Bibliographie de Médecine d'Urgence

Mois de décembre 2020


Academic Emergency Medicine

Out-of-hospital Respiratory Measures to Identify Patients With Serious Injury: A Systematic Review.
Daya MR, Cheney TP, Chou R, Fu R, Newgard CD, O'Neil ME, Wasson N, Hart EL, Totten AM. | Acad Emerg Med. 2020 Dec;27(12):1312-1322
DOI: https://doi.org/10.1111/acem.14055
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META‐ANALYSES)

Introduction : The objective was to systematically review the published literature on the diagnostic accuracy of out-of-hospital respiratory measures for identifying patients with serious injury, focusing on measures feasible for field triage by emergency medical services personnel.

Méthode : We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from January 1, 1996, through August 31, 2017. We included studies on the diagnostic accuracy (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) for all respiratory measures used to identify patients with serious injury (resource use, serious anatomic injury, and mortality). We assessed studies for risk of bias and strength of evidence (SOE). We performed meta-analysis for measures with sufficient data.

Résultats : We identified 46 articles reporting results of 44 studies. Out-of-hospital respiratory measures included respiratory rate, pulse oximetry, and airway support. Meta-analysis was only possible for respiratory rate, which demonstrated a pooled sensitivity for serious injury of 13% (95% confidence interval [CI] = 5 to 29, I2 = 97.8%), specificity of 96% (95% CI = 83 to 99, I2 = 99.6%), and AUROC of 0.70 (95% CI = 0.66 to 0.79, I2 = 16.6%). For oxygen saturation, sensitivity ranged from 13% to 63%; specificity, 85% to 99%; and AUROC, 0.53 to 0.76. Need for airway support had a sensitivity of 8% to 53% and specificity of 61% to 100%; studies did not report AUROC. Across respiratory measures, the SOE was low. Other respiratory measures (pH, end-tidal carbon dioxide [CO2], and sublingual partial pressure of CO2) were reported only in emergency department studies.

Conclusion : Data on the accuracy of out-of-hospital respiratory measures for field triage are limited and of low quality. Based on available research, respiratory rate, oxygen saturation, and need for airway intervention all have low sensitivity, high specificity, and poor to fair discrimination for identifying seriously injured patients.

Conclusion (proposition de traduction) : Les données sur l'exactitude des mesures des paramètres respiratoires extra-hospitalières pour le triage sur le terrain sont limitées et de faible qualité. Sur la base des recherches disponibles, la fréquence respiratoire, la saturation en oxygène et la nécessité d'une intervention sur les voies respiratoires ont tous une faible sensibilité, une spécificité élevée et une discrimination faible à passable pour identifier les patients gravement blessés.

Out-of-hospital Circulatory Measures to Identify Patients With Serious Injury: A Systematic Review.
Newgard CD, Cheney TP, Chou R, Fu R, Daya MR, O'Neil ME, Wasson N, Hart EL, Totten AM. | Acad Emerg Med. 2020 Dec;27(12):1323-1339
DOI: https://doi.org/10.1111/acem.14056
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META‐ANALYSES)

Introduction : The objective was to systematically identify and summarize out-of-hospital measures of circulatory compromise as diagnostic predictors of serious injury, focusing on measures usable by emergency medical services to inform field triage decisions.

Méthode : We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from 1996 through August 2017 for published literature on individual circulatory measures in trauma. We reviewed reference lists of included articles for additional relevant citations. Measures of diagnostic accuracy included sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Indicators of serious injury included resource need, serious anatomic injury, and mortality. We pooled estimates when data permitted.

Résultats : We identified 114 articles, reporting results of 111 studies. Measures included systolic blood pressure (sBP), heart rate (HR), shock index (SI), lactate, base deficit, and HR variability. Pooled out-of-hospital sensitivity estimates were sBP < 90 mm Hg = 19% (95% confidence interval [CI] = 12% to 29%), HR ≥ 110 beats/min = 28% (95% CI = 20% to 37%), SI > 0.9 = 37% (95% CI = 22% to 56%), and lactate > 2.0 mmol/L = 74% (95% CI = 48% to 90%). Pooled specificity estimates were sBP < 90 mm Hg = 95% (95% CI = 91% to 97%), HR ≥ 110 beats/min = 85% (95% CI = 74% to 91%), SI > 0.9 = 85% (95% CI = 72% to 92%), and lactate > 2.0 mmol/L = 62% (95% CI = 51% to 72%). Pooled AUROCs included sBP = 0.67 (95% CI = 0.58 to 0.75), HR = 0.67 (95% CI = 0.56 to 0.79), SI = 0.72 (95% CI = 0.66 to 0.77), and lactate = 0.77 (95% CI = 0.67 to 0.82). Strength of evidence was low to moderate.

Conclusion : Out-of-hospital circulatory measures are associated with poor to fair discrimination for identifying trauma patients with serious injuries. Many seriously injured patients have normal circulatory measures (low sensitivity), but when present, the measures are highly specific for identifying patients with serious injuries.

Conclusion (proposition de traduction) : La mesure de paramètres circulatoires extrahospitalières sont associées à une discrimination faible à équivalente pour identifier les patients traumatisés avec des blessures graves. De nombreux patients gravement blessés ont des mesures circulatoires normales (faible sensibilité), mais lorsqu'elles sont présentes, les mesures sont très spécifiques pour identifier les patients souffrant de blessures graves.

Noninvasive Positive Pressure Ventilation for Cardiogenic Pulmonary Edema.
Killeen BM, Wolfson AB. | Acad Emerg Med. 2020 Dec;27(12):1358-1359
DOI: https://doi.org/10.1111/acem.13986  | Télécharger l'article au format  
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Acute cardiogenic pulmonary edema (ACPE) has tradi-tionally been treated pharmacologically, with a combina-tion of nitrates, diuretics, morphine, and inotropes.Since the introduction of noninvasive positive pressure ventilation (NIPPV), a method of providing mechanicalventilation that does not bypass the upper airway, thismodality has been widely used as an important additionto the acute care of ACPE. NIPPV encompasses bothCPAP (continuous positive airway pressure) and BiPAP(bilevel positive airway pressure), two slightly vari edmodalities of breathing support where oxygen and addi-tional pressure are delivered most commonly through afacial mask. CPAP delivers a constant pressure through-out the respiratory cycle, while BiPAP delivers indepen-dent levels of pressure support set by the clinician forboth inspiratory and expiratory phases.

Conclusion : In conclusion, NIPPV in ACPE (for those notrequiring immediate ETI) appears to provide beneficialeffects, including reduced mortality and decreased intu-bation rates, without an apparent increase in clinicallysignificant harms. We thus assign a color rating ofgreen (benefits > harms) to this treatmen t.

Conclusion (proposition de traduction) : En conclusion, la ventilation non invasive à pression positive dans l'œdème pulmonaire cardiogénique aigu (pour ceux qui ne nécessitent pas d'intubation endotrachéale immédiate) semble fournir des effets bénéfiques, notamment une réduction de la mortalité et une diminution des taux d'intubation, sans augmentation apparente des effets néfastes cliniquement significatifs.
Nous attribuons ainsi une note de couleur verte (bénéfices > méfaits) à ce traitement.

Annals of Emergency Medicine

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal.
Scheuermeyer FX, Miles I, Lane DJ, Grunau B, Grafstein E, Sljivic I, Duley S, Yan A, Chiu I, Kestler A, Barbic D, Moe J, Slaunwhite A, Nolan S, Ti L, Innes G. | Ann Emerg Med. 2020 Dec;76(6):774-781
DOI: https://doi.org/10.1016/j.annemergmed.2020.05.029
Keywords: Aucun

Toxicology

Introduction : Alcohol withdrawal is a common emergency department (ED) presentation. Although benzodiazepines reduce symptoms of withdrawal, there is little ED-based evidence to assist clinicians in selecting appropriate pharmacotherapy. We compare lorazepam with diazepam for the management of alcohol withdrawal to assess 1-week ED and hospital-related outcomes.

Méthode : From January 1, 2015, to December 31, 2018, at 3 urban EDs in Vancouver, Canada, we studied patients with a discharge diagnosis of alcohol withdrawal. We excluded individuals presenting with a seizure or an acute concurrent illness. We performed a structured chart review to ascertain demographics, ED treatments, and outcomes. Patients were stratified according to initial management with lorazepam versus diazepam. The primary outcome was hospital admission, and secondary outcomes included in-ED seizures and 1-week return visits for discharged patients.

Résultats : Of 1,055 patients who presented with acute alcohol withdrawal, 898 were treated with benzodiazepines. Median age was 47 years (interquartile range 37 to 56 years) and 73% were men. Baseline characteristics were similar in the 2 groups. Overall, 69 of 394 patients (17.5%) receiving lorazepam were admitted to the hospital compared with 94 of 504 patients receiving diazepam (18.7%), a difference of 1.2% (95% confidence interval -4.2% to 6.3%). Seven patients (0.7%; 95% confidence interval 0.3% to 1.4%) had an in-ED seizure, but all seizures occurred before receipt of benzodiazepines. Among patients discharged home, 1-week return visits occurred for 78 of 325 (24.0%) who received lorazepam and 94 of 410 (23.2%) who received diazepam, a difference of 0.8% (95% confidence interval -5.3% to 7.1%).

Conclusion : In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam. The few in-ED seizures occurred before medication administration. For discharged patients, the 1-week ED return visit rate of nearly 25% could warrant enhanced follow-up and community support.

Conclusion (proposition de traduction) : Dans notre échantillon de patients pris en charge pour un sevrage alcoolique aigu, les patients recevant du lorazépam avaient un taux d'admission similaire à celui de ceux recevant du diazépam. Les quelques crises convulsives aux urgences se sont produites avant l'administration du médicament. Pour les patients sortant, le taux de retour aux urgences dans la semaine de près de 25% des patients pourrait justifier un suivi et un soutien communautaires améliorés.

Lung ultrasound in the emergency department - a valuable tool in the management of patients presenting with respiratory symptoms during the SARS-CoV-2 pandemic.
Schmid B, Feuerstein D, Lang CN, Fink K, Steger R, Rieder M, Duerschmied D, Busch HJ, Damjanovic D. | BMC Emerg Med. 2020 Dec 7;20(1):96
DOI: https://doi.org/10.1186/s12873-020-00389-w  | Télécharger l'article au format  
Keywords: COVID-19; Emergency department; Lung ultrasound; Triage.

Research article

Introduction : Typical lung ultrasound (LUS) findings in patients with a COVID-19 infection were reported early on. During the global SARS-CoV-2 pandemic, LUS was propagated as a useful instrument in triage and monitoring. We evaluated LUS as a rapid diagnostic triage tool for the management of patients with suspected COVID-19 in the emergency department (ED).

Méthode : The study retrospectively enrolled patients with suspected COVID-19, who were admitted from 1st April to 25th of April 2020 to the ED of a tertiary care center in Germany. During clinical work-up, patients underwent LUS and polymerase chain reaction (PCR) testing for SARS-CoV-2. The recorded ultrasound findings were analyzed and judged regarding typical signs of viral pneumonia, blinded for clinical information of the patients. The results were compared with PCR test and chest computed tomography (CT).

Résultats : 2236 patients were treated in the ED during the study period. 203 were tested for SARS-CoV-2 using PCR, 135 (66.5%) underwent LUS and 39 (28.9%) of the patients were examined by chest CT scan. 39 (28.9%) of the 135 patients were tested positive for SARS-CoV-2 with PCR. In 52 (38.5%) COVID-19 was suspected from the finding of the LUS, resulting in a sensitivity of 76.9% and a specificity of 77.1% compared with PCR results. The negative predictive value reached 89.2%. The findings of the LUS had - compared to a positive chest CT scan for COVID-19 - a sensitivity of 70.6% and a specificity of 72.7%.

Conclusion : LUS is a rapid and useful triage tool in the work-up of patients with suspected COVID-19 infection during a pandemic scenario. Still, the results of the LUS depend on the physician's experience and skills.

Conclusion (proposition de traduction) : L'échographie pulmonaire est un outil de triage rapide et utile dans le bilan des patients suspectés d'infection à COVID-19 pendant un scénario de pandémie. Pourtant, les résultats de l'échographie pulmonaire dépendent de l'expérience et des compétences du médecin.

A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department.
Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. | Ann Emerg Med. 2020 Dec 22:S0196-0644(20)31265-8
DOI: https://doi.org/10.1016/j.annemergmed.2020.10.004
Keywords: Aucun

Pain Management and Sedation

Introduction : We compare the efficacy and adverse effects of 5 oral analgesics in emergency department (ED) patients aged 21 to 64 years with acute musculoskeletal pain.

