The Infant Scalp Score: A Validated Tool to Stratify Risk of Traumatic Brain Injury in Infants With Isolated Scalp Hematoma.
Schutzman SA, Nigrovic LE, Mannix R. | Acad Emerg Med. 2021 Jan;28(1):92-97
DOI: https://doi.org/10.1111/acem.14087
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : The objective was to validate the previously derived Infant Scalp Score (ISS) that uses clinical signs in infants with isolated scalp hematoma (ISH) after head trauma to stratify risk for clinically important traumatic brain injury (ciTBI) or TBI on computed tomography (CT).

Méthode : Using the publicly available Pediatric Emergency Care Applied Research Network TBI data set, we selected infants ≤ 1 year with GCS 14 to 15 who had ISH (defined as hematoma without other signs/symptoms of TBI). CT scans were obtained at the treating physician's discretion. We calculated ISS based on age, hematoma size, and location (range = 0-8) for each patient and calculated the sensitivity and specificity of the score for ciTBI and TBI on CT across a range of ISS cut-points.

Résultats : We included 1,289 infants ≤ 1 year of whom 462 (36%) had CT performed. Twelve had ciTBI and 59 had TBI on CT. An ISS cutoff ≥ 4 had sensitivity of 100% for ciTBI (95% confidence interval [CI] = 0.74 to 1.0) and TBI with specificity of 0.49 (95% CI = 0.46 to 0.51). An ISS cutoff of ≥5 had a sensitivity of 100% for ciTBI (95% CI = 0.74 to 1.0) and specificity of 0.68 (95% CI = 0.66 to 0.71), but missed three infants with TBI on CT (none of whom required intervention). The receiver operating characteristic curves for clinical score to detect ciTBI and TBI had areas under the curve of 0.916 and 0.807, respectively.

Conclusion : The ISS accurately stratified risk for ciTBI and TBI on CT in infants with ISH and is a useful tool to help guide clinical decision making.

Conclusion (proposition de traduction) : Le score ISS a stratifié avec précision le risque de traumatisme crânien et de traumatisme crânien cliniquement important par la tomodensitométrie chez les nourrissons atteints d'hématome isolé du cuir chevelu et constitue un outil utile pour aider à guider la prise de décision clinique.

Commentaire :  Les scores « Infant Scalp Score » allaient de 1 (risque le plus faible) à 8 (risque le plus élevé), car seuls les nourrissons de moins d'un an étaient inclus. Pour les enfants ayant plus d'un hématome du cuir chevelu, nous avons sélectionné celui avec le score le plus élevé.
En utilisant un seuil de score du cuir chevelu ≥ 4 pour demander un scanner cérébral, aucun traumatisme crânien et aucun traumatisme crânien cliniquement important ne seraient manqués ; cependant, 669 des 1289 (52 %) patients auraient été scannés. En utilisant un seuil de ≥ 5, aucun nourrisson avec traumatisme crânien cliniquement important et trois avec traumatisme crânien n'aurait été manqués, mais seulement 417 des 1289 (32 %) auraient eu une imagerie.
Les trois nourrissons avec un score « Infant Scalp Score » de 4 qui avaient un traumatisme crânien à la tomodensitométrie n'ont nécessité ni neurochirurgie ni d'hospitalisation de plus d'une nuit.

Ondansetron (Zofran) for Pediatric Gastroenteritis.
Hanuscin C, Hassel J, Khan A. | Acad Emerg Med. 2021 Jan;28(1):135-137
DOI: https://doi.org/10.1111/acem.14042  | Télécharger l'article au format  
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Gastroenteritis is a common disease in children that presents predominantly with vomiting and diarrhea. According to the Centers for Disease Control and Prevention (CDC), it accounts for 220,000 hospitalizations in the United States. Vomiting and diarrhea, in combination with decreased oral intake, can lead to dehydration. Ondansetron (an antiemetic) has been increasingly used in the pediatric population to help reduce the vomiting and hopefully decrease the risk for dehydration in the child. This review is an update of a previous evidence based review published on TheNNT.com. The most recent systematic review on ondansetron use in pediatric gastroenteritis was published in 2016.

Conclusion : In summary, in children presenting with vomiting due to acute gastroenteritis, oral or IV administration of ondansetron decreases the rate of vomiting within 1 hour of presentation and reduces the risk of hospitalization but may not reduce the need for IV hydration. We have assigned a color recommendation of green (benefit > harm) to this treatment.

Conclusion (proposition de traduction) : En résumé, chez les enfants présentant des vomissements dus à une gastro-entérite aiguë, l'administration orale ou IV d'ondansétron diminue le taux de vomissements dans l'heure suivant la présentation et réduit le risque d'hospitalisation mais peut ne pas réduire la nécessité d'une hydratation IV. Nous avons attribué une recommandation de couleur verte (bénéfice > dommage) à ce traitement.

Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis. A Randomized Trial.
Kyriazopoulou E, Liaskou-Antoniou L, Adamis G, Panagaki A, Melachroinopoulos N, Drakou E, Marousis K, Chrysos G, Spyrou A, Alexiou N, Symbardi S, Alexiou Z, Lagou S, Kolonia V, Gkavogianni T, Kyprianou M, Anagnostopoulos I, Poulakou G, Lada M, Makina A, Roulia E, Koupetori M, Apostolopoulos V, Petrou D, Nitsotolis T, Antoniadou A, Giamarellos-Bourboulis EJ. | Am J Respir Crit Care Med. 2021 Jan 15;203(2):202-210
DOI: https://doi.org/10.1164/rccm.202004-1201oc  | Télécharger l'article au format  
Keywords: mortality; multidrug-resistant; procalcitonin; sepsis.

Critical Care/Pulmonary Infections

Introduction : Although early antimicrobial discontinuation guided by procalcitonin (PCT) has shown decreased antibiotic consumption in lower respiratory tract infections, the outcomes in long-term sepsis sequelae remain unclear.
Objectives: To investigate if PCT guidance may reduce the incidence of long-term infection-associated adverse events in sepsis.

Méthode : In this multicenter trial, 266 patients with sepsis (by Sepsis-3 definitions) with lower respiratory tract infections, acute pyelonephritis, or primary bloodstream infection were randomized (1:1) to receive either PCT-guided discontinuation of antimicrobials or standard of care. The discontinuation criterion was ≥80% reduction in PCT levels or any PCT ≤0.5 μg/L at Day 5 or later. The primary outcome was the rate of infection-associated adverse events at Day 180, a composite of the incidence of any new infection by Clostridioides difficile or multidrug-resistant organisms, or any death attributed to baseline C. difficile or multidrug-resistant organism infection. Secondary outcomes included 28-day mortality, length of antibiotic therapy, and cost of hospitalization.

Discussion : The rate of infection-associated adverse events was 7.2% (95% confidence interval [CI], 3.8-13.1%; 9/125) versus 15.3% (95% CI, 10.1-22.4%; 20/131) (hazard ratio, 0.45; 95% CI, 0.20-0.98; P = 0.045); 28-day mortality 15.2% (95% CI, 10-22.5%; 19/125) versus 28.2% (95% CI, 21.2-36.5%; 37/131) (hazard ratio, 0.51; 95% CI, 0.29-0.89; P = 0.02); and median length of antibiotic therapy 5 (range, 5-7) versus 10 (range, 7-15) days (P < 0.001) in the PCT and standard-of-care arms, respectively. The cost of hospitalization was also reduced in the PCT arm.

Conclusion : In sepsis, PCT guidance was effective in reducing infection-associated adverse events, 28-day mortality, and cost of hospitalization.

Conclusion (proposition de traduction) : Dans la septicémie, le suivi de la procalcitonine a été efficaces pour réduire les événements indésirables associés à l'infection, la mortalité à 28 jours et le coût de l'hospitalisation.

Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis. A Randomized Trial.
Kyriazopoulou E, Liaskou-Antoniou L, Adamis G, Panagaki A, Melachroinopoulos N, Drakou E, Marousis K, Chrysos G, Spyrou A, Alexiou N, Symbardi S, Alexiou Z, Lagou S, Kolonia V, Gkavogianni T, Kyprianou M, Anagnostopoulos I, Poulakou G, Lada M, Makina A, Roulia E, Koupetori M, Apostolopoulos V, Petrou D, Nitsotolis T, Antoniadou A, Giamarellos-Bourboulis EJ. | Am J Respir Crit Care Med. 2021 Jan 15;203(2):202-210
DOI: https://doi.org/10.1164/rccm.202004-1201oc  | Télécharger l'article au format  
Keywords: mortality; multidrug-resistant; procalcitonin; sepsis.

Original Article

Introduction : Although early antimicrobial discontinuation guided by procalcitonin (PCT) has shown decreased antibiotic consumption in lower respiratory tract infections, the outcomes in long-term sepsis sequelae remain unclear.
Objectives: To investigate if PCT guidance may reduce the incidence of long-term infection-associated adverse events in sepsis.

Méthode : In this multicenter trial, 266 patients with sepsis (by Sepsis-3 definitions) with lower respiratory tract infections, acute pyelonephritis, or primary bloodstream infection were randomized (1:1) to receive either PCT-guided discontinuation of antimicrobials or standard of care. The discontinuation criterion was ≥80% reduction in PCT levels or any PCT ≤0.5 μg/L at Day 5 or later. The primary outcome was the rate of infection-associated adverse events at Day 180, a composite of the incidence of any new infection by Clostridioides difficile or multidrug-resistant organisms, or any death attributed to baseline C. difficile or multidrug-resistant organism infection. Secondary outcomes included 28-day mortality, length of antibiotic therapy, and cost of hospitalization.

Résultats : The rate of infection-associated adverse events was 7.2% (95% confidence interval [CI], 3.8-13.1%; 9/125) versus 15.3% (95% CI, 10.1-22.4%; 20/131) (hazard ratio, 0.45; 95% CI, 0.20-0.98; P = 0.045); 28-day mortality 15.2% (95% CI, 10-22.5%; 19/125) versus 28.2% (95% CI, 21.2-36.5%; 37/131) (hazard ratio, 0.51; 95% CI, 0.29-0.89; P = 0.02); and median length of antibiotic therapy 5 (range, 5-7) versus 10 (range, 7-15) days (P < 0.001) in the PCT and standard-of-care arms, respectively. The cost of hospitalization was also reduced in the PCT arm.

Conclusion : In sepsis, PCT guidance was effective in reducing infection-associated adverse events, 28-day mortality, and cost of hospitalization.

Conclusion (proposition de traduction) : Dans la septicémie, la durée de l’antibiothérapie guidée par la procalcitonine a été efficaces pour réduire les événements indésirables associés à l'infection, la mortalité à 28 jours et le coût d'hospitalisation.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Rôle du dosage de la procalcitonine pour diminuer les conséquences à long terme du sepsis  . Rédigé par le Dr Olivier Leroy, le 1 mai 2021.

Barrier Devices, Intubation, and Aerosol Mitigation Strategies: Personal Protective Equipment in the Time of Coronavirus Disease 2019.
Fried EA, Zhou G, Shah R, Shin DW, Shah A, Katz D, Burnett GW. | Anesth Analg. 2021 Jan;132(1):38-45
DOI: https://doi.org/10.1213/ane.0000000000005249  | Télécharger l'article au format  
Keywords: Aucun

Original Clinical Research Report

Introduction : Numerous barrier devices have recently been developed and rapidly deployed worldwide in an effort to protect health care workers (HCWs) from exposure to coronavirus disease 2019 (COVID-19) during high-risk procedures. However, only a few studies have examined their impact on the dispersion of droplets and aerosols, which are both thought to be significant contributors to the spread of COVID-19.

