oxygen percentage; EtO2) value < 70%. We measured EtO2 breath by breath until loss of preoxygenation occurred.

Résultats : We enrolled 42 patients, median age was 43 years (interquartile range [IQR] 30 to 54 years) and 72% were male. Median time to loss of preoxygenation was 20 s (IQR 17-25 s, 4.5 breaths) when all oxygen devices were removed, and 39 s (IQR 21-56 s, 8 breaths) when the nasal cannula was left in place.

Conclusion : In this population of non-critically ill ED patients, most had loss of preoxygenation after 5 breaths if all oxygen devices were removed, and after 8 breaths if a nasal cannula was left in place. These data suggest that during ED RSI, preoxygenation devices should be left in place until the patient is completely apneic.

Conclusion (proposition de traduction) : Dans cette population de patients des urgences non gravement malades, la plupart avaient une perte du bénéfice de la préoxygénation après 5 respirations si tous les dispositifs d'oxygène étaient retirés, et après 8 respirations si une canule nasale était laissée en place. Ces données suggèrent que pendant l'intubation à séquence rapide au service des urgences, les dispositifs de préoxygénation doivent être laissés en place jusqu'à ce que le patient soit complètement apnéique.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians.
Sorge R, DeBlieux P. | J Emerg Med. 2020 Nov;59(5):643-659
DOI: https://doi.org/10.1016/j.jemermed.2020.07.001
Keywords: AECOPD; discharge bundle; emergency department; management; optimized care.

Clinical Reviews

Introduction : Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) impose a significant burden on patients and the emergency health care system. Patients with COPD who present to the emergency department (ED) often have comorbidities that can complicate their management.

Méthode : To discuss strategies for the management of acute exacerbations in the ED, from initial assessment through disposition, to enable effective patient care and minimize the risk of treatment failure and prevent hospital readmissions.

Résultats : Establishing a correct diagnosis early on is critical; therefore, initial evaluations should be aimed at differentiating COPD exacerbations from other life-threatening conditions. Disposition decisions are based on the intensity of symptoms, presence of comorbidities, severity of the disease, and response to therapy. Patients who are appropriate for discharge from the ED should be prescribed evidence-based treatments and smoking cessation to prevent disease progression. A patient-centric discharge care plan should include medication reconciliation; bedside "teach-back," wherein patients demonstrate proper inhaler usage; and prompt follow-up.

Conclusion : An effective assessment, accurate diagnosis, and appropriate discharge plan for patients with AECOPD could improve treatment outcomes, reduce hospitalization, and decrease unplanned repeat visits to the ED.

Conclusion (proposition de traduction) : Une évaluation efficace, un diagnostic précis et un plan de retour à domicile approprié pour les patients souffrant d'exacerbations aiguës de bronchopneumopathie chronique obstructive pourraient améliorer les résultats du traitement, réduire les hospitalisations et diminuer les visites répétées imprévues au service d'urgence.

LUCAS II Device for Cardiopulmonary Resuscitation in a Nonselective Out-of-Hospital Cardiac Arrest Population Leads to Worse 30-Day Survival Rate Than Manual Chest Compressions.
Karasek J, Ostadal P, Klein F, Rechova A, Seiner J, Strycek M, Polasek R, Widimsky P. | J Emerg Med. 2020 Nov;59(5):673-679
DOI: https://doi.org/10.1016/j.jemermed.2020.06.022
Keywords: CPR; LUCAS 2; prehospital care.

Selected Topics: Prehospital Care

Introduction : The LUCAS (Lund University Cardiopulmonary Assist System; Physio-Control Inc./Jolife AB, Lund, Sweden) was developed for automatic chest compressions during cardiopulmonary resuscitation (CPR). Evidence on the use of this device in out-of-hospital cardiac arrest (OHCA) suggests that it should not be used routinely because it has no superior effects.
Objective: The aim of this study was to compare the effect of CPR for OHCA with and without LUCAS via a regional nonurban emergency medical service (EMS) physician-present prehospital medical system.

Méthode : We analyzed a prospective registry of all consecutive OHCA patients in four EMS stations. Two of them used a LUCAS device in all CPR, and the EMS crews in the other two stations used manual CPR. Individuals with contraindication to LUCAS or with EMS-witnessed arrest were excluded.

Résultats : Data from 278 patients were included in the analysis, 144 with LUCAS and 134 with manual CPR. There were more witnessed arrests in the LUCAS group (79.17% vs. 64.18%; p = 0.0074) and patients in the LUCAS group were older (p = 0.03). We found no significant difference in return of spontaneous circulation (30.6% in non-LUCAS vs. 25% in LUCAS; p = 0.35). In the LUCAS group, we observed significantly more conversions from nonshockable to shockable rhythm (20.7% vs. 10.10%; p = 0.04). The 30-day survival rate was significantly lower in the LUCAS group (5.07% vs. 16.31% in the non-LUCAS group; p = 0.044). At 180-day follow-up, we observed no significant difference (5.45% in non-LUCAS vs. 9.42% in LUCAS; p = 0.25).

Conclusion : Use of the LUCAS system decreased survival rate in OHCA patients. Significantly higher 30-day mortality was seen in LUCAS-treated patients.

Conclusion (proposition de traduction) : L'utilisation du système LUCAS a réduit le taux de survie chez les patients en arrêt cardiaque extra-hospitalier. Une mortalité à 30 jours significativement plus élevée a été observée chez les patients traités par LUCAS.