Méthode : This was a randomized clinical trial conducted in 2 urban EDs. Patients received 400 mg ibuprofen/1,000 mg acetaminophen, 800 mg ibuprofen/1,000 mg acetaminophen, 30 mg codeine/300 mg acetaminophen, 5 mg hydrocodone/300 mg acetaminophen, or 5 mg oxycodone/325 mg acetaminophen. The primary outcome was change in pain before administration of medication (baseline) to 1 hour postbaseline. A numeric rating scale was used, varying from 0="no pain" to 10="worst imaginable pain." Secondary outcomes included receipt of rescue medication and adverse effects at 1 and 2 hours postbaseline. ANOVA was used to test differences in the primary outcome between treatment groups.

Résultats : Six hundred participants, predominantly men and Latino, were enrolled. Change in pain from baseline to 60 minutes did not differ by treatment (P=.69). The mean change in pain in numeric rating scale units was 400 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% confidence interval [CI] 2.6 to 3.5); 800 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% CI 2.5 to 3.5), 30 mg codeine/300 mg acetaminophen 3.4 (95% CI 2.9 to 3.9), 5 mg hydrocodone/300 mg acetaminophen 3.1 (95% CI 2.7 to 3.5), and 5 mg oxycodone/325 mg acetaminophen 3.3 (95% CI 2.8 to 3.7). Rescue medication was received before 1 hour had elapsed by 2 patients receiving 400 mg ibuprofen/1,000 mg acetaminophen (1.7%), 3 patients receiving 800 mg ibuprofen/1,000 mg acetaminophen (2.5%), zero patients receiving 30 mg codeine/300 mg acetaminophen (0.0%), 3 patients receiving 5 mg hydrocodone/300 mg acetaminophen (2.5%), and zero patients receiving 5 mg oxycodone/325 mg acetaminophen (0.0%) (P=.21). More patients who received opioids were nauseated or vomited compared with those who did not: 6.7% versus 1.7% (5.0% difference; 95% CI 1.7% to 8.2%). The findings at 2 hours were similar.

Conclusion : No analgesic was more efficacious than others 1 or 2 hours after baseline. There was significantly more nausea and vomiting among patients treated with opioids.

Conclusion (proposition de traduction) : Aucun analgésique n'était plus efficace que les autres, 1 ou 2 heures après l'administration. Il y avait beaucoup plus de nausées et de vomissements chez les patients traités par morphiniques.

Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting.
Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. | Ann Emerg Med. 2020 Dec 17:S0196-0644(20)31318-4
DOI: https://doi.org/10.1016/j.annemergmed.2020.10.016
Keywords: Aucun

Airway

Introduction : The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie.

Méthode : A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate.

Résultats : Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% [95% confidence interval 3% to 11%]). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio 2.82 [95% confidence interval 1.96 to 4.01]).

Conclusion : Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.

Conclusion (proposition de traduction) : L'utilisation en routine extrahospitalier d'un mandrin malléable pendant la laryngoscopie directe était associée à une augmentation du taux de réussite de l'intubation à la première tentative.

Chest

How I Do It: Ultrasound-Guided Internal Jugular and Femoral Central Venous Catheter Insertion.
Millington SJ, Colvin MO, Shiloh AL, Koenig S. | Chest. 2020 Dec;158(6):2425-2430
DOI: https://doi.org/10.1016/j.chest.2020.06.026
Keywords: central venous catheter; intensive care; ultrasound.

How I Do It

Editorial : Central venous catheterization is routinely performed in the ICU to obtain venous access for hemodynamic monitoring, parenteral nutritional support, hemodialysis, and delivery of fluids and vasoactive medications. Although central venous catheters can be lifesaving, their insertion is not without risk. Historically, central veins were accessed using landmark-based techniques, but the medical literature strongly supports the use of ultrasound guidance. The purpose of this article is to review the basic principles of real-time ultrasound-guided internal jugular and femoral catheter placement. An approach for incorporating these tools into clinical practice is presented, along with illustrative figures and video.

Conclusion : Ultrasound-guided Central Venous Catheter placement significantly improves the rate of successful catheterization and decreases complications when compared to a traditional landmark-based technique.

Conclusion (proposition de traduction) : Le placement de cathéter veineux central guidé par échographie améliore considérablement le taux de réussite du cathétérisme et diminue les complications par rapport à une technique traditionnelle basée sur les points de repère (ndlr : anatomique).

Lung Ultrasound Scanning for Respiratory Failure in Acutely Ill Patients: A Review.
Koenig S, Mayo P, Volpicelli G, Millington SJ. | Chest. 2020 Dec;158(6):2511-2516
DOI: https://doi.org/10.1016/j.chest.2020.08.2052  | Télécharger l'article au format  
Keywords: acute lung injury; critical care; ultrasound.

CHEST Reviews

Editorial : Lung ultrasonography (LUS), an imaging modality quickly performed, interpreted, and integrated by the treating physician at the bedside, is a particularly useful tool for acutely ill patients. In the evaluation of a patient with respiratory failure in the ICU or ED, LUS is superior to chest radiograph and generally comparable with CT imaging and reduces the need for patient transport and radiation exposure. This article will provide a concise review of LUS as it pertains to respiratory failure in general and will include examples of relevant ultrasound images and video clips from critically ill patients.

Conclusion : Lung ultrasound, an imaging modality quickly performed, interpreted, and integrated by the treating physician at the bedside, is a particularly useful tool for acutely ill patients. Commonly encountered conditions such as pneumonia, pulmonary edema, and pneumothorax can be efficiently evaluated, and the skill set is generally straightforward to learn.

Conclusion (proposition de traduction) : L'échographie pulmonaire, une modalité d'imagerie rapidement réalisée, interprétée et intégrée par le médecin traitant au chevet du patient, est un outil particulièrement utile pour les patients gravement malades. Les conditions fréquemment rencontrées telles que la pneumonie, l'œdème pulmonaire et le pneumothorax peuvent être évaluées efficacement, et l'ensemble des compétences est généralement simple à apprendre.

Emergency Care Journal

Peripheral Intravenous Cannula Usage in the Emergency Department.
Stanley AK, Barnett-vanes A, Reed MJ. | Emerg Care J. 2020 Dec;16(3):132-133
DOI: https://doi.org/10.4081/ecj.2020.9205  | Télécharger l'article au format  
Keywords: Aucun

Article

Editorial : Over a billion Peripheral Intra-Venous Cannulas (PIVC) are used globally every year with at least 25 million sold annually in the UK. The NHS spends an estimated £29m of its annual acute sector budget on PIVC procurement3 and around 70% of all hospitalised patients require at least one PIVC during their stay. Despite their extensive and routine use, PIVC failure rates are reported as high as 50-69%. In addition, many PIVCs remain unused following insertion, particularly in the Emergency Department (ED). The risk factors for PIVC failure are not well understood and the literature has found extensive regional variation in practice when it comes to PIVC insertion and management. While various technologies have been developed to address these issues, there remains a need for standardised, evidence-based guidelines.

Conclusion : In conclusion, we found a high PIVC failure rate (43%) in admitted patients. Dominant arm and pre-hospital insertion were significantly associated with PIVC failure and this is consistent with previous research.

Conclusion (proposition de traduction) : En conclusion, nous avons trouvé un taux d'échec de VVP élevé (4 3%) chez les patients admis. Le bras dominant et l'insertion pré-hospitalière étaient significativement associés à l'échec de la VVP et ceci est cohérent avec les recherches précédentes.

Rapid response air medical evacuation by civilian HEMS crew of critical patients during COVID-19 outbreak – First Fixed Points.
Romano M Del, Ciapessoni L, Mola F Di, Romanò G, Gavezzotti M, Rigamonti M, et al.. | Émergeas Care J. 2020 Dec;16:134-136
DOI: https://doi.org/10.4081/ecj.2020.9373  | Télécharger l'article au format  
Keywords: Aucun

Article

Editorial : The Covid-19 emergency requires a shared plan for the long- range helicopter transfer of patients affected by the virus in order to reduce the overload of intensive care units. To date, there is lim- ited peer reviewed literature on aeromedical transport of patients with highly hazardous communicable diseases, most of it is mili- tary, and none deals specifically with patients affected by Covid- 19. To meet this need, we propose reference criteria regarding pre- flight, in-flight and post-flight patient management and helicopter sanitization.

Conclusion : The transport of patients affected by Covid-19 is a very special HEMS activity, and it is strictly dependent on an excellent synergy between all the actors involved, the experience of a highly quali- fied staff and of the emergency system network. The lack of specific civil literature on the topic led the Authors to develop a pro- tocol in the attempt to standardize transport procedures for Covid- 19 patients with severe respiratory symptoms. During the first phase of response to the current pandemic, these procedures have allowed the safe transport of eleven patients with severe respirato- ry insufficiency from Covid-19, without significant complications for patients or health personnel. Further studies will be required to confirm the efficacy and safety of the procedures adopted and of the parameters used to validate patient transportability.

Conclusion (proposition de traduction) : Le transport des patients atteint par la Covid-19 est une activité du SMUR héliportée très particulière, et il est strictement dépendant d'une excellente synergie entre tous les acteurs impliqués, de l'expérience d'un personnel hautement qualifié et du réseau du système d'urgence.
Le manque de littérature civile spécifique sur le sujet a conduit les auteurs à développer un protocole pour tenter de standardiser les procédures de transport pour les patients atteints de la Covid-19 présentant des symptômes respiratoires sévères. Au cours de la première phase de réponse à la pandémie actuelle, ces procédures ont permis de transporter en toute sécurité onze patients souffrant d'insuffisance respiratoire sévère de la Covid-19, sans complications significatives pour les patients ou le personnel de santé. Des études supplémentaires seront nécessaires pour confirmer l'efficacité et la sécurité des procédures adoptées et des paramètres utilisés pour valider la transportabilité des patients.

Commentaire : 

Emergency Radiology

Feasibility of using point-of-care lung ultrasound for early triage of COVID-19 patients in the emergency room.
Narinx N, Smismans A, Symons R, Frans J, Demeyere A, Gillis M. | Emerg Radiol. 2020 Dec;27(6):663-670
DOI: https://doi.org/10.1007/s10140-020-01849-3  | Télécharger l'article au format  
Keywords: COVID-19; Emergency room; Negative predictive value; POCUS lung; Sensitivity.

Original Article

Introduction : Diagnostic value of point-of-care lung ultrasound (POCUS) in detection of coronavirus disease (COVID-19) in an emergency setting is currently unclear. In this study, we aimed to compare diagnostic performance, in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, of POCUS lung, chest CT, and RT-PCR for clinically suspected COVID-19 infections in patients submitting to the emergency room (ER).

Méthode : This retrospective study enrolled 93 patients with a suspected COVID-19 infection, admitted to the ER between March 28th and April 20th, 2020. Test subjects showed one or more symptoms of an acute respiratory infection, for which consequent COVID-19 testing was achieved using POCUS lung, chest CT, and RT-PCR. CT images were analyzed by 2 radiologists blinded to RT-PCR results. POCUS lung was performed by three emergency medical doctors, and reports were analyzed by the researcher, blinded to clinical information, US imaging, CT, and RT-PCR test results.

Résultats : Compared with RT-PCR, POCUS lung demonstrated outstanding sensitivity and NPV (93.3% and 94.1% respectively) while showing poor values for specificity, PPV, and accuracy (21.3%, 19.2%, and 33.3% respectively). In contrast, similar inquiries using chest CT as index test, excellent sensitivity, specificity, NPV, and accuracy (80.0%, 86.7%, 95.6%, and 85.6%, respectively) were reported, beside a moderate value for PPV (54.5%).

Conclusion : POCUS may provide early ER triage with a useful, rapid, low-threshold, and safe screening tool in evaluating possible COVID-19 infections. Due to limited specificity, suggestive POCUS lung findings should be confirmed with RT-PCR or chest CT.

Conclusion (proposition de traduction) : L'échographie pulmonaire au point d'intervention peut fournir un triage précoce aux urgences avec un outil de dépistage utile, rapide, à faible seuil et sûr pour évaluer les infections possibles à COVID-19. En raison de leur spécificité limitée, les résultats évocateurs de l'échographie pulmonaire au point d'intervention doivent être confirmés par PCR ou tomodensitométrie thoracique.

A higher D-dimer threshold for predicting pulmonary embolism in patients with COVID-19: a retrospective study.
Ventura-Díaz S, Quintana-Pérez JV, Gil-Boronat A, Herrero-Huertas M, Gorospe-Sarasúa L, Montilla J, Acosta-Batlle J, Blázquez-Sánchez J, Vicente-Bártulos A. | Emerg Radiol. 2020 Dec;27(6):679-689
DOI: https://doi.org/10.1007/s10140-020-01859-1  | Télécharger l'article au format  
Keywords: COVID-19; Computed tomography pulmonary angiogram; D-dimer; Pulmonary embolism; Retrospective study.

Original Article

Introduction : COVID-19 raises D-dimer (DD) levels even in the absence of pulmonary embolism (PE), resulting in an increase in computed tomography pulmonary angiogram (CTPA) requests. Our purpose is to determine whether there are differences between DD values in PE-positive and PE-negative COVID-19 patients and, if so, to establish a new cutoff value which accurately determines when a CTPA is needed.