Méthode : Two commonly used barrier devices, an intubation box and a clear plastic intubation sheet, were evaluated using a physiologically accurate cough simulator. Aerosols were modeled using a commercially available fog machine, and droplets were modeled with fluorescein dye. Both particles were propelled by the cough simulator in a simulated intubation environment. Data were captured by high-speed flash photography, and aerosol and droplet dispersion were assessed qualitatively with and without a barrier in place.

Résultats : Droplet contamination after a simulated cough was seemingly contained by both barrier devices. Simulated aerosol escaped the barriers and flowed toward the head of the bed. During barrier removal, simulated aerosol trapped underneath was released and propelled toward the HCW at the head of the bed. Usage of the intubation sheet concentrated droplets onto a smaller area. If no barrier was used, positioning the patient in slight reverse Trendelenburg directed aerosols away from the HCW located at the head of the bed.

Conclusion : Our observations imply that intubation boxes and sheets may reduce HCW exposure to droplets, but they both may merely redirect aerosolized particles, potentially resulting in increased exposure to aerosols in certain circumstances. Aerosols may remain within the barrier device after a cough, and manipulation of the box may release them. Patients should be positioned to facilitate intubation, but slight reverse Trendelenburg may direct infectious aerosols away from the HCW. Novel barrier devices should be used with caution, and further validation studies are necessary.

Conclusion (proposition de traduction) : Nos observations impliquent que les boîtes et les barrières plastiques pour l'intubation peuvent réduire l'exposition les techniciens de santé aux gouttelettes, mais qu'elles peuvent simplement rediriger les particules en aérosol, ce qui peut entraîner une exposition accrue aux aérosols dans certaines circonstances. Les aérosols peuvent rester à l'intérieur du dispositif de barrière après une toux et la manipulation de la boîte peut les libérer. Les patients doivent être placés de manière à faciliter l'intubation, mais un léger Trendelenburg inversé peut éloigner les aérosols infectieux de l'opérateur. Les nouveaux dispositifs de barrière doivent être utilisés avec prudence et des études de validation supplémentaires sont nécessaires.

The Clinical Use of Cricoid Pressure: First, Do No Harm.
Zdravkovic M, Rice MJ, Brull SJ. | Anesth Analg. 2021 Jan;132(1):261-267
DOI: https://doi.org/10.1213/ane.0000000000004360
Keywords: Aucun

Special Article

Editorial : Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a "standard" of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration.

Conclusion : Appropriate power calculations, establishment of actual aspiration risk (using gastric ultrasound), implementing methods with highest sensitivity and specificity, development of a global database reporting system, and incorporating objective evaluation methods such as airway ultrasound are reasonable first steps in future research on the effectiveness of CP. The sad truth is we now rely on personal preference and “folklore” rather than evidence, because we have few high-quality scientific data on the effectiveness or safety of CP. Therefore, many anesthesiologists will continue to use CP, some might abandon it, while other clinicians might suggest ultrasonographically guided esophageal compression as its replacement. What we do know, however, is that, even when following a rigorous rapid sequence induction and intubation protocol using the best currently available techniques, the incidence of pulmonary aspiration is not zero. This fact should be universal knowledge and should be well explained in medico-legal situations. Unfortunately, pulmonary aspiration is always a potential complication that is not always preventable.

Conclusion (proposition de traduction) : Des calculs de puissance appropriés, l'établissement du risque d'inhalation réel (à l'aide de l'échographie gastrique), la mise en œuvre de méthodes avec la sensibilité et la spécificité les plus élevées, le développement d'un système de rapport de base de données mondiale et l'intégration de méthodes d'évaluation objectives telles que l'échographie des voies respiratoires sont des premières étapes raisonnables dans les recherches futures sur l'efficacité de la pression cricoïdienne. La triste vérité est que nous nous appuyons désormais sur les préférences personnelles et le « folklore » plutôt que sur des preuves, car nous disposons de peu de données scientifiques de haute qualité sur l'efficacité ou la sécurité de la pression cricoïdienne. Par conséquent, de nombreux anesthésistes continueront d'utiliser la pression cricoïdienne, certains pourraient l'abandonner, tandis que d'autres cliniciens pourraient suggérer une compression œsophagienne guidée par échographie en remplacement. Ce que nous savons, cependant, c'est que, même en suivant un protocole rigoureux d'induction et d'intubation à séquence rapide utilisant les meilleures techniques actuellement disponibles, l'incidence de l'inhalation pulmonaire n'est pas nulle. Ce fait doit être connu de tous et doit être bien expliqué dans les situations médico-légales. Malheureusement, l'inhalation pulmonaire est toujours une complication potentielle qui n'est pas toujours évitable.

Aerosol Retention Characteristics of Barrier Devices.
Fidler RL, Niedek CR, Teng JJ, Sturgeon ME, Zhang Q, Robinowitz DL, Hirsch J. | Anesthesiology. 2021 Jan 1;134(1):61-71.
DOI: https://doi.org/10.1097/aln.0000000000003597  | Télécharger l'article au format  
Keywords: Aucun

Perioperative Medicine: Basic Science

Introduction : Disease severity in coronavirus disease 2019 (COVID-19) may be associated with inoculation dose. This has triggered interest in intubation barrier devices to block droplet exposure; however, aerosol protection with these devices is not known. This study hypothesized that barrier devices reduce aerosol outside of the barrier.

Méthode : Aerosol containment in closed, semiclosed, semiopen, and open barrier devices was investigated: (1) "glove box" sealed with gloves and caudal drape, (2) "drape tent" with a drape placed over a frame, (3) "slit box" with armholes and caudal end covered by vinyl slit diaphragms, (4) original "aerosol box," (5) collapsible "interlocking box," (6) "simple drape" over the patient, and (7) "no barrier." Containment was investigated by (1) vapor instillation at manikin's right arm with video-assisted visual evaluation and (2) submicrometer ammonium sulfate aerosol particles ejected through the manikin's mouth with ventilation and coughs. Samples were taken from standardized locations inside and around the barriers using a particle counter and a mass spectrometer. Aerosol evacuation from the devices was measured using standard hospital suction, a surgical smoke evacuator, and a Shop-Vac.

Résultats : Vapor experiments demonstrated leakage via arm holes and edges. Only closed and semiclosed devices and the aerosol box reduced aerosol particle counts (median [25th, 75th percentile]) at the operator's mouth compared to no barrier (combined median 29 [-11, 56], n = 5 vs. 157 [151, 166], n = 5). The other barrier devices provided less reduction in particle counts (133 [128, 137], n = 5). Aerosol evacuation to baseline required 15 min with standard suction and the Shop-Vac and 5 min with a smoke evacuator.

Conclusion : Barrier devices may reduce exposure to droplets and aerosol. With meticulous tucking, the glove box and drape tent can retain aerosol during airway management. Devices that are not fully enclosed may direct aerosol toward the laryngoscopist. Aerosol evacuation reduces aerosol content inside fully enclosed devices. Barrier devices must be used in conjunction with body-worn personal protective equipment.

Conclusion (proposition de traduction) : Les dispositifs barrière peuvent réduire l'exposition aux gouttelettes et aux aérosols. Grâce à un rangement méticuleux, la boîte à gants et la tente drapée peuvent retenir les aérosols pendant la gestion des voies respiratoires. Les appareils qui ne sont pas entièrement fermés peuvent diriger l'aérosol vers l'opérateur qui réalise la laryngoscopie. L'évacuation des aérosols réduit la teneur en aérosols à l'intérieur des appareils entièrement fermés. Les dispositifs barrière doivent être utilisés en conjonction avec un équipement de protection individuelle porté sur le corps.

Pulse Wave Analysis to Estimate Cardiac Output.
Kouz K, Scheeren TWL, de Backer D, Saugel B. | Anesthesiology. 2021 Jan 1;134(1):119-126
DOI: https://doi.org/10.1097/aln.0000000000003553
Keywords: Aucun

Education: Clinical Focus Review

Editorial : Cardiac output–guided therapy is a promising approach to hemodynamic management in high-risk patients having major surgery and in critically ill patients with circulatory shock. Pulmonary artery thermodilution remains the clinical reference method for cardiac output measurement, but the use of the pulmonary artery catheter decreased over the past two decades. Today, various cardiac output monitoring methods with different degrees of invasiveness are available, including pulse wave analysis. Pulse wave analysis is the mathematical analysis of the arterial blood pressure waveform and enables cardiac output to be estimated continuously and in real time. In this article, we review pulse wave analysis methods for cardiac output estimation, including their underlying measurement principles and their clinical application

Conclusion : Pulse wave analysis is the mathematical analysis of the arterial blood pressure waveform and enables cardiac output to be estimated continuously and in real time. In addition to cardiac output, pulse wave analysis allows assessing dynamic cardiac preload variables, i.e., pulse pressure variation and stroke volume variation that can be used to predict fluid responsiveness in patients with sinus rhythm and controlled mechanical ventilation. Pulse wave analysis methods are classified into invasive, minimally invasive, and noninvasive methods. Pulse wave analysis methods are further classified into externally calibrated, internally calibrated, and uncalibrated methods depending on the type of calibration they use to calibrate pulse wave analysis–derived cardiac output values. In high-risk patients having major surgery, pulse wave analysis–derived cardiac output and dynamic cardiac preload variables can be used for perioperative goal-directed therapy. In critically ill patients, pulse wave analysis–derived continuous real-time cardiac output estimations can be used to monitor cardiac output during tests of fluid responsiveness (fluid challenges or passive leg raising test).

Conclusion (proposition de traduction) : L'analyse des ondes de pouls est l'analyse mathématique de la forme d'onde de la pression artérielle et permet d'estimer le débit cardiaque en continu et en temps réel. En plus du débit cardiaque, l'analyse des ondes de pouls permet d'évaluer les variables de précharge cardiaque dynamique, c'est-à-dire la variation de la pression cardiaque et la variation du volume d'éjection systolique qui peuvent être utilisées pour prédire la réactivité du remplissage chez les patients présentant un rythme sinusal et une ventilation mécanique contrôlée. Les méthodes d'analyse des ondes de pouls sont classées en méthodes invasives, mini-invasives et non invasives. Les méthodes d'analyse des ondes de pouls sont ensuite classées en méthodes étalonnées en externe, étalonnées en interne et non étalonnées en fonction du type d'étalonnage qu'elles utilisent pour étalonner les valeurs de débit cardiaque dérivées de l'analyse des ondes de pouls. Chez les patients à haut risque subissant une intervention chirurgicale majeure, le débit cardiaque dérivé de l'analyse des ondes de pouls et les variables de précharge cardiaque dynamique peuvent être utilisés pour un traitement périopératoire orienté vers un objectif. Chez les patients de réanimation, les estimations du débit cardiaque continu en temps réel dérivées de l'analyse des ondes de pouls peuvent être utilisées pour surveiller le débit cardiaque pendant les tests de réactivité au remplissage (tests de fluidité ou test passif de levée de jambe).

Improved Testing and Design of Intubation Boxes During the COVID-19 Pandemic.
Turer DM, Good CH, Schilling BK, Turer RW, Karlowsky NR, Dvoracek LA, Ban H, Chang JS, Rubin JP. | Ann Emerg Med. 2021 Jan;77(1):1-10
DOI: https://doi.org/10.1016/j.annemergmed.2020.08.033  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : Throughout the coronavirus disease 2019 pandemic, many emergency departments have been using passive protective enclosures ("intubation boxes") during intubation. The effectiveness of these enclosures remains uncertain. We sought to quantify their ability to contain aerosols using industry standard test protocols.