The Comparison of Manual and Mechanical Chest Compression on Survival and Long-Term Neurological Outcome of Nontraumatic Out-of-Hospital Cardiac Arrest Patients.
Halhalli HC, Şancı E, Uslu T.. | J Emerg Med. 2020 Nov;59(5):680-686
DOI: https://doi.org/10.1016/j.jemermed.2020.06.010
Keywords: cardiopulmonary resuscitation; favorable neurological outcome; manual chest compressions; mechanical chest compression device; out-of-hospital cardiac arrest.

Selected Topics: Prehospital Care

Introduction : High-quality chest compressions are an important determinant for favorable neurological outcome. Associations of long-term mortality and neurological outcomes with chest compression types still require investigation. Objectives: This study aimed to evaluate 'mechanical or manual CPR' provided in the emergency department after manual cardiopulmonary resuscitation (CPR) initiated in prehospital settings until admission. Efficacy of chest compression types on survival and favorable neurological outcomes were compared in out-of-hospital cardiac arrest (OHCA) patients.

Méthode : A total of 818 nontraumatic OHCA patients were evaluated (345 in the manual CPR group and 473 in the mechanical CPR group) retrospectively. One-year survival with a modified Rankin scale (mRS) ≤ 3 was accepted as a favorable neurological outcome.

Résultats : There was no significant difference between the CPR methods (mechanical CPR vs. manual CPR) in terms of mortality at 1, 3, 6, and 12 months (p = 0.353, p = 0.660, p = 0.679, p = 0.034, respectively). mRS ≤ 3, which was accepted as a favorable neurological status, was found to be 12 (3.5%) and 19 (4%) for the manual CPR and mechanical CPR groups, respectively (p = 0.501).

Conclusion : Comparisons of mechanical and manual chest compressions in terms of survival rates and favorable neurological outcomes showed no significant differences. Further investigation of long-term neurological outcomes with mechanical CPR utilization is required.

Conclusion (proposition de traduction) : Les comparaisons des compressions thoraciques mécaniques et manuelles en termes de taux de survie et de résultats neurologiques favorables n'ont montré aucune différence significative. Une étude plus approfondie des résultats neurologiques à long terme avec l'utilisation de la RCP mécanique est nécessaire.

Colchicine in Patients with Chronic Coronary Disease.
Nidorf SM, Fiolet ATL, Mosterd A, Eikelboom JW, Schut A, Opstal TSJ, The SHK, Xu XF, Ireland MA, Lenderink T, Latchem D, Hoogslag P, Jerzewski A, Nierop P, Whelan A, Hendriks R, Swart H, Schaap J, Kuijper AFM, van Hessen MWJ, Saklani P, Tan I, Thompson AG, Morton A, Judkins C, Bax WA, Dirksen M, Alings M, Hankey GJ, Budgeon CA, Tijssen JGP, Cornel JH, Thompson PL; LoDoCo2 Trial Investigators. | N Engl J Med. 2020 Nov 5;383(19):1838-1847
DOI: https://doi.org/10.1056/nejmoa2021372
Keywords: Aucun

Original article

Introduction : Evidence from a recent trial has shown that the antiinflammatory effects of colchicine reduce the risk of cardiovascular events in patients with recent myocardial infarction, but evidence of such a risk reduction in patients with chronic coronary disease is limited.

Méthode : In a randomized, controlled, double-blind trial, we assigned patients with chronic coronary disease to receive 0.5 mg of colchicine once daily or matching placebo. The primary end point was a composite of cardiovascular death, spontaneous (nonprocedural) myocardial infarction, ischemic stroke, or ischemia-driven coronary revascularization. The key secondary end point was a composite of cardiovascular death, spontaneous myocardial infarction, or ischemic stroke.

Résultats : A total of 5522 patients underwent randomization; 2762 were assigned to the colchicine group and 2760 to the placebo group. The median duration of follow-up was 28.6 months. A primary end-point event occurred in 187 patients (6.8%) in the colchicine group and in 264 patients (9.6%) in the placebo group (incidence, 2.5 vs. 3.6 events per 100 person-years; hazard ratio, 0.69; 95% confidence interval [CI], 0.57 to 0.83; P<0.001). A key secondary end-point event occurred in 115 patients (4.2%) in the colchicine group and in 157 patients (5.7%) in the placebo group (incidence, 1.5 vs. 2.1 events per 100 person-years; hazard ratio, 0.72; 95% CI, 0.57 to 0.92; P = 0.007). The incidence rates of spontaneous myocardial infarction or ischemia-driven coronary revascularization (composite end point), cardiovascular death or spontaneous myocardial infarction (composite end point), ischemia-driven coronary revascularization, and spontaneous myocardial infarction were also significantly lower with colchicine than with placebo. The incidence of death from noncardiovascular causes was higher in the colchicine group than in the placebo group (incidence, 0.7 vs. 0.5 events per 100 person-years; hazard ratio, 1.51; 95% CI, 0.99 to 2.31).

Conclusion : In a randomized trial involving patients with chronic coronary disease, the risk of cardiovascular events was significantly lower among those who received 0.5 mg of colchicine once daily than among those who received placebo.

Conclusion (proposition de traduction) : Dans une étude randomisée incluant des patients atteints de coronaropathie chronique, le risque d’événements cardiovasculaires était significativement plus faible chez les patients ayant reçu 0,5 mg de colchicine une fois par jour que chez ceux ayant reçu le placebo.

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 Nov 12;383(20):1907-1919
DOI: https://doi.org/10.1056/nejmoa2014320
Keywords: Aucun

Randomized Controlled Trial

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 avaient subi une appendicectomie à 90 jours. La présence d'un appendicolithe étaient à un risque plus élevé d'appendicectomie et de complications que ceux sans appendicolithe.