Méthode : This study retrospectively analyzed all COVID-19 patients who underwent a CTPA due to suspected PE between March 1 and April 30, 2020, at Ramón y Cajal University Hospital, Madrid (Spain). DD level comparisons between PE-positive and PE-negative groups were made using Student's t test. The optimal DD cutoff value to predict PE risk in COVID-19 patients was calculated in the ROC curve.

Résultats : Two hundred forty-two patients were included in the study. One hundred fifty-one (62%) were men and the median age was 68 years (IQR 55-78). An increase of DD (median 3260; IQR 1203-9625 ng/mL) was detected in 205/242 (96%) patients. 73/242 (30%) of the patients were diagnosed with PE on CTPA. The DD median value was significantly higher (p < .001) in the PE-positive group (7872, IQR 3150-22,494 ng/mL) compared with the PE-negative group (2009, IQR 5675-15,705 ng/mL). The optimal cutoff value for DD to predict PE was 2903 ng/mL (AUC was 0.76 [CI 95% 0.69-0.83], sensitivity 81%). The overall mortality rate was 16% (39/242).

Conclusion : A higher threshold (2903 ng/mL) for D-dimer could predict the risk of PE in COVID-19 patients with a sensitivity of 81%.

Conclusion (proposition de traduction) : Un seuil plus élevé (2903 ng/mL) pour les D-dimères pourrait prédire le risque d'embolie pulmonaire chez les patients COVID-19 avec une sensibilité de 81 %.

Neuroradiologic manifestations of COVID-19: what the emergency radiologist needs to know.
Goldberg MF, Goldberg MF. | Emerg Radiol. 2020 Dec;27(6):737-745
DOI: https://doi.org/10.1007/s10140-020-01840-y  | Télécharger l'article au format  
Keywords: COVID-19; Encephalopathy; PRES; SARS-CoV-2; Stroke.

Review Article

Editorial : Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a global pandemic with a wide spectrum of clinical signs and symptoms. Neurologic manifestations are relatively common, with severe cases often demonstrating striking findings on neuroimaging. Because the neuroradiologic findings may be the first evidence of COVID-19, the emergency radiologist has a critical role to play in not only the detection and management of the disease but also in the safety of other patients and hospital staff. Therefore, radiologists, especially those who specialize in emergency radiology, need to be aware of the neuroradiologic manifestations of COVID-19.

Conclusion : Although initially considered a respiratory disease, COVID- 19 actually affects a wide range of organ systems, including the CNS. Importantly, the neurologic manifestations are rela- tively common, and their neuroradiologic correlates may be the first signs of infection. Radiologists, especially those who practice in the emergency setting, therefore play a critical role in evaluating COVID-19 patients and protecting other patients and hospital staff.

Conclusion (proposition de traduction) : Bien qu'initialement considéré comme une maladie respiratoire, la COVID-19 affecte en fait un large éventail de systèmes organiques, y compris le système nerveux central. Surtout, les manifestations neurologiques sont relativement fréquentes et leurs corrélats neuroradiologiques peuvent être les premiers signes d'infection. Les radiologues, en particulier ceux qui exercent en situation d'urgence, jouent donc un rôle essentiel dans l'évaluation des patients COVID-19 et la protection des autres patients et du personnel hospitalier.

European Journal of Emergency Medicine

Inhaled methoxyflurane for the management of trauma related pain in patients admitted to hospital emergency departments: a randomised, double-blind placebo-controlled trial (PenASAP study).
Ricard-Hibon A, Lecoules N, Savary D, Jacquin L, Wiel E, Deschamps P, Douplat M, Montestruc F, Chomier B, Tazarourte K, Adnet F. | Eur J Emerg Med. 2020 Dec;27(6):414-421
DOI: https://doi.org/10.1097/mej.0000000000000686
Keywords: Aucun

Original Article

Introduction : Oligo-analgesia is common in the emergency department (ED). This study aimed at reporting, when initiated by triage nurse, the superior efficacy of inhaled methoxyflurane plus standard of care (m-SoC) analgesia versus placebo plus SoC (p-SoC) for moderate-to-severe trauma-related pain in the hospital ED.

Méthode : A randomised, double-blind, placebo-controlled trial was conducted at eight EDs. Adults with pain score ≥4 (11-point numerical rate scale, NRS) at admission were randomised to receive one or two inhalers containing m-SoC or p-SoC. Primary outcome measure was time until pain relief ≤30 mm, assessed on the 100-mm Visual Analogic Scale (VAS).

Résultats : A total of 351 patients were analysed (178 m-SoC; 173 p-SoC). Median pain prior to first inhalation was 66 mm, 75% had severe pain (NRS 6-10). Median time to pain relief was 35 min [95% confidence interval (CI), 28-62] for m-SoC versus not reached in p-SoC (92 - not reached) [hazard ratio), 1.93 (1.43-2.60), P < 0.001]. Pain relief was most pronounced in the severe pain subgroup: hazard ratio, 2.5 (1.7-3.7). As SoC, 24 (7%) patients received weak opioids (6 versus 8%), 4 (1%) strong opioid and 44 (13%) escalated to weak or strong opioids (8 versus 17%, respectively, P = 0.02). Most adverse events were of mild (111/147) intensity.

Conclusion : In this study, we report that methoxyflurane, initiated at triage nurse as part of a multimodal analgesic approach, is effective in achieving pain relief for trauma patients. This effect was particularly pronounced in the severe pain subgroup.

Conclusion (proposition de traduction) : Dans cette étude, nous rapportons que le méthoxyflurane (Penthrox®), initié par l'infirmière de triage dans le cadre d'une approche analgésique multimodale, est efficace pour soulager la douleur des patients traumatisés. Cet effet était particulièrement prononcé dans le sous-groupe de la douleur sévère.

Impact of emergency department management of atrial fibrillation with amiodarone on length of stay. A propensity score analysis based on the URGFAICS registry.
Cabello I, Jacob J, Arranz M, Yuguero O, Guzman J, Moreno-Pena A, Frances P, Santos J, Esquerrà A, Mòdol JM; URGFAICS Research Group. | Eur J Emerg Med. 2020 Dec;27(6):429-435
DOI: https://doi.org/10.1097/mej.0000000000000696
Keywords: Aucun

original article

Introduction : Amiodarone is a widely used drug in the emergency department (ED) for control of atrial fibrillation, but it has a delayed onset of action and slow metabolism, leading to longer length of ED stay. The aim of this study was to compare the length of ED stay of atrial fibrillation patients who were treated with or without amiodarone.

Méthode : We undertook a multicenter, observational, cohort study of the URGFAICS registry of older adults with atrial fibrillation who presented to five Spanish EDs and compared patients who had received amiodarone with those who had not. Afterward, we performed a propensity score matched analysis of atrial fibrillation to determine the ED length of stay related to amiodarone.

Résultats : Of the 1199 patients included in the registry, 225 patients (18.8%) were treated with amiodarone while 974 (81.2%) were not. We performed a univariate study depending on amiodarone administration followed by propensity score calculation according to the 14 statistically different features found previously and six significant variables, obtaining 150 patients (75 for each group) suitable for the analysis. The length of ED stay was analyzed using box plot, with a P <0.001 in the crude analysis and P = 0.012 after propensity score matching and using survival curves for the analysis of prolonged ED stay, with a log rank <0.001 in the crude analysis and log rank 0.021 after the propensity score-matched analysis.

Conclusion : Amiodarone is associated with longer length of ED stay until discharge independently of the baseline characteristics of the patients.

Conclusion (proposition de traduction) : L'amiodarone est associée à une durée de séjour aux urgences jusqu'à la sortie, plus longue, indépendamment des caractéristiques de base des patients.

Effect of propofol-based procedural sedation on risk of adverse events in a French emergency department: a retrospective analysis.
Muller B, Michalon A, Reuillard A, Holman AM, Guihard B, Combes X. | Eur J Emerg Med. 2020 Dec;27(6):436-440
DOI: https://doi.org/10.1097/mej.0000000000000697
Keywords: Aucun

Original article

Introduction : Propofol is widely used today outside the operating room to facilitate painful procedures. The objective of this retrospective study was to evaluate the frequency and type of complications related to a propofol-based procedural sedation protocol used in a French emergency department.

Méthode : This retrospective study reviewed the records over a 6-year period of all patients-adults and children-who received propofol for procedural sedation according to a pre-established protocol. The frequency and type of adverse events related to this sedation were recorded. Adverse events were classified according to the World Society of Intra-Veinous Anaesthesia International Sedation Task Force as sentinel, moderate, minor, or minimal.

Résultats : During the study period, 602 patients-395 adults (66%) and 207 (34%) children-received propofol. The main indications for procedural sedation were fracture (n = 327) and dislocation (n = 222) reduction, pleural drain placement (n = 34), and abscess incision (n = 12). Among the 602 consecutive cases, we identified 90 adverse events (14.9%; 95% confidence interval: 12-17.7%). These 90 events were classified as 1 sentinel (hypotension episode), 5 moderate (2 airway obstruction and 3 apnea episodes), 83 minor, and 1 minimal risk-averse events. There were no adverse outcomes.

Conclusion : Nearly all of the adverse events in our series were minor. In the French medical system, the use of propofol outside the operating room by non-anesthesiologist physicians for procedural sedation appears safe.

Conclusion (proposition de traduction) : Presque tous les événements indésirables de notre série étaient mineurs. Dans le système médical français, l'utilisation de propofol en dehors de la salle d'opération par des médecins non anesthésiologistes pour la sédation procédurale semble sûre.

Commentaire : L'AMM du propofol   précise dans les conditions de prescription qu'il ne doit être administré que par des médecins spécialisés en anesthésie-réanimation ou en médecine d'urgence et familiarisés avec l'utilisation des anesthésiques, ou sous leur contrôle, et disposant de tout le matériel d'anesthésie-réanimation nécessaire. Les recommandations des sociétés savantes concernées doivent être respectées, notamment en cas d'utilisation en situation extra-hospitalière (situation d'urgence ou transport médicalisé).
La dernière recommandation en médecin d'urgence date de 2010 : Sédation et analgésie en structure d’urgence   (Réactualisation de la Conférence d’experts de la Sfar de 1999).
Les indications retenues sont :
• les atteintes neurologiques aiguës, afin de faciliter une réévaluation neurologique répétée, en administration continue sous réserve de respecter les objectifs de pression de perfusion cérébrale ;
• l'entretien de la sédation dans l’état de mal épileptique (voir la conférence de Consensus  ) ;
• l'état de mal asthmatique requérant une ventilation mécanique (voir la conférence de consensus  ) ;
• la sédation profonde, en complément de l’analgésie, notamment pour la réduction d’une luxation, en administration lente et titrée ;
• la cardioversion électrique de la tachycardie responsable de la décompensation d’un état jusqu’alors stable, en administration intraveineuse, lente et titrée.
Enfin, pour l’induction du patient en état de choc, les experts recommandent de ne pas utiliser le propofol ou le thiopental.

Intensive Care Medicine

The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline.
Rochwerg B, Einav S, Chaudhuri D, Mancebo J, Mauri T, Helviz Y, Goligher EC, Jaber S, Ricard JD, Rittayamai N, Roca O, Antonelli M, Maggiore SM, Demoule A, Hodgson CL, Mercat A, Wilcox ME, Granton D, Wang D, Azoulay E, Ouanes-Besbes L, Cinnella G, Rauseo M, Carvalho C, Dessap-Mekontso A, Fraser J, Frat JP, Gomersall C, Grasselli G, Hernandez G, Jog S, Pesenti A, Riviello ED, Slutsky AS, Stapleton RD, Talmor D, Thille AW, Brochard L, Burns KEA. | Intensive Care Med. 2020 Dec;46(12):2226-2237
DOI: https://doi.org/10.1007/s00134-020-06312-y  | Télécharger l'article au format  
Keywords: Extubation; High flow nasal cannula; Mortality; Peri-intubation; Postoperative; Respiratory failure.

Conference Reports and Expert Panel

Introduction : High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings.

Méthode : We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions.

Résultats : The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty).

Conclusion : This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.

Conclusion (proposition de traduction) : Ce guide de pratique clinique synthétise les meilleures données actuelles en quatre recommandations pour l'utilisation de l'oxygénothérapie nasale à haut débit chez les patients souffrant d'insuffisance respiratoire hypoxémique, après une extubation, pendant la période de péri-intubation et en postopératoire pour les cliniciens au chevet des patients.

International Journal of Emergency Medicine

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes.
Bedard AF, Mata LV, Dymond C, Moreira F, Dixon J, Schauer SG, Ginde AA, Bebarta V, Moore EE, Mould-Millman NK. | Int J Emerg Med. 2020 Dec 9;13(1):64
DOI: https://doi.org/10.1186/s12245-020-00324-7  | Télécharger l'article au format  
Keywords: Emergency medical services; Prehospital time; Trauma.