Méthode : We tested a commercially available passive protective enclosure representing the most common design and compared this with a modified enclosure that incorporated a vacuum system for active air filtration during simulated intubations and negative-pressure isolation. We evaluated the enclosures by using the same 3 tests air filtration experts use to certify class I biosafety cabinets: visual smoke pattern analysis using neutrally buoyant smoke, aerosol leak testing using a test aerosol that mimics the size of virus-containing particulates, and air velocity measurements.

Résultats : Qualitative evaluation revealed smoke escaping from all passive enclosure openings. Aerosol leak testing demonstrated elevated particle concentrations outside the enclosure during simulated intubations. In contrast, vacuum-filter-equipped enclosures fully contained the visible smoke and test aerosol to standards consistent with class I biosafety cabinet certification.

Conclusion : Passive enclosures for intubation failed to contain aerosols, but the addition of a vacuum and active air filtration reduced aerosol spread during simulated intubation and patient isolation.

Conclusion (proposition de traduction) : Les enceintes passives pour l'intubation ne contenaient pas d'aérosols, mais l'ajout d'un vide et d'une filtration active de l'air a réduit la propagation des aérosols pendant l'intubation simulée et l'isolement du patient.

Oxygen Therapy and Risk of Infection for Health Care Workers Caring for Patients With Viral Severe Acute Respiratory Infection: A Systematic Review and Meta-analysis.
Cournoyer A, Grand'Maison S, Lonergan AM, Lessard J, Chauny JM, Castonguay V, Marquis M, Frégeau A, Huard V, Garceau-Tremblay Z, Turcotte AS, Piette É, Paquet J, Cossette S, Féral-Pierssens AL, Leblanc RX, Martel V, Daoust R. | Ann Emerg Med. 2021 Jan;77(1):19-31
DOI: https://doi.org/10.1016/j.annemergmed.2020.06.037  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : To synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Health care workers face significant risk of infection when treating patients with a viral severe acute respiratory infection. To ensure health care worker safety and limit nosocomial transmission of such infection, it is crucial to synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection.

Méthode : MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to April 1, 2020, for studies describing the risk of infection associated with the modalities of oxygen therapy used for patients with severe acute respiratory infection. The study selection, data extraction, and quality assessment were performed by independent reviewers. The primary outcome measure was the infection of health care workers with a severe acute respiratory infection. Random-effect models were used to synthesize the extracted data.

Résultats : Of 22,123 citations, 50 studies were eligible for qualitative synthesis and 16 for meta-analysis. Globally, the quality of the included studies provided a very low certainty of evidence. Being exposed or performing an intubation (odds ratio 6.48; 95% confidence interval 2.90 to 14.44), bag-valve-mask ventilation (odds ratio 2.70; 95% confidence interval 1.31 to 5.36), and noninvasive ventilation (odds ratio 3.96; 95% confidence interval 2.12 to 7.40) were associated with an increased risk of infection. All modalities of oxygen therapy generate air dispersion.

Conclusion : Most modalities of oxygen therapy are associated with an increased risk of infection and none have been demonstrated as safe. The lowest flow of oxygen should be used to maintain an adequate oxygen saturation for patients with severe acute respiratory infection, and manipulation of oxygen delivery equipment should be minimized.

Conclusion (proposition de traduction) : La plupart des modalités d'oxygénothérapie sont associées à un risque accru d'infection et aucune n'a été démontrée comme sûre. Le débit d'oxygène le plus bas doit être utilisé pour maintenir une saturation en oxygène adéquate pour les patients souffrant d'une infection respiratoire aiguë sévère, et la manipulation de l'équipement d'administration d'oxygène doit être minimisée.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Community-Acquired Pneumonia, Smith MD, Fee C, Mace SE, Maughan B, Perkins JC Jr, Kaji A, Wolf SJ. | Ann Emerg Med. 2021 Jan;77(1):e1-e57
DOI: https://doi.org/10.1016/j.annemergmed.2020.10.024
Keywords: Aucun

Infectious Disease

Editorial : This clinical policy from the American College of Emergency Physicians is a revision of the 2009

Conclusion : There is lack ofevidence to support or refute that the useof a single dose of parenteral antibiotics in adult ED patients with a diagnosis ofCAP followed by oral treatment with antibiotics improves outcomes compared with oral treatment alone. Clinicians may consider using this practice guided by patient risk profiles and preferences and should engage in shared decision making.

Conclusion (proposition de traduction) : Il n'y a pas de preuves pour soutenir ou réfuter que l'utilisation d'une dose unique d'antibiotiques en parentéral chez les patients adultes aux urgences avec un diagnostic de pneumonie communautaire suivie d'un traitement oral avec des antibiotiques améliore les résultats par rapport au traitement oral seul. Les cliniciens peuvent envisager d'utiliser cette pratique en fonction des profils de risque et des préférences des patients et devraient participer à une prise de décision partagée.

Lung ultrasound score predicts outcomes in COVID-19 patients admitted to the emergency department.
de Alencar JCG, Marchini JFM, Marino LO, da Costa Ribeiro SC, Bueno CG, da Cunha VP, Lazar Neto F, Brandão Neto RA, Souza HP; COVID U. S. P. Registry Team. | Ann Intensive Care. 2021 Jan 11;11(1):6
DOI: https://doi.org/10.1186/s13613-020-00799-w  | Télécharger l'article au format  
Keywords: COVID-19; Critical care; Emergency medicine; Severe acute respiratory syndrome coronavirus 2; Ultrasonography.

Research

Introduction : During the COVID-19 pandemic, creating tools to assess disease severity is one of the most important aspects of reducing the burden on emergency departments. Lung ultrasound has a high accuracy for the diagnosis of pulmonary diseases; however, there are few prospective studies demonstrating that lung ultrasound can predict outcomes in COVID-19 patients. We hypothesized that lung ultrasound score (LUS) at hospital admission could predict outcomes of COVID-19 patients.

Méthode : This is a prospective cohort study conducted from 14 March through 6 May 2020 in the emergency department (ED) of an urban, academic, level I trauma center. Patients aged 18 years and older and admitted to the ED with confirmed COVID-19 were considered eligible. Emergency physicians performed lung ultrasounds and calculated LUS, which was tested for correlation with outcomes.

Résultats : The primary endpoint was death from any cause. The secondary endpoints were ICU admission and endotracheal intubation for respiratory failure. Among 180 patients with confirmed COVID-19 who were enrolled (mean age, 60 years; 105 male), the average LUS was 18.7 ± 6.8. LUS correlated with findings from chest CT and could predict the estimated extent of parenchymal involvement (mean LUS with < 50% involvement on chest CT, 15 ± 6.7 vs. 21 ± 6.0 with > 50% involvement, p < 0.001), death (AUC 0.72, OR 1.13, 95% CI 1.07 to 1.21; p < 0.001), endotracheal intubation (AUC 0.76, OR 1.17, 95% CI 1.09 to 1.26; p < 0.001), and ICU admission (AUC: 0.71, OR 1.14, 95% CI 1.07 to 1.21; p < 0.001).

Conclusion : In COVID-19 patients admitted in ED, LUS was a good predictor of death, ICU admission, and endotracheal intubation.

Conclusion (proposition de traduction) : Chez les patients COVID-19 admis aux urgences, le score échographique pulmonaire était un bon prédicteur de décès, d'admission en soins intensifs et d'intubation endotrachéale.

Performance of the ROX index to predict intubation in immunocompromised patients receiving high-flow nasal cannula for acute respiratory failure.
Lemiale V, Dumas G, Demoule A, Pène F, Kouatchet A, Bisbal M, Nseir S, Argaud L, Kontar L, Klouche K, Barbier F, Seguin A, Louis G, Constantin JM, Mayaux J, Wallet F, Peigne V, Girault C, Oziel J, Nyunga M, Terzi N, Bouadma L, Lautrette A, Bige N, Raphalen JH, Papazian L, Bruneel F, Lebert C, Benoit D, Meert AP, Jaber S, Mokart D, Darmon M, Azoulay E; Groupe de Recherche en Reanimation Respiratoire du patient d’Onco-Hématologie (GRRR-OH). | Ann Intensive Care. 2021 Jan 27;11(1):17
DOI: https://doi.org/10.1186/s13613-021-00801-z  | Télécharger l'article au format  
Keywords: Acute respiratory failure; High-flow nasal oxygen; Immunocompromised.

Research

Introduction : Delayed intubation is associated with high mortality. There is a lack of objective criteria to decide the time of intubation. We assessed a recently described combined oxygenation index (ROX index) to predict intubation in immunocompromised patients.

Méthode : The study is a secondary analysis of randomized trials in immunocompromised patients, including all patients who received high-flow nasal cannula (HFNC). The first objective was to evaluate the accuracy of the ROX index to predict intubation for patients with acute respiratory failure.

Résultats : In the study, 302 patients received HFNC. Acute respiratory failure was mostly related to pneumonia (n = 150, 49.7%). Within 2 (1-3) days, 115 (38.1%) patients were intubated. The ICU mortality rate was 27.4% (n = 83). At 6 h, the ROX index was lower for patients who needed intubation compared with those who did not [4.79 (3.69-7.01) vs. 6.10 (4.48-8.68), p < 0.001]. The accuracy of the ROX index to predict intubation was poor [AUC = 0.623 (0.557-0.689)], with low performance using the threshold previously found (4.88). In multivariate analysis, a higher ROX index was still independently associated with a lower intubation rate (OR = 0.89 [0.82-0.96], p = 0.04).

Conclusion : A ROX index greater than 4.88 appears to have a poor ability to predict intubation in immunocompromised patients with acute respiratory failure, although it remains highly associated with the risk of intubation and may be useful to stratify such risk in future studies.

Conclusion (proposition de traduction) : Un indice ROX supérieur à 4,88 semble avoir une faible capacité à prédire l'intubation chez les patients immunodéprimés souffrant d'insuffisance respiratoire aiguë, bien qu'il reste fortement associé au risque d'intubation et puisse être utile pour stratifier ce risque dans les études futures.

Current use of inotropes in circulatory shock.
Scheeren TWL, Bakker J, Kaufmann T, Annane D, Asfar P, Boerma EC, Cecconi M, Chew MS, Cholley B, Cronhjort M, De Backer D, Dubin A, Dünser MW, Duranteau J, Gordon AC, Hajjar LA, Hamzaoui O, Hernandez G, Kanoore Edul V, Koster G, Landoni G, Leone M, Levy B, Martin C, Mebazaa A, Monnet X, Morelli A, Payen D, Pearse RM, Pinsky MR, Radermacher P, Reuter DA, Sakr Y, Sander M, Saugel B, Singer M, Squara P, Vieillard-Baron A, Vignon P, Vincent JL, van der Horst ICC,. | Ann Intensive Care. 2021 Jan 29;11(1):21
DOI: https://doi.org/10.1186/s13613-021-00806-8  | Télécharger l'article au format  
Keywords: Acute circulatory failure; Cardiac output; Cardiogenic shock; Catecholamines; Inotropes; Levosimendan; PDE-inhibitors; Resuscitation; Sepsis; Septic shock; Vasoactive agents.

Research

Introduction : Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock.

Méthode : From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions.

Résultats : A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81-90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement).

Conclusion : Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.

Conclusion (proposition de traduction) : L'utilisation d'inotrope chez les patients de réanimation est assez hétérogène selon les auto-déclarations individuels des soignants. Onze recommandations fortes sur les indications, le choix, les déclencheurs et les cibles pour l'utilisation des inotropes sont données par des experts internationaux. Les études futures devraient se concentrer sur des indications cohérentes pour l'utilisation et la mise en œuvre des inotropes dans une directive pour le choc circulatoire qui englobe des objectifs et des résultats individualisés.

Commentaire :  Résumé du consensus entre experts et du degré des recommandations

Prehospital arterial hypercapnia in acute heart failure is associated with admission to acute care units and emergency room length of stay: a retrospective cohort study.
Fabre M, Fehlmann CA, Gartner B, Zimmermann-Ivoll CG, Rey F, Sarasin F, Suppan L. | BMC Emerg Med. 2021 Jan 26;21(1):14
DOI: https://doi.org/10.1186/s12873-021-00411-9  | Télécharger l'article au format  
Keywords: Acute heart failure; Arterial blood gas; Prehospital.

Research article

Introduction : Acute Heart Failure (AHF) is a common condition that often presents with acute respiratory distress and requires urgent medical evaluation and treatment. Arterial hypercapnia is common in AHF and has been associated with a higher rate of intubation and non-invasive ventilation in the Emergency Room (ER), but its prognostic value has never been studied in the prehospital setting.

Méthode : A retrospective study was performed on the charts of all patients taken care of by a physician-staffed prehospital mobile unit between June 2016 and September 2019 in Geneva. After approval by the ethics committee, charts were screened to identify all adult patients with a diagnosis of AHF in whom a prehospital arterial blood gas (ABG) sample was drawn. The main predictor was prehospital hypercapnia. The primary outcome was the admission rate in an acute care unit (ACU, composite of intensive care and high-dependency units). Secondary outcomes were ER length of stay (LOS), orientation from ER (intensive care unit, high-dependency unit, general ward, discharge home), intubation rate at 24 h, hospital LOS and hospital mortality.

Résultats : A total of 106 patients with a diagnosis of AHF were analysed. Hypercapnia was found in 61 (58%) patients and vital signs were more severely altered in this group. The overall ACU admission rate was 48%, with a statistically significant difference between hypercapnic and non-hypercapnic patients (59% vs 33%, p = 0.009). ER LOS was shorter in hypercapnic patients (5.4 h vs 8.9 h, p = 0.016).

Conclusion : There is a significant association between prehospital arterial hypercapnia, acute care unit admission, and ER LOS in AHF patients.

Conclusion (proposition de traduction) : Il existe une association significative entre l'hypercapnie artérielle préhospitalière, l'admission en unité de soins de courte durée et la durée du séjour aux urgences chez les patients souffrant d'insuffisance cardiaque aiguë.

Comparison of hypoxemia, intubation procedure, and complications for non-invasive ventilation against high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure: a non-randomized retrospective analysis for effectiveness and safety (NIVaHIC-aHRF).
Zhang C, Ou M. | BMC Emerg Med. 2021 Jan 14;21(1):6
DOI: https://doi.org/10.1186/s12873-021-00402-w  | Télécharger l'article au format  
Keywords: High-flow oxygen therapy; Hypoxia; Intubation; Laryngoscopy; Non-invasive ventilation; Preoxygenation.

Research article

Introduction : Optimization of preoxygenation procedure can help to secure the method of intubation by reducing the risks of severe hypoxemia and other problems. There is confusion for efficacy of non-invasive ventilation compared to high-flow oxygen therapy regarding occurrence of severe hypoxemia during the intubation procedure. The purpose of the study was to compare the difference between noninvasive ventilation and high flow oxygen therapy to prevent desaturation during laryngoscopy.

Méthode : Patients underwent high-flow nasal cannula oxygen therapy (HCO cohort, n = 161) or non-invasive ventilation procedure (NIV cohort, n = 154) for oxygenation and ventilation due to acute hypoxemic respiratory failure in the intensive care unit. Data before preoxygenation, preoxygenation, intubation, laryngoscopy, and complications of patients due to tracheal intubation were retrospectively collected and analyzed.

Résultats : There was no difference between both cohorts for the demographical and clinical conditions of the patients before preoxygenation (p > 0.05 for all parameters), numbers of patients with severe hypoxia during the intubation procedure (35 vs. 45, p = 0.303), the time duration of laryngoscopy (p = 0.847), number of laryngoscopies attempts (p = 0.804), and immediate and late complications during the intubation procedure. The values of pulse oximetry were reported higher for patients of NIV cohort than those of HCO cohort during preoxygenation. Fewer numbers of patients were reported with severe hypoxia among patients of the NIV cohort than those of the HCO cohort (24 vs., 40, p = 0.042) who have moderate-to-severe hypoxemia (partial pressure of arterial oxygen to fraction of inspired oxygen ratio ≤ 200 mmHg) before preoxygenation. The most common complications were hypertension, pulmonary aspiration, and increased 30-day mortality.

Conclusion : When compared, there was no difference between non-invasive ventilation technique and high-flow oxygen therapy to minimize severe hypoxia prior to laryngoscopy and endotracheal intubation in patients with acute respiratory failure.

Conclusion (proposition de traduction) : En comparaison, il n'y avait aucune différence entre la technique de ventilation non invasive et l'oxygénothérapie à haut débit pour minimiser l'hypoxie sévère avant la laryngoscopie et l'intubation endotrachéale chez les patients présentant une insuffisance respiratoire aiguë.

Association between prehospital prognostic factors on out-of-hospital cardiac arrest in different age groups.
Huang JB, Lee KH, Ho YN, Tsai MT, Wu WT, Cheng FJ. | BMC Emerg Med. 2021 Jan 7;21(1):3
DOI: https://doi.org/10.1186/s12873-020-00400-4  | Télécharger l'article au format  
Keywords: Age; Bystander CPR; Defibrillation; Out-of-hospital cardiac arrest; Prehospital.

Research article

Introduction : The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. While several prehospital factors are known to be associated with improved survival, the impact of prehospital factors on different age groups is unclear. The objective of the study was to access the impact of prehospital factors and pre-existing comorbidities on OHCA outcomes in different age groups.

Méthode : A retrospective observational analysis was conducted using the emergency medical service (EMS) database from January 2015 to December 2019. We collected information on prehospital factors, underlying diseases, and outcome of OHCAs in different age groups. Kaplan-Meier type survival curves and multivariable logistic regression were used to analyze the association between modifiable pre-hospital factors and outcomes.

Résultats : A total of 4188 witnessed adult OHCAs were analyzed. For the age group 1 (age ≦75 years old), after adjustment for confounding factors, EMS response time (odds ratio [OR] = 0.860, 95% confidence interval [CI]: 0.811-0.909, p < 0.001), public location (OR = 1.843, 95% CI: 1.179-1.761, p < 0.001), bystander CPR (OR = 1.329, 95% CI: 1.007-1.750, p = 0.045), attendance by an EMT-Paramedic (OR = 1.666, 95% CI: 1.277-2.168, p < 0.001), and prehospital defibrillation by automated external defibrillator (AED)(OR = 1.666, 95% CI: 1.277-2.168, p < 0.001) were prognostic factors for survival to hospital discharge in OHCA patients. For the age group 2 (age > 75 years old), age (OR = 0.924, CI:0.880-0.966, p = 0.001), EMS response time (OR = 0.833, 95% CI: 0.742-0.928, p = 0.001), public location (OR = 4.290, 95% CI: 2.450-7.343, p < 0.001), and attendance by an EMT-Paramedic (OR = 2.702, 95% CI: 1.704-4.279, p < 0.001) were independent prognostic factors for survival to hospital discharge in OHCA patients.

Conclusion : There were variations between younger and older OHCA patients. We found that bystander CPR and prehospital defibrillation by AED were independent prognostic factors for younger OHCA patients but not for the older group.

Conclusion (proposition de traduction) : Il y avait des variations entre les patients en arrêt cardiaque non hospitalisés plus jeunes et plus âgés. Nous avons constaté que la réanimation cardio-respiratoire et la défibrillation préhospitalière par défibrillateur externe automatisé étaient des facteurs pronostiques indépendants pour les patients jeunes en arrêt cardiaque non hospitalisés, mais pas pour le groupe plus âgé.

Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial.
Grassin-Delyle S, Shakur-Still H, Picetti R, Frimley L, Jarman H, Davenport R, McGuinness W, Moss P, Pott J, Tai N, Lamy E, Urien S, Prowse D, Thayne A, Gilliam C, Pynn H, Roberts I. | Br J Anaesth. 2021 Jan;126(1):201-209
DOI: https://doi.org/10.1016/j.bja.2020.07.058  | Télécharger l'article au format  
Keywords: antifibrinolytic; clinical trial; haemorrhage; intramuscular; tranexamic acid; trauma.

CRITICAL CARE

Introduction : Intravenous tranexamic acid (TXA) reduces bleeding deaths after injury and childbirth. It is most effective when given early. In many countries, pre-hospital care is provided by people who cannot give i.v. injections. We examined the pharmacokinetics of intramuscular TXA in bleeding trauma patients.

Méthode : We conducted an open-label pharmacokinetic study in two UK hospitals. Thirty bleeding trauma patients received a loading dose of TXA 1 g i.v., as per guidelines. The second TXA dose was given as two 5 ml (0·5 g each) i.m. injections. We collected blood at intervals and monitored injection sites. We measured TXA concentrations using liquid chromatography coupled to mass spectrometry. We assessed the concentration time course using non-linear mixed-effect models with age, sex, ethnicity, body weight, type of injury, signs of shock, and glomerular filtration rate as possible covariates.

Résultats : Intramuscular TXA was well tolerated with only mild injection site reactions. A two-compartment open model with first-order absorption and elimination best described the data. For a 70-kg patient, aged 44 yr without signs of shock, the population estimates were 1.94 h-1 for i.m. absorption constant, 0.77 for i.m. bioavailability, 7.1 L h-1 for elimination clearance, 11.7 L h-1 for inter-compartmental clearance, 16.1 L volume of central compartment, and 9.4 L volume of the peripheral compartment. The time to reach therapeutic concentrations (5 or 10 mg L-1) after a single intramuscular TXA 1 g injection are 4 or 11 min, with the time above these concentrations being 10 or 5.6 h, respectively.

Conclusion : In bleeding trauma patients, intramuscular TXA is well tolerated and rapidly absorbed.

Conclusion (proposition de traduction) : Chez les patients ayant subi un traumatisme avec hémorragie, l'acide tranexamique intramusculaire est bien toléré et rapidement absorbé.

Higher vs Lower Oxygenation Strategies in Acutely Ill Adults: A Systematic Review With Meta-Analysis and Trial Sequential Analysis.
Barbateskovic M, Schjørring OL, Krauss SR, Meyhoff CS, Jakobsen JC, Rasmussen BS, Perner A, Wetterslev J. | Chest. 2021 Jan;159(1):154-173
DOI: https://doi.org/10.1016/j.chest.2020.07.015
Keywords: critical care; meta-analysis; mortality; oxygen; systematic review.

Original Research

Introduction : Liberal oxygen supplementation is often used in acute illness but has, in some studies, been associated with harm.
Research question: The goal of this study was to assess the benefits and harms of higher vs lower oxygenation strategies in acutely ill adults.