Review

Introduction : Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

Méthode : We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

Conclusion : The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

Conclusion (proposition de traduction) : La littérature existante représente de manière disproportionnée les milieux à revenu élevé et la mortalité hospitalière la plus souvent évaluée en fonction du temps préhospitalier brut. Les études futures devraient se concentrer sur l'impact des intervalles préhospitaliers spécifiques sur les résultats de la morbidité (par exemple, défaillance d'un organe) et de la mortalité à des moments plus anciens (par exemple, 3 ou 7 jours) afin de mieux refléter l'effet de la réanimation et du transport préhospitaliers précoces. Les registres des traumatismes peuvent être un outil pour faciliter ces recherches et peuvent promouvoir des enquêtes de meilleure qualité en Afrique et dans les pays à revenu faible ou intermédiaire.

Journal Européen des Urgences et de Réanimation

Manzo-Silberman S. | JEUR. 2020 Dec;32(4):161-166
DOI: https://doi.org/10.1016/j.jeurea.2020.08.005  | Télécharger l'article au format  
Keywords: Aucun

Cardiologie

Editorial : En France, le nombre d’hospitalisations et de décès pour infarctus du myocarde (IDM) croît de manière plus importante chez les femmes, notamment de moins de 65 ans. Jusqu’à ce jour, les femmes ayant un IDM avaient 5 à 10 ans de plus que les hommes, plus de facteurs de risque et de comorbidités, principalement diabète et hypertension. Cependant, les données françaises récentes retrouvent de plus en plus de femmes jeunes, tabagiques et obèses. Leurs présentations comportent, en plus de la douleur rétrosternale, plus de symptômes rapportés, en particuliers les « atypiques » : nausées, gêne épigastrique. Plus fréquemment, il n’y a pas de lésion thrombotique obstructive à la coronarographie. Cependant, même à âge égal, lors d’un IDM, les femmes ont un pronostic plus sombre, avec des taux de mortalité hospitalière significativement supérieurs à ceux des hommes. Il existe des moyens à mettre en œuvre afin de limiter les complications et d’améliorer le pronostic par des stratégies d’information et de prévention primaire de dépistage et de prise en charge adaptée des facteurs de risque. Il est également important de sensibiliser la population et l’ensemble des acteurs de soins sur le risque chez la femme, même jeune, ses formes parfois atypiques et la nécessité de prise en charge rapide et agressive. Une meilleure compréhension des mécanismes physiopathologiques spécifiques apparaît nécessaire et doit faire l’objet d’études prospectives dédiées.

Conclusion (proposition de traduction) : Il existe à ce jour de nombreuses différences entre les hommeset les femmes, non seulement en termes d'incidence desfacteurs de risque mais également de traitement. Même sices différences ne peuvent rendre compte à elles seules dupronostic plus sombre qui est encore constaté chez la femmeayant une maladie coronaire, a fortiori aiguë, il est essentiel dedévelopper des stratégies spécifiques et ciblées de préventionprimaire avec dépistage et traitement adapté des facteurs derisque afin d'améliorer le pronostic de la femme. Ces stratégiesne pourront être développées que s'appuyant sur une meilleureconnaissance des mécanismes physiopathologiques sous-ten-dant ces disparités.

Commentaire : Cet article a fait l’objet d’une première publication dans La Presse Médicale Formation. Nous remercions la rédaction en chef de la revue La Presse Médicale Formation, ainsi que l’auteur de nous avoir donné l’autorisation de le republier dans nos pages. Ne pas utiliser, pour la citation, la référence de l’article mais celle de sa première parution : Presse Med Form 2020 (1):161–166. https://doi.org/10.1016/j.lpmfor.2020.05.018.

Pediatric Emergency Care

Diagnosis and Treatment of Headache in a Pediatric Emergency Department.
Costa FM, Ferreira IP, Mascarenhas IF, Alves CF, Bento VA, Loureiro HC. | Pediatr Emerg Care. 2020 Dec;36(12):571-574
DOI: https://doi.org/10.1097/pec.0000000000002284
Keywords: Aucun

Original article

Introduction : The aims of the study were (1) to analyze the etiology and clinical management of headaches in children in the emergency department and (2) to analyze the treatment used in children diagnosed with headaches and with migraines.

Méthode : Retrospective study of all the patients who were admitted to the pediatric emergency department of Hospital Professor Doutor Fernando Fonseca, Lisbon, in 2014, with a chief complaint of headaches or the primary discharge diagnosis was headache/migraine.

Résultats : Headache related cases represented 3.8% of all the visits, a total of 2354 subjects. The median age was 10 years and 52.6% were female. The most frequent diagnoses were as follow: headaches (21.3%), upper respiratory infections (18.4%), and migraines (6.1%). There were 4 cases of meningitis, 6,5% of all patients underwent computed tomography which was mostly requested in school-age children and adolescents. The average time from the first medical observation until discharge was 85 minutes. Fifty-five percent did not take any pain relief medication, 17.2% took acetaminophen, and 11.1% took ibuprofen. Patients who received ondansetron had less revisits (P = 0.000). Subjects with mild-moderate pain treated with acetaminophen or no medication had more revisits (P = 0.000).

Conclusion : Secondary benign headaches were the most common and very rarely headache as a symptom was associated with life-threatening situations. Antiemetics seem to be efficient ally in the treatment of primary headaches, but it is important to consider alternative pharmacological regimes in patients who present with higher pain scores.

Conclusion (proposition de traduction) : Les céphalées bénignes secondaires étaient les céphalées les plus courantes et très rarement, car un symptôme était associé à des situations potentiellement mortelles. Les antiémétiques semblent être des alliés efficaces dans le traitement des céphalées primaires, mais il est important d'envisager des régimes pharmacologiques alternatifs chez les patients qui présentent des scores de douleur plus élevés.

Use of Capnography and Cardiopulmonary Resuscitation Feedback Devices Among Prehospital Advanced Life Support Providers.
Sahyoun C, Siliciano C, Kessler D. | Pediatr Emerg Care. 2020 Dec;36(12):582-585
DOI: https://doi.org/10.1097/pec.0000000000001685
Keywords: Aucun

Original article

Introduction : Capnography and cardiopulmonary resuscitation (CPR) feedback devices have been shown to improve resuscitation outcomes, with the American Heart Association recommending their use during advanced life support (ALS). Little is known about the availability of these devices, their protocoled use, and the attitudes toward them in the prehospital setting.
Objectives: The objectives of this study were to assess the availability of capnography and CPR feedback devices among prehospital ALS agencies in New York State (NYS), to describe the protocoled use of these devices, and to evaluate the attitudes of providers toward the use of these devices.

Méthode : Prehospital agencies that provide ALS services in NYS were identified using an online registry. Managers in these agencies were contacted by electronic mail and asked to complete a questionnaire regarding their agency's experience with capnography and CPR feedback devices. The questionnaire included questions on the availability of capnography and CPR feedback devices, the existence of clinical protocols for using capnography, and provider opinion on the utility of capnography and CPR feedback devices for improving pediatric resuscitation.

Résultats : Of 710 ALS agencies, 238 (33.5%) completed the survey. Ninety-five percent and 24% of agencies reported having capnography and CPR feedback devices available aboard ambulances, respectively. Ninety-seven percent of agencies reported having capnography clinical protocols for endotracheal intubation, 63% for return of spontaneous circulation, and 54% for guiding CPR. Forty-seven percent agreed that capnography improves outcomes in the resuscitation of pediatric patients, whereas 51% of providers were neutral and 2% disagreed.

Conclusion : Capnography is available in most NYS ALS agencies surveyed. Cardiopulmonary resuscitation feedback devices are less common. Protocols for the use of capnography mainly focused on endotracheal intubation and less for the recognition of return of spontaneous circulation and for guiding CPR. Half of the providers surveyed were neutral on whether capnography improves outcomes in the resuscitation of pediatric patients.

Conclusion (proposition de traduction) : La capnographie est disponible dans la plupart des service de soins préhospitaliers de l'État de New York étudiées. Les dispositifs de rétroaction de la réanimation cardio-pulmonaire sont moins courants. Les protocoles d'utilisation de la capnographie se sont principalement concentrés sur l'intubation endotrachéale et moins pour la reconnaissance du retour de la circulation spontanée et pour guider la réanimation cardio-pulmonaire. La moitié des prestataires interrogés étaient neutres sur le point de savoir si la capnographie améliore les résultats de la réanimation des patients pédiatriques.

Rapid Administration of Ketamine for Abscess Drainage in Children-A Dose Finding Study.
Chinta SS, Schrock CR, McAllister JD, Jaffe DM, Liu J, Kennedy RM. | Pediatr Emerg Care. 2020 Dec;36(12):e671-e676
DOI: https://doi.org/10.1097/pec.0000000000002281
Keywords: Aucun

Original article

Introduction : To estimate the minimum dose and total sedation time of rapidly infused ketamine that achieves 3 to 5 minutes of effective sedation in children undergoing abscess incision and drainage in the emergency department.

Méthode : The Up-Down method was used to estimate the dose of intravenous ketamine infused over 5 seconds or less that provided effective sedation in 50% (ED50) and 95% (ED95) for healthy children aged 2 to 5 years and 6 to 11 years undergoing abscess incision and drainage. None were pretreated with opioids. Three investigators blinded to ketamine dose independently graded sedation effectiveness by viewing a video recording of the first 5 minutes of sedation. Recovery was determined when patients reached a Modified Aldrete score of 10.

Résultats : We enrolled 20 children in each age group. The estimated ED50 was 0.9 and 0.6 mg/kg for the 2 to 5 years and 6 to 11 years' groups and the estimated ED95 was 1.1 mg/kg for both groups. The median time to full recovery for the 2 groups was 20.5 and 17.5 minutes when only 1 dose of ketamine was administered and 27.5 and 35 minutes when additional doses of ketamine were administered. No participants experienced serious adverse events.

Conclusion : We estimated ED50 and ED95 for rapidly infused ketamine for 2 age groups undergoing abscess incision and drainage. Further studies are needed to get a more precise estimate of ED95. The total sedation time with this technique in the abscess group was shorter than most previous studies and is consistent with our previous observations in patients undergoing fracture reduction.

Conclusion (proposition de traduction) : Nous avons estimé une sédation efficace à 50% et une sédation efficace à 95% pour la kétamine perfusée rapidement pour 2 groupes d'âge subissant une incision et un drainage d'abcès. D'autres études sont nécessaires pour obtenir une estimation plus précise de la sédation efficace à 50%. Le temps total de sédation avec cette technique dans le groupe abcès était plus court que la plupart des études précédentes et est cohérent avec nos observations précédentes chez les patients subissant une réduction de fracture.

Pain Intensity and Risk of Bone Fracture in Children With Minor Extremity Injuries.
Zanchi C, Giangreco M, Ronfani L, Germani C, Giorgi R, Calligaris L, Norbedo S, Liccari G, Cozzi G, Barbi E. | Pediatr Emerg Care. 2020 Dec;36(12):e677-e681
DOI: https://doi.org/10.1097/pec.0000000000001418
Keywords: Aucun

Orignal article

Introduction : Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture.

Méthode : We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated.

Résultats : We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively.

Conclusion : In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.

Conclusion (proposition de traduction) : Dans cette série, l'intensité de la douleur chez les enfants présentant une blessure mineure des extrémités n'était pas un bon marqueur de fracture. Néanmoins, les enfants présentant une légère douleur à la palpation ou une légère augmentation de la douleur entre la douleur spontanée et la douleur à la palpation présentaient un faible risque de fracture.

Two-Thumb Encircling Technique With a Novel Compression Assist Device Provides Safe and Effective Chest Compressions in Infants.
Lee SU, Kim DK, Chang I, Jung JY, Paek SH, Park JW, Lee JH, Kwak YH. | Pediatr Emerg Care. 2020 Dec;36(12):e700-e703
DOI: https://doi.org/10.1097/pec.0000000000001738
Keywords: Aucun

Orignal article

Introduction : Currently, 2-thumb encircling technique is recommended in 2-rescuer infant cardiopulmonary resuscitation (CPR). However, many complications can occur during CPR. Therefore, we developed a novel compression assist device (Reheart) that can reduce chest compression area and determined whether using our device provides better compression quality.

Méthode : A novel compression assist device consists of 2 parts. The upper part was designed to put 2 thumbs together in the thumb sleeves, and the lower part was designed based on a circular rubber plate with a 2.0-cm diameter to confine compression area. Infant manikin CPR simulations using the 2-thumb encircling technique with Reheart and without Reheart were sequentially performed by participants in randomized crossover fashion.

Résultats : A total of 32 health care providers were included. The average age of the participants was 30.2 ± 3.5 years, and 21 participants (65.6%) were male. The accuracy in the Reheart group was better than that in the conventional group (proportion of compression on target area, 52.5% ± 13.2% vs 35.4% ± 17.6%; P < 0.001). The difference in the rates of chest compressions between the 2 groups was not significant (119.6 ± 14.4 vs 120.7 ± 14.0 compressions/min, P = 0.59). The depth of chest compressions was also not significantly different between the 2 groups (34.5 mm [33.6-34.9 mm] vs 34.2 mm [33.0-34.9 mm], P = 0.32).