Méthode : This study was an updated systematic review with meta-analysis and Trial Sequential Analysis (TSA) of randomized clinical trials. A clear differentiation (separation) was made between a higher (liberal) oxygenation and a lower (conservative) oxygenation strategy and their effects on all-cause mortality, serious adverse events, quality of life, lung injury, sepsis, and cardiovascular events at time points closest to 90 days in acutely ill adults.

Résultats : The study included 50 randomized clinical trials of 21,014 participants; 36 trials with a total of 20,166 participants contributed data to the analyses. Meta-analysis and TSAs showed no difference between higher and lower oxygenation strategies in trials at overall low risk of bias except for blinding: mortality relative risk (RR), 0.98 (95% CI, 0.89-1.09; TSA-adjusted CI, 0.86-1.12; low certainty evidence); serious adverse events RR, 0.99 (95% CI, 0.89-1.12; TSA-adjusted CI, 0.83-1.19; low certainty evidence). The corresponding summary estimates including trials with overall low and high risk of bias showed similar results. No difference was found between higher and lower oxygenation strategies in meta-analyses and TSAs regarding quality of life, lung injury, sepsis, and cardiovascular events (very low certainty evidence).

Conclusion : No evidence was found of beneficial or harmful effects of higher vs lower oxygenation strategies in acutely ill adults (low to very low certainty evidence).

Conclusion (proposition de traduction) : On n’a trouvé aucune preuve d’effets bénéfiques ou nocifs pour les stratégies d’oxygénation plus élevées versus plus faibles chez les adultes présentant une maladie aiguë (évidence de faible à très faible certitude).

Lung Ultrasound for Patients With Coronavirus Disease 2019 Pulmonary Disease.
Millington SJ, Koenig S, Mayo P, Volpicelli G. | Chest. 2021 Jan;159(1):205-211
DOI: https://doi.org/10.1016/j.chest.2020.08.2054  | Télécharger l'article au format  
Keywords: acute lung injury; critical care; lung ultrasound.

How I Do It

Editorial : Given the general utility of lung ultrasound for the evaluation of respiratory failure in acutely ill patients, it is logical to consider its specific advantages in coronavirus disease 2019-related pulmonary disease. The authors, representing the extensive experience of the North American and European coronavirus disease 2019 epicenters, present an ultrasound scanning protocol and report on the common associated ultrasound findings.

Conclusion : Although the specific role for LUS in the management of COVID-19 is still evolving, its utility in the management of patients with respiratory failure in general is very well established. Given the severity of illness associated with this particular pathogen and the need for strict isolation protocols, there is evidence to suggest that LUS will emerge as the best available imaging modality for these patients.

Conclusion (proposition de traduction) : Bien que le rôle spécifique de l'échographie pulmonaire dans la prise en charge de la COVID-19 évolue encore, son utilité dans la prise en charge des patients souffrant d'insuffisance respiratoire en général est très bien établie. Compte tenu de la gravité de la maladie associée à ce pathogène particulier et de la nécessité de protocoles d'isolement stricts, il existe des preuves suggérant que l'échographie pulmonaire apparaîtra comme la meilleure modalité d'imagerie disponible pour ces patients.

Early corticosteroids are associated with lower mortality in critically ill patients with COVID-19: a cohort study.
Monedero P, Gea A, Castro P, Candela-Toha AM, Hernández-Sanz ML, Arruti E, Villar J, Ferrando C; COVID-19 Spanish ICU Network. | Crit Care. 2021 Jan 4;25(1):2
DOI: https://doi.org/10.1186/s13054-020-03422-3  | Télécharger l'article au format  
Keywords: COVID-19; Cohort study; Corticosteroids; Critically ill patient; Intensive Care Unit; Mortality; Outcomes; Ventilator-free days.

Research

Introduction : Critically ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, although there are still some concerns regarding its use, timing, and dose.

Méthode : This is a nationwide, prospective, multicenter, observational, cohort study in critically ill adult patients with COVID-19 admitted into Intensive Care Units (ICU) in Spain from 12th March to 29th June 2020. Using a multivariable Cox model with inverse probability weighting, we compared relevant outcomes between patients treated with early corticosteroids (before or within the first 48 h of ICU admission) with those who did not receive early corticosteroids (delayed group) or any corticosteroids at all (never group). Primary endpoint was ICU mortality. Secondary endpoints included 7-day mortality, ventilator-free days, and complications.

Résultats : A total of 691 patients out of 882 (78.3%) received corticosteroid during their hospital stay. Patients treated with early-corticosteroids (n = 485) had lower ICU mortality (30.3% vs. never 36.6% and delayed 44.2%) and lower 7-day mortality (7.2% vs. never 15.2%) compared to non-early treated patients. They also had higher number of ventilator-free days, less length of ICU stay, and less secondary infections than delayed treated patients. There were no differences in medical complications between groups. Of note, early use of moderate-to-high doses was associated with better outcomes than low dose regimens.

Conclusion : Early use of corticosteroids in critically ill patients with COVID-19 is associated with lower mortality than no or delayed use, and fewer complications than delayed use.

Conclusion (proposition de traduction) : L'utilisation précoce de corticostéroïdes chez les patients de réanimation atteints de la COVID-19 est associée à une mortalité plus faible qu'une utilisation nulle ou retardée, et moins de complications qu'une utilisation retardée.

Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?".
Godoy DA, Badenes R, Pelosi P, Robba C. | Crit Care. 2021 Jan 6;25(1):19
DOI: https://doi.org/10.1186/s13054-020-03452-x  | Télécharger l'article au format  
Keywords: Agitation; Cooperative sedation; Ketamine; Neuroprotection; Secondary insult; Sedation; Traumatic brain injury.

Viewpoint

Editorial : Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.

Conclusion : In conclusion, due to its specific pharmacological and pharmacokinetics characteristics, including neuromodulation properties, ketamine might be considered as a potential drug to optimize analgesia and sedation in the management of mechanically ventilated patients with severe TBI in association with other sedatives agents. Further, the versatility and safety profile of ketamine makes it a reliable tool in the prehospital environment. Adequately powered, randomized controlled trials and new guidelines should aim to refining the role and place of ketamine in patients with traumatic brain injury.

Conclusion (proposition de traduction) : En conclusion, en raison de ses caractéristiques pharmacologiques et pharmacocinétiques spécifiques, y compris ses propriétés de neuromodulation, la kétamine pourrait être considérée comme un médicament potentiel pour optimiser l'analgésie et la sédation dans la prise en charge des patients sous ventilation mécanique présentant un traumatisme crânien sévère en association avec d'autres agents sédatifs. De plus, la polyvalence et le profil de sécurité de la kétamine en font un outil fiable dans l'environnement préhospitalier. Des essais contrôlés randomisés de puissance adéquate et de nouvelles lignes directrices devraient viser à affiner le rôle et la place de la kétamine chez les patients souffrant de traumatisme crânien.

Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study.
Zieleskiewicz L, Lopez A, Hraiech S, Baumstarck K, Pastene B, Di Bisceglie M, Coiffard B, Duclos G, Boussuges A, Bobbia X, Einav S, Papazian L, Leone M. | Crit Care. 2021 Jan 22;25(1):34
DOI: https://doi.org/10.1186/s13054-021-03466-z  | Télécharger l'article au format  
Keywords: Handheld ultrasound device; In-hospital emergencies; POCUS; Rapid response team.

Research

Introduction : Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes.

Méthode : A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group).

Résultats : We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10-25] min vs. 34 [15-40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53).

Conclusion : Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure.

Conclusion (proposition de traduction) : Notre étude suggère que l'utilisation par protocole d'un dispositif portable d'échographie au point d'intervention du patient hospitalisé peut améliorer la proportion de diagnostics adéquats, le temps jusqu'au traitement initial et peut-être aussi la survie des patients du service développant une insuffisance respiratoire ou circulatoire aiguë.

Prehospital clinical signs are a poor predictor of raised intracranial pressure following traumatic brain injury.
Ter Avest E, Taylor S, Wilson M, Lyon RL. | Emerg Med J. 2021 Jan;38(1):21-26
DOI: https://doi.org/10.1136/emermed-2020-209635  | Télécharger l'article au format  
Keywords: head; pre-hospital; trauma; treatment.

Original research

Introduction : For the prehospital diagnosis of raised intracranial pressure (ICP), clinicians are reliant on clinical signs such as the Glasgow Coma Score (GCS), pupillary response and/or Cushing's triad (hypertension, bradycardia and an irregular breathing pattern). This study aimed to explore the diagnostic accuracy of these signs as indicators of a raised ICP.

Méthode : We performed a retrospective cohort study of adult patients attended by a Helicopter Emergency Medical Service (Air Ambulance Kent, Surrey Sussex), who had sustained a traumatic brain injury (TBI), requiring prehospital anaesthesia between 1 January 2016 and 1 January 2018. We established optimal cut-off values for clinical signs to identify patients with a raised ICP and investigated diagnostic accuracy for combinations of these values.

Résultats : Outcome data for 249 patients with TBI were available, of which 87 (35%) had a raised ICP. Optimal cut-off points for systolic blood pressure (SBP), heart rate (HR) and pupil diameter to discriminate patients with a raised ICP were, respectively, >160 mm Hg,<60 bpm and >5 mm. Cushing criteria (SBP >160 mm Hg and HR <60 bpm) and pupillary response and size were complimentary in their ability to detect patients with a raised ICP. The presence of a fixed blown pupil or a Cushing's response had a specificity of 93.2 (88.2-96.6)%, and a positive likelihood ratio (LR+) of 5.4 (2.9-10.2), whereas sensitivity and LR- were only 36.8 (26.7-47.8)% and 0.7 (0.6-0.8), respectively, (Area Under the Curve (AUC) 0.65 (0.57-0.73)). Sensitivity analysis revealed that optimal cut-off values and resultant accuracy were dependent on injury pattern.

Conclusion : Traditional clinical signs of raised ICP may under triage patients to prehospital treatment with hyperosmolar drugs. Further research should identify more accurate clinical signs or alternative non-invasive diagnostic aids in the prehospital environment.

Conclusion (proposition de traduction) : Les signes cliniques traditionnels d'augmentation de la pression intracrânienne peuvent sous-trier les patients candidat à un traitement préhospitalier avec des médicaments hyperosmolaires. Des recherches plus poussées devraient identifier des signes cliniques plus précis ou d'autres aides diagnostiques non invasives en milieu préhospitalier.

Effect of wrist dorsiflexion on ultrasound-guided radial artery catheterisation using dynamic needle tip positioning technique in adult patients: a randomised controlled clinical trial.
Xiao Q, Xu D, Zhuang S. | Emerg Med J. 2021 Jan 26;38(7):524–8
DOI: https://doi.org/10.1136/emermed-2020-209504  | Télécharger l'article au format  
Keywords: ultrasound; vascular-arterial.

IMAGING

Introduction : It is generally recommended to keep the wrist joint mildly dorsiflexed during radial artery catheterisation. However, wrist dorsiflexion might decrease the success rate of radial artery catheterisation with dynamic needle tip positioning technique. Therefore, we assessed the success rates of two groups with or without wrist dorsiflexion by 5 cm wrist elevation in adult patients.

Méthode : This randomised controlled clinical trial was performed between March and December 2018 in the First Affiliated Hospital of Shantou University Medical College, China. We recruited 120 adult patients undergoing major surgical procedures and randomly allocated them into two groups: dorsiflexion group (group D) and neutral group (group N). The primary outcome was first-attempt success rates of two groups. Secondary outcomes were overall success rates within 5 min; numbers of insertion and cannulation attempts; overall catheterisation time; duration of localisation, insertion and cannulation; and complication rates of catheterisation.

Résultats : First-attempt success rate was 88.3% in group D and 81.7% in group N (p=0.444). The overall success rate within 5 min was 93.3% in group D compared with 90.0% in group N (p=0.743). Numbers of insertion and cannulation attempts, overall catheterisation time, duration of localisation and insertion, and complication rates did not show a significant difference between the two groups. Cannulation time was longer in group N (35.68 s) than that in group D (26.19 s; p<0.05).

Conclusion : Wrist dorsiflexion may not be a necessity for ultrasound-guided radial artery catheterisation using dynamic needle tip positioning technique in adult patients.

Conclusion (proposition de traduction) : La dorsiflexion du poignet peut ne pas être une nécessité pour le cathétérisme de l'artère radiale guidé par ultrasons utilisant la technique de positionnement dynamique de la pointe de l'aiguille chez les patients adultes.

Effect of oxygen supply on mortality in acute ST-elevation myocardial infarction: systematic review and meta-analysis.
Alves M, Prada L, Costa J, Ferreira JJ, Pinto FJ, Caldeira D. | Eur J Emerg Med. 2021 Jan 1;28(1):11-18
DOI: https://doi.org/10.1097/mej.0000000000000764
Keywords: acute coronary syndrome, angina, coronary artery disease, coronary disease, chest pain, myocardial infarction, oxygen

Review

Editorial : Previous studies stated that high oxygen supply in patients with myocardial infarction (MI) was not associated with improved outcomes. However, the particularities of ST-elevation myocardial infarction (STEMI) and the results of a recent trial raised the question if this subgroup of patients benefits from high oxygen supply. This study aims to evaluate the clinical effect of high oxygen supply in patients with STEMI using a systematic review of the available literature. All randomized controlled trials (RCTs) evaluating the systematic use of high oxygen (6 L/min or higher) versus room air or lower oxygen supply in STEMI patients were included. Systematic review with meta-analysis of trials retrieved in July 2020. Six databases were searched. The confidence in the pooled estimates was ascertained through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Risk of bias was evaluated using the Cochrane risk of bias tool. There were five eligible RCTs (7703 patients). High oxygen supply was associated with a significant risk reduction of short-term mortality [risk ratio (RR) 0.83; 95% confidence interval (CI), 0.70-0.98; I2 = 0%]. Mortality (longest follow-up) (RR 0.83; 95% CI, 0.71-0.97; I2 = 0%) and heart failure (RR 0.84; 95% CI, 0.60-1.18; I2 = 0%) did not present a risk reduction. Recurrent MI presented a contradictory result, favouring the lower oxygen protocol (RR 1.47; 95% CI, 0.84-2.56; I2 = 0%). The GRADE analysis was very low. High oxygen supply may be associated with a decrease in short-term mortality in STEMI patients, but the pooled data are not robust enough to allow definitive conclusions.

Conclusion : The present data suggest that high oxygen supply may be associated with a decrease of short-term mortality, but the pooled data are not robust precluding definite con- clusions. Further trials with improved methodological features are encouraged to better prioritize the strategies that may improve the prognosis in STEMI patients.

Conclusion (proposition de traduction) : Les données actuelles suggèrent qu'un apport élevé en oxygène peut être associé à une diminution de la mortalité à court terme, mais les données mises en commun ne sont pas solides, ce qui empêche des conclusions définitives. D'autres essais avec des caractéristiques méthodologiques améliorées sont encouragés pour mieux prioriser les stratégies susceptibles d'améliorer le pronostic chez les patients STEMI.

Agreement between emergency physicians and radiologists for the diagnosis of deep venous thrombosis with compression ultrasound: a prospective study.
Elsenga HE, Collée A, Rosendaal AV. | Eur J Emerg Med. 2021 Jan 1;28(1):25-28
DOI: https://doi.org/10.1097/mej.0000000000000728
Keywords: Aucun

Original Article

Introduction : The time factor in diagnosis and management of a deep vein thrombosis of the lower extremities (LE DVT) is of increasing importance in the era of crowding of emergency departments (ED). Current techniques used to detect LE DVT include a two-point regional compression ultrasound (rCUS), yet assessments are usually performed only during office hours. Outside office hours ultrasonography is postponed and low molecular weight heparin (LMWH) prescribed.
Objectives: Primary outcome of the study was to assess the level of agreement in rCUS for LE DVT when performed by Dutch emergency physicians compared to rCUS by a radiologist. Secondary outcome was time to diagnosis.

Méthode : We performed a single-blind cohort study. All consecutive patients aged 18 years and older attending the ED with clinical suspicion of LE DVT were considered eligible for study enrolment. rCUS was ordered at the radiology department; subsequently, the bedside rCUS examination was also performed in the ED by the emergency physicians or ED residents.

Résultats : A total of 138 patients were included, of whom 28 patients were diagnosed with DVT by a radiologist. Emergency physicians and radiologists showed comparable agreement [absolute agreement 94% (P < 0.001), Cohen's Kappa 0.87]. Emergency physicians decreased overall time to diagnosis by 01:04 h, ED residents showed comparable results. During out-of-office hours, time benefit was 16:39 h on weekdays and 18:40 h during weekends.

Conclusion : Emergency physicians show comparable agreement in diagnosing LE DVT using rCUS when compared to radiologists. Average time benefit is over an hour, thereby reducing unnecessary waiting and improving time to disposition. ED residents demonstrated similar results in both agreement and time-saving.

Conclusion (proposition de traduction) : Les médecins urgentiste ont une concordance comparable pour le diagnostic de la thrombose veineuse profonde des membres inférieurs en utilisant l'échographie de compression régionale par rapport aux radiologues. Le gain de temps moyen est supérieur à une heure, ce qui réduit les attentes inutiles et améliore le temps de mise à disposition. Les résidents des services d'urgence ont démontré des résultats similaires en termes d'accord et de gain de temps.

Effect of gender on out-of-hospital cardiac arrest survival: a registry-based study.
Hubert H, Jaeger D, Baert V, Vilhelm C, Genin M, Manzo-Silberman S, Sadoune S, Denayer FO, Javaudin F, Gueugniaud PY, Tazarourte K, Mounier-Vehier C, El Khoury C, Chouihed T; GR-RéAC. | Eur J Emerg Med. 2021 Jan 1;28(1):50-57
DOI: https://doi.org/10.1097/mej.0000000000000747
Keywords: Aucun

Original article

Introduction : The aim of the study was to compare outcomes after out-of-hospital cardiac arrest (OHCA) between comparable female and male OHCA cohorts in a large nationwide registry.

Méthode : This was a national multicentre retrospective, case-control propensity score-matched study based on French National Cardiac Arrest Registry data from 1 July 2011 to 21 September 2017. Female and male survival rates at D30 were compared.

Résultats : At baseline 66 395 OHCA victims were included, of which 34.3% were women. At hospital admission, survival was 18.2% for female patients and 20.2% for male patients [odds ratio (OR), 1.138 (1.092-1.185)]; at 30 days, survival was 4.3 and 5.9%, respectively [OR, 1.290 (1.191-1.500)]. After matching (14 051 patients within each group), female patients received less advanced life support by mobile medical team (MMT), they also had a longer no-flow duration and shorter resuscitation effort by MMT than male patients. However, 15.3% of female patients vs. 9.1% of male patients were alive at hospital admission [OR, 0.557 (0.517-0.599)] and 3.2 vs. 2.6% at D30 [OR, 0.801 (0.697-0.921)], with no statistically significant difference in neurological outcome [OR, 0.966 (0.664-1.407)].

Conclusion : In this large nationwide matched OHCA study, female patients had a better chance of survival with no significant difference in neurological outcome. We also noticed that female patients received delayed care with a shorter resuscitation effort compared to men; these complex issues warrant further specific investigation. Encouraging bystanders to act as quickly as possible and medical teams to care for female patients in the same way as male patients should increase survival rates.

Conclusion (proposition de traduction) : Dans cette grande étude d'arrêt cardiaque extrahospitalière appariée à l'échelle nationale, les patientes avaient de meilleures chances de survie sans différence significative dans les résultats neurologiques. Nous avons également remarqué que les patientes recevaient des soins différés avec un effort de réanimation plus court que les hommes ; ces questions complexes méritent une enquête plus approfondie. Encourager les témoins à agir le plus rapidement possible et les équipes médicales à prendre en charge les patientes de la même manière que les hommes devrait augmenter les taux de survie.

Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials.
Lawati KA , Sharif S, Maqbali SA, Rimawi HA, Petrosoniak A, Belley-Cote EP, Sharma SV, Morgenstern J, Fernando SM, Owen JJ, Zeller M, Quinlan D, Alhazzani W, Rochwerg B. | Intensive Care Med. 2021 Jan;47(1):14-27
DOI: https://doi.org/10.1007/s00134-020-06279-w
Keywords: Brain injury; Clinical trial; Randomized; Tranexamic acid; Traumatic.

Systematic Review

Introduction : With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI).

Méthode : In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach.

Résultats : Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA.

Conclusion : In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.

Conclusion (proposition de traduction) : Chez les patients présentant une lésion cérébrale traumatique aiguë, l'acide tranexamique n'a probablement aucun effet sur la mortalité ou l'invalidité. L'acide tranexamique peut diminuer l'expansion de l'hématome lors de l'imagerie ultérieure ; cependant, ce résultat est probablement moins important pour les patients. L'utilisation d'acide tranexamique n'augmente probablement pas le risque d'événements indésirables.

Role of liver enzymes in patients with blunt abdominal trauma to diagnose liver injury.
Shrestha A, Neupane HC, Tamrakar KK, Bhattarai A, Katwal G. | Int J Emerg Med. 2021 Jan 19;14(1):7
DOI: https://doi.org/10.1186/s12245-021-00332-1  | Télécharger l'article au format  
Keywords: ALT; AST; Blunt abdominal trauma; Liver enzymes; Liver injury.

Original Research

Introduction : The liver is the second most injured organ following blunt abdominal trauma (BAT) after the spleen. Although the computed tomography (CT) scan is considered as the gold standard for diagnosing liver injury in BAT, it may not readily available in all the hospitals. This study was performed to evaluate the role of aspartate transaminase (AST) and alanine transaminase (ALT) in patients with BAT and its significance in predicting the diagnosis and severity of the liver injury.

Méthode : The study was conducted in Chitwan Medical College Teaching Hospital (CMCTH) from February 2019 to May 2020. It was a prospective observational study. All the patients with BAT were received by on-duty surgical residents in the emergency department. Based on the imaging and operative finding, patients with liver injury and without liver injury were noted with the associated injury. For comparisons of clinical and grading characteristics between the two groups (liver injury and no liver injury), the chi-squared test was used for categorical variables as appropriate, and the Mann-Whitney U test used for quantitative variables (AST and ALT). The comparisons between more than two groups (grade of injury) were performed using the Kruskal-Wallis test. The receiver operating characteristic (ROC) was used to calculate the optimal cut-off value of AST and ALT.

Résultats : Among the 96 patients admitted with BAT, 38 patients had liver injury and 58 patients had no liver injury. The median length of the intensive care unit (ICU) stay of patients with liver injury was higher than without liver injury. There was a significant difference in the median level of AST and ALT (< 0.001) between patients with liver injury and no liver injury. The area under the ROC curve of AST was 0.89 (95% confidence interval 0.86-0.98) and of ALT was 0.92 (95% confidence interval 0.83-0.97). The area under the curve demonstrated that the test was a good predictor for the identification of liver injury and also the severity of liver enzymes. The cut-off values for the liver injury were 106 U/l and 80 U/l for AST and ALT, respectively. Based on these values, AST ≥ 106 U/l had a sensitivity of 71.7%, a specificity of 90%, a positive predictive value of 86.8%, and a negative predictive value of 77.6%. The corresponding values for ALT ≥ 80 U/l were 77.8%, 94.1%, 92.1%, and 82.8%, respectively.