Conclusion : Our new compression assist device can help provide safe and effective chest compressions during 2-rescuer infant CPR.

Conclusion (proposition de traduction) : Notre nouveau dispositif d'assistance à la compression peut aider à fournir des compressions thoraciques sûres et efficaces pendant la RCR à 2 secouristes.

Commentaire : 

Estimating the Weight of Children During Simulated Emergency Situations Using the Broselow Tape: Are We Underestimating the Risks of Errors?.
Larose G, Levy A, Bailey B, Cummins-McManus B, Lebel D, Gravel J.. | Pediatr Emerg Care. 2020 Dec;36(12):e704-e708
DOI: https://doi.org/10.1097/pec.0000000000001581
Keywords: Aucun

Orignal article

Introduction : The objective of this study was to evaluate whether residents can accurately estimate children's weight using the Broselow tape.

Méthode : We conducted a preplanned secondary analysis from an experimental trial. Participants were residents in pediatrics, family medicine, and emergency medicine rotating in the ED. Residents were randomly assigned to 2 sets of paired scenarios during 2 sessions. They were asked to estimate the weight of a manikin using the Broselow tape at the beginning of each scenario. The first scenario from the initial session and the last scenario from the second session were used for the current study. The primary analysis was the proportion of participants who accurately estimated manikin weight within a 10% margin of error.

Résultats : Forty residents were recruited. Thirty-two (80%) reported knowledge of the Broselow tape and 13 (32.5%) reported previous use. Weight estimation was accurate in 60% (24/40; 95% confidence interval [CI], 45%-74%) during the first scenarios. Error in weight estimation differed by greater than 25% in 28% (11/40). Error in estimation was not associated with previous knowledge (odds ratio, 6.2; 95% CI, 0.68-56) or previous use (odds ratio, 0.9; 95% CI, 0.23-3.5) of the Broselow tape. In the last scenario, 88% accurately estimated manikin weight (35/40; 95% CI, 73%-95%).

Conclusion : Although most residents reported knowledge of the Broselow tape, 40% made erroneous weight estimations by at least 10% with the first use in this simulation study. With repeated use, they improved significantly over time. Teaching appropriate use of the Broselow tape should be part of residency-training curricula and pediatric advanced life support course.

Conclusion (proposition de traduction) : Bien que la plupart des résidents aient déclaré connaître la bande Broselow, 40 % ont fait des estimations de poids erronées d'au moins 10 % lors de la première utilisation dans cette étude de simulation. Avec une utilisation répétée, ils se sont considérablement améliorés au fil du temps. L'enseignement de l'utilisation appropriée de la bande Broselow devrait faire partie des programmes de formation en résidence et du cours avancé de réanimation pédiatrique.

Effectiveness of Emergency Department Treatment of Pediatric Headache and Relation to Rebound Headache.
Sheridan DC, Dhatt S, Narayan K, Lin A, Fu R, Meckler GD. | Pediatr Emerg Care. 2020 Dec;36(12):e720-e725
DOI: https://doi.org/10.1097/pec.0000000000002027
Keywords: Aucun

Origanl article

Introduction : This study aimed to assess the association between the degree of headache relief obtained in the pediatric emergency department (PED) with abortive treatment and unscheduled return visits to the PED for a recurrent or persistent headache within 72 hours.

Méthode : This was a retrospective observational study with 369 patients, all younger than 18 years, who presented to the PED with a primary complaint of either a headache or migraine. Patient and visit details were collected from the medical chart, along with presenting and discharge pain score. Percent pain reduction at discharge was determined through the following calculation: (Presenting Pain Score - Discharge Pain Score)/Presenting Pain Score. Associations were assessed using multivariable logistic regression.

Résultats : No significant association was found between the percent pain reduction and return to the PED (P = 0.49). Mean presenting pain score at the index visit was statistically higher for those who ended up returning to the PED versus those who did not (8.1 vs 7.4; P = 0.02). A trend toward increase in return visits was seen among patients who had a headache duration greater than 3 days (odds ratio, 1.99) and patients who experienced less than 50% pain reduction in the PED (odds ratio, 1.77).

Conclusion : Complete resolution in the PED may not be necessary, given the lack of association between the degree of pain relief and revisit rates. Perhaps, the goal should be to achieve at least 50% pain reduction before discharge.

Conclusion (proposition de traduction) : Une résolution complète au service des urgences pédiatriques peut ne pas être nécessaire, étant donné le manque d'association entre le degré de soulagement de la douleur et les taux de revisite. Peut-être que l'objectif devrait être de réduire la douleur d'au moins 50 % avant le congé.

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department.
Mace SE, Whiteman P, Avarello JT, Ojo A, Rose E, Valente J, Joseph M. | Pediatr Emerg Care. 2020 Dec;36(12):593-601
DOI: https://doi.org/10.1097/pec.0000000000002285
Keywords: Aucun

Review Article

Editorial : Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

Conclusion : Topical anesthetics and vapocoolants achieve local anesthe- sia without a needlestick. Used appropriately, they have few side effects, and should decrease ED length of stay and increase patient satisfaction. The disadvantage is the duration of application to be effective is from 20 to 60 minutes, although vapocoolants are effective almost instantaneously. Topical anesthetic agents and vapocoolants prevent wound margin distortion that occurs with local infiltration and increase patient/family satisfaction be- cause of better pain management. The AAP report supports using triage protocols for topical anesthetics for patients likely to undergo a nonemergent procedure, such as laceration repair, incision and drainage, lumber puncture, venipuncture, and IV cannulation. Topical anesthetics (but not vapocoolants) are lo- cal anesthetics and maximum doses of local anesthetics should never be exceeded. Proper application of topical anesthetics and vapocoolants are critical to their efficacy. These modalities are not mutually exclusive but can be used simultaneously and be- fore local infiltrative anesthesia. Well-written triage protocols optimize the use of topical agents.

Conclusion (proposition de traduction) : Les anesthésiques topiques et les vapocoolants permettent une anesthésie locale sans piqûre d'aiguille. Utilisés de manière appropriée, ils ont peu d'effets secondaires et devraient réduire la durée du séjour aux urgences et augmenter la satisfaction des patients. L'inconvénient est que la durée d'application pour être efficace est de 20 à 60 minutes, bien que les vapocoolants soient efficaces presque instantanément. Les agents anesthésiques topiques et les vapocoolants préviennent la distorsion de la marge de la plaie qui se produit avec l'infiltration locale et augmentent la satisfaction du patient/de la famille grâce à une meilleure gestion de la douleur. Le rapport de l'American Academy of Pediatrics soutient l'utilisation de protocoles de triage pour les anesthésiques topiques pour les patients susceptibles de subir une procédure non urgente, telle que la réparation de lacération, l'incision et le drainage, la ponction d'une écharde, la ponction veineuse et la voie veineuse périphérique. Les anesthésiques topiques (mais pas les vapocoolants) sont des anesthésiques locaux et les doses maximales d'anesthésiques locaux ne doivent jamais être dépassées. Une bonne application des anesthésiques topiques et des vapocoolants est essentielle à leur efficacité. Ces modalités ne sont pas mutuellement exclusives mais peuvent être utilisées simultanément et avant une anesthésie infiltrante locale. Des protocoles de triage bien rédigés optimisent l'utilisation d'agents topiques.

Commentaire : Les sprays « vapocoolants » topiques peuvent produire une anesthésie cutanée immédiate. Les « vapocoolants » couramment utilisés comprennent le chlorure d’éthyle, le fluorohydrocarbone, et des mélanges d’alcanes (butane, propane et pentane). Les sprays « vapocoolants » à base d’alcanes sont principalement utilisés pour soulager la douleur des traumatismes musculaires aigus.
L’évaporation rapide du spray liquide volatil répandu sur la surface cutanée provoque une baisse de température et se traduit par une interruption temporaire de la sensation de douleur, peut-être par désensibilisation des récepteurs à la douleur ou par activation des canaux ioniques impliqués dans la transmission de la douleur. Les sprays « vapocoolants » topiques constituent donc potentiellement un anesthésique adapté et efficace dans la canulation veineuse.

Prehospital and Disaster Medicine

Ability of Critical Care Medics to Confirm Endotracheal Tube Placement by Ultrasound.
Joyce M, Tozer J, Vitto M, Evans D. | Prehosp Disaster Med. 2020 Dec;35(6):629-631
DOI: https://doi.org/10.1017/s1049023x20001004
Keywords: ACLS; intubation; ultrasound.

Original Research

Introduction : The Advanced Cardiac Life Support (ACLS) guidelines were recently updated to include ultrasound confirmation of endotracheal tube (ETT) location as an adjunctive tool to verify placement. While this method is employed in the emergency department under the guidance of the most recent American College of Emergency Physicians (ACEP; Irving, Texas USA) guidelines, it has yet to gain wide acceptance in the prehospital setting where it has the potential for greater impact. The objective of this study to is determine if training critical care medics using simulation was a feasible and reliable method to learn this skill.

Méthode : Twenty critical care paramedics with no previous experience with point-of-care ultrasound volunteered for advanced training in prehospital ultrasound. Four ultrasound fellowship trained emergency physicians proctored two three-hour training sessions. Each session included a brief introduction to ultrasound "knobology," normal sonographic neck and lung anatomy, and how to identify ETT placement within the trachea or esophagus. Immediately following this, the paramedics were tested with five simulated case scenarios using pre-obtained images that demonstrated a correctly placed ETT, an esophageal intubation, a bronchial intubation, and an improperly functioning ETT. Their accuracy, length of time to respond, and comfort with using ultrasound were all assessed.

Résultats : All 20 critical care medics completed the training and testing session. During the five scenarios, 37/40 (92.5%) identified the correct endotracheal placements, 18/20 (90.0%) identified the esophageal intubations, 18/20 (90.0%) identified the bronchial intubation, and 20/20 (100.0%) identified the ETT malfunctions correctly. The average time to diagnosis was 10.6 seconds for proper placement, 15.5 seconds for esophageal, 15.6 seconds for bronchial intubation, and 11.8 seconds for ETT malfunction.

Conclusion : The use of ultrasound to confirm ETT placement can be effectively taught to critical care medics using a short, simulation-based training session. Further studies on implementation into patient care scenarios are needed.

Conclusion (proposition de traduction) : L'utilisation de l'échographie pour confirmer le placement de la sonde endotrachéale peut être enseignée efficacement aux médecins de soins intensifs à l'aide d'une courte session de formation basée sur la simulation. D'autres études sur la mise en œuvre dans les scénarios de soins aux patients sont nécessaires.

Rescue Intubation in the Emergency Department After Prehospital Ketamine Administration for Agitation.
Parks DJ, Alter SM, Shih RD, Solano JJ, Hughes PG, Clayton LM. | Prehosp Disaster Med. 2020 Dec;35(6):651-655
DOI: https://doi.org/10.1017/s1049023x20001168
Keywords: airway management; delirium; intubation; ketamine; psychomotor agitation.

Original Research

Introduction : Prehospital intramuscular (IM) ketamine is increasingly used for chemical restraint of agitated patients. However, few studies have assessed emergency department (ED) follow-up of patients receiving prehospital ketamine for this indication, with previous reports suggesting a high rate of post-administration intubation. This study examines the rate of and reasons for intubation and other airway interventions in agitated patients who received ketamine by Emergency Medical Services (EMS).

Méthode : This retrospective cohort study included patients who received prehospital ketamine for agitation and were transported to two community hospital EDs. Charts were reviewed for demographics, ketamine dose, and airway intervention by EMS or in the ED. Characteristics of patients who were intubated versus those who did not receive airway intervention were analyzed.

Résultats : Over 28 months, 86 patients received ketamine for agitation. Fourteen (16.3%) underwent endotracheal intubation. Patients with a higher temperature and a lower Glasgow Coma Score (GCS) were more likely to require intubation. There was no age or dose-dependent association on intubation rate. Intubated patients averaged 39 years old versus 44 for patients not intubated (negative five-year difference; 95% CI, -16 to 6). The mean ketamine dose was 339.3mg in patients intubated versus 350.7mg in patients not (-11.4mg difference; 95% CI, -72.4 to 49.6). The mean weight-based ketamine dose was 4.44mg/kg in patients intubated versus 4.96mg/kg in patients not (-0.53mg/kg difference; 95% CI, -1.49 to 0.43).

Conclusion : The observed rate of intubation in patients receiving prehospital ketamine for agitation was 16.3%. Study data did not reveal an age or dose-dependent rate of intubation. Further research should be conducted to compare the airway intervention rate of agitated patients receiving ketamine versus other sedatives in a controlled fashion.

Conclusion (proposition de traduction) : Le taux d'intubation observé chez les patients recevant de la kétamine préhospitalière pour agitation était de 16,3 %. Les données de l'étude n'ont pas révélé de taux d'intubation dépendant de l'âge ou de la dose. Des recherches supplémentaires devraient être menées pour comparer le taux d'intervention sur les voies respiratoires des patients agités recevant de la kétamine par rapport à d'autres sédatifs de manière contrôlée.

Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin.
Perlmutter MC, Cohen MW, Stratton NS, Conterato M. | Prehosp Disaster Med. 2020 Dec;35(6):663-668
DOI: https://doi.org/10.1017/s1049023x20001193
Keywords: Emergency Medical Services; cardiac; edema; heart failure; nitroglycerin; pulmonary edema; systolic.

Original research

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

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

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

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

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

Prehospital Emergency Care

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 Dec 18:1-25
DOI: https://doi.org/10.1080/10903127.2020.1852354
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 réanimation cardio-pulmonaire par compression uniquement ou une réanimation cardio-pulmonaire standard, que la cause soit asphyxique ou non.

Resuscitation

Conservative or liberal oxygen therapy in adults after cardiac arrest: An individual-level patient data meta-analysis of randomised controlled trials.
Young PJ, Bailey M, Bellomo R, Bernard S, Bray J, Jakkula P, Kuisma M, Mackle D, Martin D, Nolan JP, Panwar R, Reinikainen M, Skrifvars MB, Thomas M.. | Resuscitation. 2020 Dec;157:15-22
DOI: https://doi.org/10.1016/j.resuscitation.2020.09.036
Keywords: Cardiac arrest; Hyperoxaemia; Hypoxaemia; Hypoxic ischaemic encephalopathy; Individual patient data meta-analysis; Oxygen therapy; Randomised controlled trial.

Clinical paper

Introduction : The effect of conservative versus liberal oxygen therapy on mortality rates in post cardiac arrest patients is uncertain.

Méthode : We undertook an individual patient data meta-analysis of patients randomised in clinical trials to conservative or liberal oxygen therapy after a cardiac arrest. The primary end point was mortality at last follow-up.

Résultats : Individual level patient data were obtained from seven randomised clinical trials with a total of 429 trial participants included. Four trials enrolled patients in the pre-hospital period. Of these, two provided protocol-directed oxygen therapy for 60 min, one provided it until the patient was handed over to the emergency department staff, and one provided it for a total of 72 h or until the patient was extubated. Three trials enrolled patients after intensive care unit (ICU) admission and generally continued protocolised oxygen therapy for a longer period, often until ICU discharge. A total of 90 of 221 patients (40.7%) assigned to conservative oxygen therapy and 103 of 206 patients (50%) assigned to liberal oxygen therapy had died by this last point of follow-up; absolute difference; odds ratio (OR) adjusted for study only; 0.67; 95% CI 0.45 to 0.99; P = 0.045; adjusted OR, 0.58; 95% CI 0.35 to 0.96; P = 0.04.

Conclusion : Conservative oxygen therapy was associated with a statistically significant reduction in mortality at last follow-up compared to liberal oxygen therapy but the certainty of available evidence was low or very low due to bias, imprecision, and indirectness.

Conclusion (proposition de traduction) : L’oxygénothérapie conservatrice a été associée à une réduction statistiquement significative de la mortalité au dernier suivi comparativement à l’oxygénothérapie libérale, mais la certitude des données disponibles était faible ou très faible en raison de biais, d’imprécision et d’indirectitude.

Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest.
Riva G, Jonsson M, Ringh M, Claesson A, Djärv T, Forsberg S, Nordberg P, Rubertsson S, Rawshani A, Nord A, Hollenberg J.. | Resuscitation. 2020 Dec;157:195-201
DOI: https://doi.org/10.1016/j.resuscitation.2020.08.125  | Télécharger l'article au format  
Keywords: Basic Life Support; Dispatcher assisted CPR; Out-of-Hospital Cardiac Arrest; Telephone CPR.

Clinical paper

Introduction : Strategies to increase provision of bystander CPR include mass education of laypersons. Additionally, programs directed at emergency dispatchers to provide CPR instructions during emergency calls to untrained bystanders have emerged. The aim of this study was to evaluate the association between dispatcher-assisted CPR (DA- CPR) and 30-day survival compared with no CPR or spontaneously initiated CPR by lay bystanders prior to emergency medical services in out of hospital cardiac arrest (OHCA).

Méthode : Nationwide observational cohort study including all consecutive lay bystander witnessed OHCAs reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010-2017. Exposure was categorized as: no CPR (NO-CPR), DA-CPR and spontaneously initiated CPR (SP-CPR) prior to EMS arrival. Propensity-score matched cohorts were used for comparison between groups. Main Outcome was 30-day survival.

Résultats : A total of 15 471 patients were included and distributed as follows: NO-CPR 6440 (41.6%), DA-CPR 4793 (31.0%) and SP-CPR 4238 (27.4%). Survival rates to 30 days were 7.1%, 13.0% and 18.3%, respectively. In propensity-score matched analysis (DA-CPR as reference), NO-CPR was associated with lower survival (conditional OR 0.61, 95% CI 0.52-0.72) and SP-CPR was associated with higher survival (conditional OR 1.21 (95% CI 1.05-1.39).

Conclusion : DA-CPR was associated with a higher survival compared with NO-CPR. However, DA-CPR was associated with a lower survival compared with SP-CPR. These results reinforce the vital role of DA-CPR, although continuous efforts to disseminate CPR training must be considered a top priority if survival after out of hospital cardiac arrest is to continue to increase.

Conclusion (proposition de traduction) : La RCP assistée par un assistant de régulation était associée à une survie plus élevée par rapport à l'absence de RCP. Cependant, la RCP assistée par l'assistant de régulateur était associée à une survie plus faible que la RCP initiée spontanément. Ces résultats renforcent le rôle vital de la RCP assistée par un assistant de régulation, bien que des efforts continus pour diffuser la formation à la RCP doivent être considérés comme une priorité absolue si la survie après un arrêt cardiaque extra-hospitalier doit continuer d'augmenter.

The American Journal of Emergency Medicine

Clinical factors associated with intubation in the high flow nasal cannula era.
Suessman A, Gray LL, Cavenaugh S, Camp EA, Shi Y, Meskill SD. | Am J Emerg Med. 2020 Dec;38(12):2500-2505
DOI: https://doi.org/10.1016/j.ajem.2019.12.017
Keywords: Bronchiolitis; Emergency department; High flow nasal cannula; Intubation; Respiratory failure.

Original Contribution

Introduction : Bronchiolitis is the most common cause for hospitalization in infants. While the use of high flow nasal cannula (HFNC) has increased, it has not uniformly reduced intubation rates.
Objective: We identified factors associated with respiratory failure in children with bronchiolitis on HFNC.

Méthode : We conducted a retrospective study of previously healthy children <24 months of age with bronchiolitis, who were treated with HFNC in two pediatric emergency departments from 1/2014-1/2018. The primary outcome was the identification of demographic and clinical factors that are associated with intubation after an antecedent trial of HFNC. A multivariable logistic regression model was constructed to identify predictors of respiratory failure.

Résultats : Of 2657 children on HFNC, the median age was 7 months, while the median age of the intubated cohort was 3 months. Ten percent (271) progressed to mechanical ventilation within 48 h of PED presentation. Of the 301 patients that needed escalation to CPAP and/or BiPAP, 91 required intubation. Factors associated with intubation were young age and a high respiratory tool score; factors associated with no progression to intubation were a reduction in tachycardia after initiation of HFNC and presentation after day 5 of illness. A secondary analysis also revealed decreased rate of intubation with the use of bronchodilators. We identified demographic, clinical, and therapeutic factors that are associated with requiring intubation.

Conclusion : Given the high burden of bronchiolitis in pediatric emergency departments, these factors can be considered upon presentation of children with bronchiolitis to selectively identify children at higher risk for respiratory failure.

Conclusion (proposition de traduction) : Étant donné le poids élevé imputable à la bronchiolite dans les services d'urgence pédiatriques, ces facteurs peuvent être pris en compte lors de la présentation d'enfants atteints de bronchiolite pour identifier de manière sélective les enfants à risque plus élevé d'insuffisance respiratoire.

Demographic characteristics and delayed neurological sequelae risk factors in carbon monoxide poisoning.
Sarı Doğan F, Güneysel Ö, Gökdağ E, Güneş M, Sümen SG. | Am J Emerg Med. 2020 Dec;38(12):2552-2556
DOI: https://doi.org/10.1016/j.ajem.2019.12.037
Keywords: Carbon monoxide poisoning; Carboxyhemoglobin; Delayed neurological sequelae; Hyperbaric oxygen.

Original Contribution

Introduction : Carbon monoxide (CO) is a colorless, odorless gas and tasteless. CO poisoning (COP) is one of the most frequently encountered inhalation poisonings. The most common cause of morbidity in COP is delayed neurological sequelae (DNS). DNS is the occurrence of neuropsychiatric findings within 2-240 days after discharge of patients with COP and there are no definitive diagnostic criteria. The aim of our study is; to determine the risk factors and incidence of DNS.

Méthode : Our study is a retrospective, observational study. Patients with the diagnosis of COP in the emergency department between 2015 and 2016 were included in the study. Patients age, gender, findings in the initial physical examination (PE) and neurological examination (NE), blood carboxyhemoglobin (COHb) level, relation between hyperbaric oxygen (HBO) treatment and DNS were assessed.

Résultats : Total of 72 patients were included in the study. Mean age was 33.43 ± 20.89. It was determined that pathological findings in the initial NE are a significant predictive factor for DNS (Odds ratio 18.600, p:0.004). Significant relation between NE and HBO treatment was present (p:00.1). There was no statistically significant relationship between initial COHb level and receiving HBO treatment (p:0.9). Median COHb level of patients with DNS was 30 (min:10, max: 43), median COHb level of patients without DNS was 25 (min:10, max:44) and there was no statistically significant relationship between the two groups according to COHb levels (p:0.7).

Conclusion : Pathological findings in the initial neurological examination had a predictive value for delayed neurological sequelae in patients with carbon monoxide poisoning.

Conclusion (proposition de traduction) : Les découvertes pathologiques de l'examen neurologique initial avaient une valeur prédictive des séquelles neurologiques retardées chez les patients présentant une intoxication au monoxyde de carbone.

Evaluation of opioid requirements in the management of renal colic after guideline implementation in the emergency department.
Minhaj FS, Hoang-Nguyen M, Tenney A, Bragg A, Zhang W, Foster J, Rotoli J, Acquisto NM. | Am J Emerg Med. 2020 Dec;38(12):2564-2569
DOI: https://doi.org/10.1016/j.ajem.2019.12.042
Keywords: Emergency department; Lidocaine; Nephrolithiasis; Opioid; Pain; Renal colic; Urolithiasis.

Original Contribution

Introduction : Evaluate opioid prescribing before and after emergency department (ED) renal colic guideline implementation focused on multi-modal pain management.

Méthode : Retrospective study of ED patients who received analgesia for urolithiasis before and after guideline implementation. The guideline recommends oral acetaminophen, intravenous (IV) ketorolac, and a fluid bolus as first line, IV lidocaine as second line, and opioids as refractory therapy to control pain. Opioid exposure, adverse effects, length of stay (LOS), and ED representation were evaluated. Comparisons were made with univariate analyses. Backwards stepwise binomial multivariate logistic regression to identify factors related to opioid use was performed.

Résultats : Overall, 962 patients were included (451 pre- and 511 post-implementation). ED and discharge opioid use decreased; 65% vs. 58% and 71% vs. 63% in pre- and post-implementation groups, respectively. More post-implementation patients received non-opioid analgesia (65% vs. 56%) and non-opioid analgesia prior to opioids (50% vs. 38%). A longer ED LOS and higher initial pain score were associated with ED opioid administration. Guideline implementation, receiving non-opioid therapy first, and first renal colic episode were associated with decreased ED opioid administration. Seventeen adverse events (1.8%) were reported. There was no difference in change in ED pain score between groups, but patients in the post-implementation group were admitted more and had a higher 7-day ED representation (11% vs. 7%).

Conclusion : A multimodal analgesia protocol for renal colic was associated with decreased opioid prescribing, higher rates of admission to the hospital, and a higher 7-day ED representation rate.

Conclusion (proposition de traduction) : Un protocole d'analgésie multimodale dans la colique néphrétique était associé à une diminution de la prescription d'opioïdes, à des taux plus élevés d'admission à l'hôpital et à un taux de reconsultation plus élevé au service des urgences à 7 jours.

Heart rate variability measures for prediction of severity of illness and poor outcome in ED patients with sepsis.
Arbo JE, Lessing JK, Ford WJH, Clark S, Finkelsztein E, Schenck EJ, Sharma R, Heerdt PM. | Am J Emerg Med. 2020 Dec;38(12):2607-2613
DOI: https://doi.org/10.1016/j.ajem.2020.01.012
Keywords: Aucun

Original Contribution

Introduction : This study evaluates the utility of heart rate variability (HRV) for assessment of severity of illness and poor outcome in Emergency Department (ED) patients with sepsis. HRV measures evaluated included low frequency (LF) signal, high frequency (HF) signal, and deviations in LF and HF signal from age-adjusted reference values.

Méthode : This was a prospective, observational study. Seventy-two adult ED patients were assessed within 6 h of arrival.

Résultats : Severity of illness as defined by sepsis subtype correlated with decreased LF signal (sepsis: 70.68 ± 22.95, severe sepsis: 54.00 ± 28.41, septic shock: 45.54 ± 23.31, p = 0.02), increased HF signal (sepsis: 27.87 ± 19.42, severe sepsis: 44.63 ± 27.29, septic shock: 47.66 ± 20.98, p = 0.01), increasingly negative deviations in LF signal (sepsis: 0.41 ± 24.53, severe sepsis: -21.43 ± 30.09, septic shock -30.39 ± 26.09, p = 0.005) and increasingly positive deviations in HF signal (sepsis: -1.86 ± 21.09, severe sepsis: 20.07 ± 29.03, septic shock: 23.6 ± 24.17, p = 0.004). Composite poor outcome correlated with decreased LF signal (p = 0.008), increased HF signal (p = 0.03), large negative deviations in LF signal (p = 0.004) and large positive deviations in HF signal (p = 0.02). Deviations in LF and HF signal from age-adjusted reference values correlated with individual measures of poor outcome with greater consistency than LF or HF signal.

Conclusion : Accounting for the influence of age on baseline HRV signal improves the predictive value of HRV measures in ED patients with sepsis.

Conclusion (proposition de traduction) : La prise en compte de l'influence de l'âge sur le signal de la variabilité de la fréquence cardiaque de base améliore la valeur prédictive des mesures de la variabilité de la fréquence cardiaque chez les patients aux urgences souffrant de septicémie.

Validation of the diagnosis and triage algorithm for acute myocardial infarction in the setting of left bundle branch block.
Lai YC, Chen YH, Wu KH, Chen YC. | Am J Emerg Med. 2020 Dec;38(12):2614-2619
DOI: https://doi.org/10.1016/j.ajem.2020.03.024
Keywords: Acute myocardial infarction; Emergent percutaneous coronary intervention; Left bundle branch block.

Original contribution

Introduction : Detecting acute ST-segment elevation myocardial infarction (STEMI) in the setting of left bundle branch block (LBBB) remains a challenge to clinicians. Several diagnostic and triage algorithms have been proposed to accurately identify LBBB patients with an acute culprit vessel. We aimed to validate the algorithm proposed by Cai et al., which uses patients' hemodynamic status and the modified Sgarbossa electrocardiography criteria to guide reperfusion therapy.

Méthode : This retrospective study was performed with a chart review in emergency departments (EDs) of 2 medical centers, 2 regional hospitals, and 1 local hospital. From January 2010 to December 2014, 2432 consecutive patients were diagnosed as having STEMI in the ED, including 65 patients with LBBB (2.6%).

Résultats : The patients with LBBB were older and more frequently presented with acute pulmonary edema (58.5% vs 22.1%, p < 0.001), cardiogenic shock (16.9% vs 6.3% p = 0.006), and VT/VF episodes (7.7% vs 2.2%, p = 0.034) and had a higher 30-day mortality rate (20.0% vs 10.4% p = 0.032) than those without LBBB. We then tested the algorithm proposed by Cai et al. and noted a sensitivity of 93.8% in identifying a culprit lesion.

Conclusion : The inconsistency of the guideline recommendations reflects the uncertainty of diagnostic and therapeutic strategies and the pressing need for tools to accurately identify the true acute myocardial infarction in patients presenting with chest pain and LBBB. The algorithm proposed by Cai et al. had good sensitivity and would allow emergency physicians to implement the timely treatment protocol for this high-risk population.

Conclusion (proposition de traduction) : L'incohérence des recommandations des lignes directrices reflète l'incertitude des stratégies diagnostiques et thérapeutiques et le besoin pressant d'outils pour identifier avec précision le véritable infarctus aigu du myocarde chez les patients présentant des douleurs thoraciques et un bloc de branche gauche. L'algorithme proposé par Cai et al. avait une bonne sensibilité et permettrait aux médecins urgentistes de mettre en œuvre le protocole de traitement en temps opportun pour cette population à haut risque.

Effectiveness and safety of small-bore tube thoracostomy (≤20 Fr) for chest trauma patients: A retrospective observational study.
Maezawa T, Yanai M, Huh JY, Ariyoshi K. | Am J Emerg Med. 2020 Dec;38(12):2658-2660
DOI: https://doi.org/10.1016/j.ajem.2020.09.028
Keywords: Chest trauma; Chest tube; Complications; Tube thoracostomy.

Brief Reports

Introduction : Tube thoracostomy is an important treatment for traumatic hemothorax and pneumothorax. The optimal tube diameter remains unclear. To reduce invasiveness, we use small-bore chest tubes (≤20 Fr) for all trauma patients for whom tube thoracostomy is indicated in our emergency department (ED). The aim of this study was to investigate the effectiveness and safety of small-bore tube thoracostomy for traumatic hemothorax or pneumothorax.

Méthode : We conducted a retrospective observational study at a single emergency medical center. This study included adult patients (≥18 years old) who had undergone tube thoracostomy for chest trauma in the ED during the 5 years from October 2013 to September 2018. We used 20 Fr chest tubes or 8 Fr pigtail catheters. The examined outcome was tube-related complications, such as tube obstruction, retained hemothorax, and unresolved pneumothorax.

Résultats : A total of 107 tube thoracostomies were performed in 102 patients. The mean Injury Severity Score of these patients was 17.8 (±9.6), and the mean duration of the tube placement period was 3.9 days (±1.8). Eight patients developed tube-related complications (7.8%) (retained hemothorax: 4 patients (3.9%), unresolved pneumothorax: 4 patients (3.9%)). None of these cases were caused by tube obstruction. Although the drainage itself was effective, they underwent definitive invasive interventions to stop bleeding or air leak.

Conclusion : Our study showed that the use of small-bore (≤20 Fr) chest tubes to treat traumatic hemothorax/pneumothorax achieved the purposes of tube thoracostomy. It might be possible to safely manage chest trauma with small-bore chest tubes.

Conclusion (proposition de traduction) : Notre étude a montré que l'utilisation de drains thoraciques de petit diamètre (≤ 20 Fr) pour traiter l'hémothorax/pneumothorax traumatique atteignait les objectifs de la thoracostomie par drain. Il pourrait être possible de gérer en toute sécurité un traumatisme thoracique avec des drains thoraciques de petit diamètre.

Massive transfusion protocol in adult trauma population.
Meneses E, Boneva D, McKenney M, Elkbuli A. | Am J Emerg Med. Am J Emerg Med.
DOI: https://doi.org/10.1016/j.ajem.2020.07.041
Keywords: Acute blood loss; Balanced transfusion ratio; Blood products; Coagulopathy; Massive transfusion protocol; Trauma mortality.

Reviews

Introduction : Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions.

Méthode : PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes.

Résultats : Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient.

Conclusion : Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.

Conclusion (proposition de traduction) : Les protocoles actuels de transfusion massive devraient utiliser des rapports entre 1:1:1 et 1:1:2 des 3 principaux produits ; plasma, plaquettes et globules rouges. Les protocoles de transfusion massive sont efficaces pour réduire la mortalité. De meilleurs efforts de réanimation ont été observés lorsque les produits sanguins étaient facilement disponibles dans la zone de traumatologie à l'arrivée du patient et plus le remplacement du sang est rapide, meilleurs sont les résultats.

COVID-19 cardiac arrest management: A review for emergency clinicians.
Ramzy M, Montrief T, Gottlieb M, Brady WJ, Singh M, Long B. | Am J Emerg Med. 2020 Dec;38(12):2693-2702
DOI: https://doi.org/10.1016/j.ajem.2020.08.011  | Télécharger l'article au format  
Keywords: COVID-19; Cardiac arrest; Critical care; Emergency medicine; Intensive care; SARS-CoV-2.

Reviews

Introduction : A great deal of literature has recently discussed the evaluation and management of the coronavirus disease of 2019 (COVID-19) patient in the emergency department (ED) setting, but there remains a dearth of literature providing guidance on cardiac arrest management in this population.

Méthode : This narrative review outlines the underlying pathophysiology of patients with COVID-19 and discusses approaches to cardiac arrest management in the ED based on the current literature as well as extrapolations from experience with other pathogens.

Discussion : Patients with COVID-19 may experience cardiovascular manifestations that place them at risk for acute myocardial injury, arrhythmias, and cardiac arrest. The mortality for these critically ill patients is high and increases with age and comorbidities. While providing resuscitative interventions and performing procedures on these patients, healthcare providers must adhere to strict infection control measures and prioritize their own safety through the appropriate use of personal protective equipment. A novel approach must be implemented in combination with national guidelines. The changes in these guidelines emphasize early placement of an advanced airway to limit nosocomial viral transmission and encourage healthcare providers to determine the effectiveness of their efforts prior to placing staff at risk for exposure.

Conclusion : While treatment priorities and goals are identical to pre-pandemic approaches, the management of COVID-19 patients in cardiac arrest has distinct differences from cardiac arrest patients without COVID-19. We provide a review of the current literature on the changes in cardiac arrest management as well as details outlining team composition.

Conclusion (proposition de traduction) : Alors que les priorités et les objectifs du traitement sont identiques à ceux des approches prépandémiques, la prise en charge des patients atteints de COVID-19 en arrêt cardiaque présente des différences distinctes par rapport aux patients en arrêt cardiaque sans COVID-19. Nous fournissons une revue de la littérature actuelle sur les changements dans la gestion de l'arrêt cardiaque ainsi que des détails décrivant la composition de l'équipe.

Intravenous thiamine for septic shock: A meta-analysis of randomized controlled trials.
Qian X, Zhang Z, Li F, Wu L. | Am J Emerg Med. 2020 Dec;38(12):2718-2722
DOI: https://doi.org/10.1016/j.ajem.2020.08.050
Keywords: Mortality; Randomized controlled trials; Septic shock; Thiamine.

Reviews

Introduction : The efficacy of intravenous thiamine to treat septic shock remains controversial. We conduct a systematic review and meta-analysis to explore the impact of intravenous thiamine on treatment efficacy of septic shock.

Méthode : We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2020 and included randomized controlled trials (RCTs) assessing the effect of intravenous thiamine on septic shock. This meta-analysis was performed using the random-effect model.

Résultats : Four RCTs were included in the meta-analysis. Overall, compared with control group in patients with septic shock, intravenous thiamine revealed no substantial impact on mortality (odd ratio [OR] = 0.87; 95% confidence interval [CI) = 0.62 to 1.21; P = 0.40), lactate change (standard mean difference [SMD] = 0.04; 95% CI = -0.28 to 0.35; P = 0.82), Sequential Organ Failure Assessment (SOFA) change (SMD = 0.02; 95% CI = -0.18 to 0.21; P = 0.87), intensive care unit (ICU) stay (SMD = -0.02; 95% CI = -0.33 to 0.30; P = 0.90) or renal replacement therapy (OR = 0.47; 95% CI = 0.07 to 3.15; P = 0.43).

Conclusion : Intravenous thiamine showed no benefit over placebo in treating patients with septic shock.

Conclusion (proposition de traduction) : La thiamine intraveineuse n'a montré aucun bénéfice par rapport au placebo dans le traitement des patients présentant un choc septique.

The Journal of Emergency Medicine

Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis.
Wu KH, Chang CY, Chen YC, Chang CP, Hsiao CT, Weng HH. | J Emerg Med. 2020 Dec;59(6):856-864
DOI: https://doi.org/10.1016/j.jemermed.2020.08.012
Keywords: cardiac arrest; meta-analysis; sodium bicarbonate.

Clinical Reviews

Introduction : The 2010 Advanced Cardiac Life Support guidelines stated that routine sodium bicarbonate (SB) use for cardiac arrest patients was not recommended. However, SB administration during resuscitation is still common.
Objectives: To evaluate the effect of SB on return of spontaneous circulation (ROSC) and survival-to-discharge rates in adult cardiac arrest patients.

Méthode : We searched Medline, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to December 2019. We included trials on nontraumatic adult patients after cardiac resuscitation and SB treatment vs. controls.

Résultats : A meta-analysis was performed with six observational studies, including 18,406 adult cardiac arrest patients. There were no significant differences in the ROSC rate (odds ratio [OR] 1.185; 95% confidence interval [CI] 0.680-2.065) and survival-to-discharge rate (OR 0.296; 95% CI 0.066-1.323) between the SB and no-SB groups. In the subgroup analysis based on the year factor, there were no significant differences in the mortality rate in the After-2010 group. In the subgroup analysis based on the continent, the ROSC rate (OR 0.521; 95% CI 0.432-0.628) and survival-to-discharge rate (OR 0.102; 95% CI 0.066-0.156) were significantly lower in the North American group.