Conclusion : In conclusion, we report the optimal cut-off value of AST and ALT for liver injury in BAT as ≥ 106 U/l and 80 U/l, respectively. The elevated level of AST and ALT might assist the emergency physicians and surgeons to timely refer the suspected patients with the liver injury to a tertiary center.

Conclusion (proposition de traduction) : En conclusion, nous rapportons la valeur seuil optimale de l'AST et de l'ALT pour les lésions hépatiques dans les traumatismes abdominaux contondants comme ≥ 106 U / l et 80 U / l, respectivement. Le niveau élevé d'AST et d'ALT pourrait aider les médecins d'urgence et les chirurgiens à orienter en temps opportun les patients suspects de lésion hépatique vers un centre tertiaire.

A Rationale for Use of High Flow Nasal Cannula for Select Patients With Suspected or Confirmed Severe Acute Respiratory Syndrome Coronavirus-2 Infection.
Suffredini DA, Allison MG. | J Intensive Care Med. 2021 Jan;36(1):9-17
DOI: https://doi.org/10.1177/0885066620956630  | Télécharger l'article au format  
Keywords: SARS-CoV-2; acute respiratory distress syndrome; aerosolization; critical care; high flow nasal cannula.

Analytic Review

Editorial : Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.

Conclusion : Patients in whom HFNC is considered should be chosen carefully. In those meeting criteria for more severe disease or who are in significant respiratory distress, early intubation should be performed. Patients considered for HFNC therapy should have proper isolation, ideally placed in negative pressure rooms with their faces and cannulas covered with a surgical mask. HCW should be donned in proper PPE attire with airborne precautions. In our experience, generally we allow for a short trial of HFNC in patients with hypoxemia from SARS-CoV-2 pneumonia that are awake, protecting their airway, controlling secretions and are not in obvious respiratory distress. Patients should be monitored closely for improvements in SpO2 or PaO2. Depending on clinical scenario and degree of patient illness and cooperation, a trial of prone positioning may also be attempted. Decisions to continue HFNC treatment would depend on clinical progression, serial lab measures and clinical stability. The ROX index (<2.85 at 2 hours or less) may be a useful discriminator of patients that are in early danger of failing HFNC, but the index has not been studied specifically in this population of SARS-CoV-2. In contrast, we preferentially intubate early those patients that have altered mental status, shock, uncontrolled acidosis, hypercapnia or severe hypoxemia and those in significant respiratory distress.

Conclusion (proposition de traduction) : Les patients chez lesquels le traitement par oxygénothérapie nasale à haut débit (OptiFlow) est envisagé doivent être choisis avec soin. Chez ceux qui répondent aux critères d'une maladie plus grave ou qui sont en détresse respiratoire importante, une intubation précoce doit être préférée. Les patients pressentis pour un traitement par oxygénothérapie nasale à haut débit (OptiFlow) doivent bénéficier d'un isolement approprié, idéalement placés dans des chambres à pression négative, le visage et les canules recouverts d'un masque chirurgical. Les soignants doivent porter un équipement de protection individuel appropriée pour le respect des précautions complémentaires gouttelettes. D'après notre expérience, nous autorisons généralement un bref essai de l'oxygénothérapie nasale à haut débit (OptiFlow) chez des patients souffrant d'hypoxémie due à la pneumonie du SRAS-CoV-2 qui sont conscient, protégeant leurs voies respiratoires, contrôlant les sécrétions et ne présentant pas de détresse respiratoire évidente. Les patients doivent être étroitement surveillés afin de détecter toute amélioration de la SpO₂ ou de la PaO₂. Selon le scénario clinique et le degré de maladie du patient et de sa coopération, un essai de décubitus ventral peut également être tenté. Les décisions de poursuivre le traitement par oxygénothérapie nasale à haut débit (OptiFlow) dépendraient de la progression clinique, des examens de biologie répétées et de la stabilité clinique. L'indice ROX (< 2,85 à 2 heures ou moins) peut être un discriminateur utile des patients qui sont précocement en danger d'échec de l'oxygénothérapie nasale à haut débit (OptiFlow), mais l'indice n'a pas été étudié spécifiquement dans cette population de SRAS-CoV-2. En revanche, nous préférons l'intubation précoce chez les patients présentant un état mental altéré, un état de choc, une acidose incontrôlée, une hypercapnie ou une hypoxémie sévère et chez ceux en détresse respiratoire importante.

Evidence-Based Management of the Critically Ill Adult With SARS-CoV-2 Infection.
Chivukula RR, Maley JH, Dudzinski DM, Hibbert K, Hardin CC. | J Intensive Care Med. 2021 Jan;36(1):18-41
DOI: https://doi.org/10.1177/0885066620969132  | Télécharger l'article au format  
Keywords: COVID-19; SARS-CoV-2; acute respiratory distress syndrome (ARDS); acute respiratory failure; coronavirus; critical care; hypoxemia; pandemic.

Analytic Review

Editorial : Human infection by the novel viral pathogen SARS-CoV-2 results in a clinical syndrome termed Coronavirus Disease 2019 (COVID-19). Although the majority of COVID-19 cases are self-limiting, a substantial minority of patients develop disease severe enough to require intensive care. Features of critical illness associated with COVID-19 include hypoxemic respiratory failure, acute respiratory distress syndrome (ARDS), shock, and multiple organ dysfunction syndrome (MODS). In most (but not all) respects critically ill patients with COVID-19 resemble critically ill patients with ARDS due to other causes and are optimally managed with standard, evidence-based critical care protocols. However, there is naturally an intense interest in developing specific therapies for severe COVID-19. Here we synthesize the rapidly expanding literature around the pathophysiology, clinical presentation, and management of COVID-19 with a focus on those points most relevant for intensivists tasked with caring for these patients. We specifically highlight evidence-based approaches that we believe should guide the identification, triage, respiratory support, and general ICU care of critically ill patients infected with SARS-CoV-2. In addition, in light of the pressing need and growing enthusiasm for targeted COVID-19 therapies, we review the biological basis, plausibility, and clinical evidence underlying these novel treatment approaches.

Conclusion : SARS-CoV-2 is a novel coronavirus of zoonotic origin that has infected millions of people worldwide and is placing severe demands on intensive care resource utilization across the globe. The biology and natural history of COVID-19 is becoming increasingly well-understood and should inform the approach to diagnostic testing, healthcare worker precautions, and ICU triage. COVID-19 associated acute hypoxemic respiratory failure develops in a substantial fraction of affected patients and represents a form of ARDS, a finding consistent with what is now understood regarding the virology and pathophysiology of SARS-CoV-2. The keys to evidence-based management of COVID-19 therefore include lung-protective low-tidal volume ventilation, avoidance of barotrauma, a conservative fluid strategy, and prone ventilation, with utilization of inhaled pulmonary vasodilators, neuromuscular blockade, and ECMO when necessary. The lifecycle of SARS-CoV-2 and its effects on the host immune system suggest possible targets for therapy and, to date, 2 such drugs are indicated in hospitalized COVID-19 patients. In time, we anticipate the continued development and adoption of additional targeted therapies which will help bring the pandemic under control.

Conclusion (proposition de traduction) : Le SRAS-CoV-2 est un nouveau coronavirus d'origine zoonotique qui a infecté des millions de personnes dans le monde et impose des exigences sévères à l'utilisation des ressources de soins intensifs à travers le monde. La biologie et l'histoire naturelle de la COVID-19 sont de mieux en mieux comprises et devraient éclairer l'approche des tests diagnostiques, des précautions par les soignants et du triage des unités de soins intensifs. L'insuffisance respiratoire hypoxémique aiguë associée à la COVID-19 se développe chez une fraction substantielle de patients affectés et représente une forme de SDRA, une constatation conforme à ce qui est maintenant compris en ce qui concerne la virologie et la physiopathologie du SRAS-CoV-2. Les clés du management par la preuve (Evidence-Based Management) de la COVID-19 comprennent donc la ventilation de protection pulmonaire à faible volume courant, l'évitement du barotraumatisme, une stratégie de remplissage conservatrice et le décubitus ventral, avec l'utilisation de vasodilatateurs pulmonaires inhalés, les curares et l'ECMO quand c'est nécessaire. Le cycle de vie du SRAS-CoV-2 et ses effets sur le système immunitaire de l'hôte suggèrent des cibles possibles pour le traitement et, à ce jour, 2 de ces médicaments sont indiqués chez les patients hospitalisés COVID-19. Avec le temps, nous prévoyons le développement continu et l'adoption de thérapies ciblées supplémentaires qui aideront à maîtriser la pandémie.

Commentaire : 

Four-Factor Prothrombin Complex Concentrate for the Reversal of Direct Oral Anticoagulants.
Zada I, Wang S, Akerman M, Hanna A. | J Intensive Care Med. 2021 Jan;36(1):58-62
DOI: https://doi.org/10.1177/0885066619882909
Keywords: 4-factor PCC; Direct Oral Anticoagulants (DOACs); hematoma; intracranial hemorrhage.

Original Research

Introduction : The prevalence of direct oral anticoagulants (DOACs) has increased with continued evidence of their efficacy and ease of use. However, the rise in their utilization also surfaced a concern regarding their reversal in patients actively bleeding and/or those requiring invasive procedures. Up until 2018, there were several reversal options available including 4-factor prothrombin complex concentrate (4-factor PCC), activated charcoal, desmopressin, and tranexamic acid. Then, in 2018, andexanet alpha, a recombinant factor Xa, was approved for the reversal of apixaban and rivaroxaban in patients with life-threatening or uncontrolled bleeding. Nonetheless, because 4-factor PCC is more easily attainable and cost-effective, it continues to be the more favorable option for many health-care professionals.

Méthode : This retrospective chart review was conducted at NYU Winthrop Hospital in patients who received 4-factor PCC for the reversal of DOACs from January 2018 to July 2018. Patient charts were reviewed and relevant data was collected (admitting diagnosis, dose of 4-factor PCC utilized, etc).

Résultats : Fifty-three patients were evaluated with 85% experiencing a positive response and complete recovery following the administration of 4-factor PCC; 8 (15%) patients died after receiving 4-factor PCC, none as a result of its administration; 3 patients died secondary to other underlying comorbidities, 4 patients died due to an intracranial hemorrhage, and 1 died due to hematoma of the tongue.

Conclusion : Based on the results thus far, the use of 4-factor PCC may be a good treatment option in patients requiring DOAC reversal.

Conclusion (proposition de traduction) : Sur la base des résultats obtenus jusqu'à présent, l'utilisation du complexe prothrombique humain concentré de 4 facteurs de coagulation peut être une bonne option de traitement chez les patients nécessitant une réversion de l'AOD.

Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms.
Couturaud F, Bertoletti L, Pastre J, Roy PM, Le Mao R, Gagnadoux F, Paleiron N, Schmidt J, Sanchez O, De Magalhaes E, Kamara M, Hoffmann C, Bressollette L, Nonent M, Tromeur C, Salaun PY, Barillot S, Gatineau F, Mismetti P, Girard P, Lacut K, Lemarié CA, Meyer G, Leroyer C; PEP Investigators. | JAMA. 2021 Jan 5;325(1):59-68
DOI: https://doi.org/10.1001/jama.2020.23567
Keywords: Aucun

Original Investigation

Introduction : The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain.
Objective: To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms.