Conclusion : SB use was not associated with improvement in ROSC or survival-to-discharge rates in cardiac resuscitation. In addition, mortality was significantly increased in the North American group with SB administration.

Conclusion (proposition de traduction) : L'utilisation de bicarbonate de sodium n'a pas été associée à une amélioration du retour à une circulation spontanée ou des taux de survie à la sortie lors de la réanimation cardiaque. De plus, la mortalité a augmenté de manière significative dans le groupe nord-américain avec l'administration de bicarbonate de sodium.

Ultrasound Guidance Versus Landmark-Guided Palpation for Radial Arterial Line Placement by Novice Emergency Medicine Interns: A Randomized Controlled Trial.
Gibbons RC, Zanaboni A, Saravitz SM, Costantino TG. | J Emerg Med. 2020 Dec;59(6):911-917
DOI: https://doi.org/10.1016/j.jemermed.2020.07.029
Keywords: arterial line; critical care; point-of-care ultrasound; resident education and training.

Ultrasound in Emergency Medicine

Introduction : More than 10 million arterial lines are placed annually worldwide, many of which happen in the emergency department. Before the introduction of point-of-care ultrasound, landmark-guided palpation (LMGP) was considered standard of care.
Objective: The objective of this study is to compare ultrasound-guided (USG) and LMGP of radial arterial line cannulation by novice emergency medicine interns.

Méthode : This was a single-center, prospective, randomized controlled trial (NCT03326739) of a convenience sample of adult patients who presented to an urban, university hospital with 100,000 visits annually. There was no funding for this study. Patients who required an arterial line were blindly randomized into LMGP or USG groups. Only novice emergency medicine interns, defined as interns with <15 previous placements, who were not blinded, performed the cannulation. Statistical analyses included t and Fisher exact tests.

Résultats : Forty patients were enrolled with 20 patients randomized to each group. USG had a first-pass success of 75% vs. 0% for LMGP (p < 0.00001) and an overall success of 100% vs. 15% for LMGP (p < 0.00001), a mean of 1.30 attempts vs. 2.95 attempts for LMGP (a difference of 1.65; p < 0.0001), and a mean time for placement of 264 s vs. 524 s for LMGP (a difference of 260; p = 0.0025). Of the failed LMGP, USG crossover was 100% successful with a mean of 1.37 attempts (95% confidence interval 0.58-2.16) and 180 s for placement (95% confidence interval 97.92-262.08). Five percent of LMGP had a complication vs. 0% for USG (p = 1.0).

Conclusion : USG improved first-pass and overall success of radial arterial line cannulation while reducing time to access and attempts when used by novice emergency medicine interns.

Conclusion (proposition de traduction) : Le guidage échographique a amélioré le premier essai et le succès global de la canulation de la ligne artérielle radiale tout en réduisant le temps d’accès et les tentatives lorsqu’elle est utilisée par des stagiaires en médecine d’urgence novices.

Rapid Systematic Review: The Appropriate Use of Quick Sequential Organ Failure Assessment (qSOFA) in the Emergency Department.
Waligora G, Gaddis G, Church A, Mills L. | J Emerg Med. 2020 Dec;59(6):977-983
DOI: https://doi.org/10.1016/j.jemermed.2020.06.043
Keywords: emergency department; qSOFA; sepsis.

AAEM Clinical Practice

Introduction : The concept of sepsis has recently been redefined by an International Task Force. The task force recommended the use of the quick Sequential Organ Failure Assessment (qSOFA) score instead of Systemic Inflammatory Response Syndrome (SIRS) criteria to identify patients at high risk of mortality from sepsis outside of the intensive care unit, including in emergency departments (EDs). However, the primary outcome for qSOFA is prediction of risk for mortality, which is not the principal outcome measure considered in the ED. From the ED perspective, the priorities are the identification (diagnosis) of the septic patient and then the initiation of time-sensitive, life-saving interventions.

Méthode : We performed a structured review of PubMed from January 2012 to December 2018, limited to reports involving human subjects and written in English language and containing relevant keywords. The highest-quality studies were then reviewed in a structured format. We utilized these studies to estimate the sensitivity and specificity of SIRS and qSOFA for diagnosis of sepsis.

Résultats : Thirteen unique articles were identified for further review, and the 11 highest-grade articles (C and D) were determined to be appropriate for inclusion in this review, and the two low-grade articles were excluded (E).

Conclusion : Based on multiple retrospective and few prospective studies, it appears that qSOFA performs poorly in comparison with SIRS as a diagnostic tool for ED patients who may have sepsis or septic shock. However, qSOFA does have a strong prognostic accuracy for mortality in those ED patients already diagnosed with sepsis or septic shock.

Conclusion (proposition de traduction) : Sur la base de multiples études rétrospectives et de quelques études prospectives, il semble que le qSOFA fonctionne mal par rapport au SIRS comme outil de diagnostic pour les patients des services d'urgence qui peuvent avoir une septicémie ou un choc septique. Cependant, le qSOFA a une forte précision pronostique pour la mortalité chez les patients des services d'urgence déjà diagnostiqués avec une septicémie ou un choc septique.

Ultrasound-Guided Chest Compressions in Out-of-Hospital Cardiac Arrests.
Zanatta M, Lorenzi C, Scorpiniti M, Cianci V, Pasini R, Barchitta A. | J Emerg Med. 2020 Dec;59(6):e225-e233
DOI: https://doi.org/10.1016/j.jemermed.2020.07.005
Keywords: cardiopulmonary resuscitation; chest compressions; end-tidal CO(2); point-of-care ultrasound; prehospital.

Ultrasound in Emergency Medicine

Introduction : There is a significant variability in survival rates for cardiopulmonary resuscitation (CPR) in out of-hospital cardiac arrest (OHCA), and some data indicate that ultrasound improves CPR.
Objectives: We evaluated the feasibility of ultrasound for monitoring chest compressions in OHCA.

Méthode : We planned a prospective study in patients with an ultrasound-integrated CPR for OHCA. Chest compressions were performed on the intermammillary line (IML), but the position was changed according to the quality of the heart squeezing, evaluated by ultrasound. End-tidal carbon dioxide (ETCO2) was used as the control parameter. Then we compared the area with the highest squeezing with the position of the heart in the chest computed tomography (CT) scans of 20 hospitalized patients.

Résultats : Chest compressions were good, partial, and inadequate on the IML in 58.4%, 48.9%, and 2.8% of cases, respectively. These percentages were 75%, 25%, and 0% after these modifications: none (47.2%), increased depth (8.3%), hands moved on the lower third of the sternum (27.8%), on left parasternal line of the lower part of the sternum (13.9%), and on the center of the sternum (1 case). Accordingly, ETCO2 improved significantly (20.37 vs. 37.10, p < 0.0001). The CT scans showed that the larger biventricular area (BVA) was under the parasternal line of the lower third of the sternum, and the mean distance IML-BVA was 5.7 cm.

Conclusion : Our study has demonstrated that CPR in OHCA can be improved using ultrasound and changing the position of the hands. This finding was connected with the ETCO2 and confirmed by chest CT scans.

Conclusion (proposition de traduction) : Notre étude a démontré que la réanimation cardio-pulmonaire en cas d'arrêt cardiaque extra-hospitalier peut être améliorée en utilisant l'échographie et en modifiant la position des mains. Cette découverte était liée à l'ETCO2 et confirmée par des tomodensitométries thoraciques.

The Journal of the American Medical Association

Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial.
Writing Committee and Steering Committee for the RELAx Collaborative Group, Algera AG, Pisani L, Serpa Neto A, den Boer SS, Bosch FFH, Bruin K, Klooster PM, Van der Meer NJM, Nowitzky RO, Purmer IM, Slabbekoorn M, Spronk PE, van Vliet J, Weenink JJ, Gama de Abreu M, Pelosi P, Schultz MJ, Paulus F. | JAMA. 2020 Dec 22;324(24):2509-2520
DOI: https://doi.org/10.1001/jama.2020.23517
Keywords: Aucun

Original Investigation

Introduction : It is uncertain whether invasive ventilation can use lower positive end-expiratory pressure (PEEP) in critically ill patients without acute respiratory distress syndrome (ARDS).
Objective: To determine whether a lower PEEP strategy is noninferior to a higher PEEP strategy regarding duration of mechanical ventilation at 28 days.
Design, setting, and participants: Noninferiority randomized clinical trial conducted from October 26, 2017, through December 17, 2019, in 8 intensive care units (ICUs) in the Netherlands among 980 patients without ARDS expected not to be extubated within 24 hours after start of ventilation. Final follow-up was conducted in March 2020.
Interventions:Participants were randomized to receive invasive ventilation using either lower PEEP, consisting of the lowest PEEP level between 0 and 5 cm H2O (n = 476), or higher PEEP, consisting of a PEEP level of 8 cm H2O (n = 493).

Méthode : The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for the difference in ventilator-free days at day 28 of -10%. Secondary outcomes included ICU and hospital lengths of stay; ICU, hospital, and 28- and 90-day mortality; development of ARDS, pneumonia, pneumothorax, severe atelectasis, severe hypoxemia, or need for rescue therapies for hypoxemia; and days with use of vasopressors or sedation.

Résultats : Among 980 patients who were randomized, 969 (99%) completed the trial (median age, 66 [interquartile range {IQR}, 56-74] years; 246 [36%] women). At day 28, 476 patients in the lower PEEP group had a median of 18 ventilator-free days (IQR, 0-27 days) and 493 patients in the higher PEEP group had a median of 17 ventilator-free days (IQR, 0-27 days) (mean ratio, 1.04; 95% CI, 0.95-∞; P = .007 for noninferiority), and the lower boundary of the 95% CI was within the noninferiority margin. Occurrence of severe hypoxemia was 20.6% vs 17.6% (risk ratio, 1.17; 95% CI, 0.90-1.51; P = .99) and need for rescue strategy was 19.7% vs 14.6% (risk ratio, 1.35; 95% CI, 1.02-1.79; adjusted P = .54) in patients in the lower and higher PEEP groups, respectively. Mortality at 28 days was 38.4% vs 42.0% (hazard ratio, 0.89; 95% CI, 0.73-1.09; P = .99) in patients in the lower and higher PEEP groups, respectively. There were no statistically significant differences in other secondary outcomes.

Conclusion : Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS.

Conclusion (proposition de traduction) : Parmi les patients de l'unité de soins intensifs sans SDRA qui ne devaient pas être extubés dans les 24 heures, une stratégie de PEEP basse (0 à 5 cm H2O) n'était pas inférieure à une stratégie PEEP plus élevée (8 cm H2O) en ce qui concerne le nombre de jours sans respirateur au 28èmejour. Ces résultats appuient l’utilisation d’une PEEP plus faible chez les patients sans SDRA.

The Lancet

Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.
Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, John R, Shaffer A, Frascone RJ, Wesley K, Conterato M, Biros M, Tolar J, Aufderheide TP. | Lancet. 2020 Dec 5;396(10265):1807-1816
DOI: https://doi.org/10.1016/s0140-6736(20)32338-2
Keywords: Aucun

Article

Introduction : Among patients with out-of-hospital cardiac arrest (OHCA) and ventricular fibrillation, more than half present with refractory ventricular fibrillation unresponsive to initial standard advanced cardiac life support (ACLS) treatment. We did the first randomised clinical trial in the USA of extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation versus standard ACLS treatment in patients with OHCA and refractory ventricular fibrillation.

Méthode : For this phase 2, single centre, open-label, adaptive, safety and efficacy randomised clinical trial, we included adults aged 18-75 years presenting to the University of Minnesota Medical Center (MN, USA) with OHCA and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System, and estimated transfer time shorter than 30 min. Patients were randomly assigned to early ECMO-facilitated resuscitation or standard ACLS treatment on hospital arrival by use of a secure schedule generated with permuted blocks of randomly varying block sizes. Allocation concealment was achieved by use of a randomisation schedule that required scratching off an opaque layer to reveal assignment. The primary outcome was survival to hospital discharge. Secondary outcomes were safety, survival, and functional assessment at hospital discharge and at 3 months and 6 months after discharge. All analyses were done on an intention-to-treat basis.

Résultats : Between Aug 8, 2019, and June 14, 2020, 36 patients were assessed for inclusion. After exclusion of six patients, 30 were randomly assigned to standard ACLS treatment (n=15) or to early ECMO-facilitated resuscitation (n=15). One patient in the ECMO-facilitated resuscitation group withdrew from the study before discharge. The mean age was 59 years (range 36-73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6-30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3-67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7-59·2; posterior probability of ECMO superiority 0·9861). The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group. No unanticipated serious adverse events were observed.

Conclusion : Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge compared with standard ACLS treatment.

Conclusion (proposition de traduction) : La réanimation précoce facilitée par l'ECMO chez les patients souffrant d'un arrêt cardiaque extra-hospitalier en fibrillation ventriculaire réfractaire a considérablement amélioré la survie à la sortie de l'hôpital par rapport au traitement de survie cardiaque médicalisé standard.


Mois de décembre 2020