Méthode : Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017.
Exposures: Acutely worsening respiratory symptoms in patients with COPD.
Main outcomes and measures: The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not.

Résultats : Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441).

Conclusion : Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.

Conclusion (proposition de traduction) : Parmi les patients atteints de bronchopneumopathie chronique obstructive admis à l'hôpital avec une aggravation aiguë des symptômes respiratoires, une embolie pulmonaire a été détectée chez 5,9 % des patients à l'aide d'un algorithme de diagnostic prédéfini. Des recherches supplémentaires sont nécessaires pour comprendre le rôle possible du dépistage systématique de l'embolie pulmonaire dans cette population de patients.

Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial.
Baek SH, Jo YH, Ahn S, Medina-Liabres K, Oh YK, Lee JB, Kim S. | JAMA Intern Med. 2021 Jan 1;181(1):81-92
DOI: https://doi.org/10.1001/jamainternmed.2020.5519
Keywords: Aucun

Original Investigation

Introduction : Few high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia.
Objective: To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia.

Méthode : This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea.
Interventions: Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms.
Main outcome and measures: The primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days.

Résultats : The 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, -15.8% [95% CI, -30.3% to -1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, -0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour.

Conclusion : This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines.

Conclusion (proposition de traduction) : Cet essai clinique randomisé a révélé que les administrations par bolus intermittent rapide et par perfusion continue lente de solution saline hypertonique pour le traitement de l'hyponatrémie étaient efficaces et sûres, sans différence dans le risque de surcorrection. Cependant, le bolus intermittent rapide avait une incidence plus faible de traitement de rechargement thérapeutique et avait tendance à avoir une meilleure efficacité pour atteindre le taux de sodium sérique en 1 heure que la perfusion continue lente. Le bolus intermittent rapide pourrait être suggéré comme traitement de choix de l'hyponatrémie symptomatique, ce qui est cohérent avec les lignes directrices consensuelles actuelles.

Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest.
Abramson TM, Bosson N, Loza-Gomez A, Eckstein M, Gausche-Hill M. | Prehosp Emerg Care. 2021 Jan 5:1-8
DOI: https://doi.org/10.1080/10903127.2020.1869873
Keywords: dextrose; glucagon; hypoglycemia; out of hospital cardiac arrest; point of care testing.

Article

Introduction : Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes.

Méthode : This was a retrospective analysis of OHCA in a large, regional EMS system from 2011-2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome.

Résultats : There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. 27 of 32,780 (0.08%) patients with a documented POC glucose result who were identified as hypoglycemic, received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference -2.0% (95%CI -4.4%, 0.4%), p = 0.1.

Conclusion : In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.

Conclusion (proposition de traduction) : Dans ce système de soins médicaux d'urgence, les tests de la glycémie au point d'intervention étaient courants dans les arrêts cardiaques extra-hospitalier chez l'adulte mais la survie à la sortie de l'hôpital avec un bon résultat neurologique ne différait pas entre les patients traités et non traités pour hypoglycémie. Ces résultats remettent en question la pratique courante de mesure et de traitement de l'hypoglycémie chez les patients en arrêt cardiaque extra-hospitalier.

First Description of a Helicopter-Borne Extracorporeal cardiopulmonary resuscitation (ECPR) Team for Remote Refractory Out-of-Hospital Cardiac Arrest.
Hutin A, Ricard-Hibon A, Briole N, Dupin A, Dagron C, Raphalen JH, Mungur A, An K, Carli P, Lamhaut L. | Prehosp Emerg Care. 2021 Jan 12:1-5
DOI: https://doi.org/10.1080/10903127.2020.1859026
Keywords: ECPR; emergency medical dispatch; refractory cardiac arrest.

Research Article

Introduction : Access time to extracorporeal cardiopulmonary resuscitation (ECPR) refractory out of hospital cardiac arrest (OHCA) is a crucial factor. In our region, some patients are not eligible to this treatment due to the impossibility to reach the hospital with reasonable delay (ideally 60 min). In order to increase accessibility for patients far from ECPR centers, we developed a helicopter-borne ECPR-team which is sent out to the patient for ECPR implementation on the scene of the OHCA.

Méthode : We conducted a retrospective monocentric study to evaluate this strategy. The team is triggered by the local emergency medical service and heliborne on the site of the OHCA. All consecutive patients implemented with ECPR by our heliborne ECPR team from January 2014 to December 2017 were included. We analyzed usual CA characteristics, different times (no-flow, low-flow, time between OHCA and dispatch…), and patient outcome.

Résultats : During this 4-year study period, 33 patients were included. Mean age was 43.9 years. Mean distance from the ECPR-team base to OHCA location was 41 km. Mean low-flow time was 110 minutes. Five patients survived with good neurological outcome; 6 patients developed brain death and became organ donors.

Conclusion : These results show the possibility to make ECPR accessible for patients far from ECPR centers. Survival rate is non negligible, especially in the absence of therapeutic alternative. An earlier trigger of the ECPR-team could reduce the low-flow time and probably increase survival. This strategy improves equity of access to ECPR and needs to be confirmed by further studies.

Conclusion (proposition de traduction) : Ces résultats montrent la possibilité de rendre l'ECPR accessible aux patients éloignés des centres ECPR. Le taux de survie est non négligeable, surtout en l'absence d'alternative thérapeutique. Un déclenchement plus précoce de l'équipe ECPR pourrait réduire le temps de faible débit et probablement augmenter la survie. Cette stratégie améliore l'équité d'accès à l'ECPR et doit être confirmée par de nouvelles études.

The effect of airway management on CPR quality in the PARAMEDIC2 randomised controlled trial.
Deakin CD, Nolan JP, Ji C, Fothergill RT, Quinn T, Rosser A, Lall R, Perkins GD. | Resuscitation. 2021 Jan;158:8-13
DOI: https://doi.org/10.1016/j.resuscitation.2020.11.005
Keywords: Adrenaline; Advanced life support; Airway; Cardiac arrest; Compression fraction; Epinephrine; Outcome.

Clinical Paper

Introduction : Good quality basic life support (BLS) is associated with improved outcome from cardiac arrest. Chest compression fraction (CCF) is a BLS quality indicator, which may be influenced by the type of airway used. We aimed to assess CCF according to the airway strategy in the PARAMEDIC2 study: no advanced airway, supraglottic airway (SGA), tracheal intubation, or a combination of the two. Our hypothesis was that tracheal intubation was associated with a decrease in the CCF compared with alternative airway management strategies.

Méthode : PARAMEDIC2 was a multicentre double-blinded placebo-controlled trial of adrenaline vs placebo in out-of-hospital cardiac arrest. Data showing compression rate and ratio from patients recruited by London Ambulance Service (LAS) as part of this study was collated and analysed according to the advanced airway used during the resuscitation attempt.

Résultats : CPR process data were available from 286/ 2058 (13.9%) of the total patients recruited by LAS. The mean compression rate for the first 5 min of data recording was the same in all groups (P = 0.272) and ranged from 104.2 (95% CI of mean: 100.5, 107.8) min^-1 to 108.0 (95% CI of mean: 105.1, 108.3) min^-1. The mean compression fraction was also similar across all groups (P = 0.159) and ranged between 74.7% and 78.4%. There was no difference in the compression rates and fractions across the airway management groups, regardless of the duration of CPR.

Conclusion : There was no significant difference in the compression fraction associated with the airway management strategy.

Conclusion (proposition de traduction) : Il n'y avait pas de différence significative dans le taux de compression associée à la stratégie de gestion des voies respiratoires.

Airway insertion first pass success and patient outcomes in adult out-of-hospital cardiac arrest: The Pragmatic Airway Resuscitation Trial.
Lesnick JA, Moore JX, Zhang Y, Jarvis J, Nichol G, Daya MR, Idris AH, Klug C, Dennis D, Carlson JN, Doshi P, Sopko G, Schmicker RH, Wang HE. | Resuscitation. 2021 Jan;158:151-156
DOI: https://doi.org/10.1016/j.resuscitation.2020.11.030
Keywords: Airway management; Cardiopulmonary arrest; Emergency medical services; Intubation (intratracheal)

Clinical paper

Introduction : While emphasized in clinical practice, the association between advanced airway insertion first-pass success (FPS) and patient outcomes is incompletely understood. We sought to determine the association of airway insertion FPS with adult out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART).

Méthode : We performed a secondary analysis of PART, a multicenter clinical trial comparing LT and ETI upon adult OHCA outcomes. We defined FPS as successful LT insertion or ETI on the first attempt as reported by EMS personnel. We examined the outcomes return of spontaneous circulation (ROSC), 72-h survival, hospital survival, and hospital survival with favorable neurologic status (Modified Rankin Scale ≤3). Using multivariable GEE (generalized estimating equations), we determined the association between FPS and OHCA outcomes, adjusting for age, sex, witnessed arrest, bystander CPR, initial rhythm, and initial airway type.

Résultats : Of 3004 patients enrolled in the trial, 1423 received LT, 1227 received ETI, 354 received bag-valve-mask ventilation only. FPS was: LT 86.2% and ETI 46.7%. FPS was associated with increased ROSC (aOR 1.23; 95%CI: 1.07-1.41)), but not 72-h survival (1.22; 0.94-1.58), hospital survival (0.90; 0.68-1.19) or hospital survival with favorable neurologic status (0.66; 0.37-1.19).

Conclusion : In adult OHCA, airway insertion FPS was associated with increased ROSC but not other OHCA outcomes. The influence of airway insertion FPS upon OHCA outcomes is unclear.

Conclusion (proposition de traduction) : Lors d'un arrêt cardiaque pré-hospitalier chez l'adulte, le succès du premier essai d'intubation était associé à une augmentation du retour à une circulation spontanée, mais pas à d’autres résultats pour l’arrêt cardiaque pré-hospitalier. L'influence du succès du premier essai d'intubation sur les résultats d'arrêt cardiaque pré-hospitalier n'est pas claire.

In-Hospital vs. Out-of-Hospital Cardiac Arrest: Patient Characteristics and Survival.
Høybye M, Stankovic N, Holmberg M, Christensen HC, Granfeldt A, Andersen LW. | Resuscitation. 2021 Jan;158:157-165
DOI: https://doi.org/10.1016/j.resuscitation.2020.11.016
Keywords: Cardiac arrest characteristics; Comorbidities; In-hospital cardiac arrest; Out-of-hospital cardiac arrest; Patient characteristics; Survival; Witnessed.

Clinical paper

Introduction : Cardiac arrests are often categorized into two separate groups depending on the location of the arrest: in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Despite this distinction, few studies have compared the two groups directly. The aim of this study was to compare patient characteristics, cardiac arrest characteristics, and outcomes for IHCA and OHCA patients.

Méthode : Data on IHCA and OHCA in Denmark were obtained from two nationwide, prospective registries. All adult (≥18 years old) patients with index IHCA or OHCA from January 1, 2017 to December 31, 2018 were included. Supplementary information on outcomes, hospitalizations, and chronic diseases came from additional national registries. The primary outcome was 30-day survival and secondary outcomes were return of spontaneous circulation (ROSC) and 1-year survival.

Résultats : The study included 3501 patients with IHCA and 8846 patients with OHCA. The two groups were similar in demographics, most comorbidities, and initial cardiac arrest rhythm. In the unadjusted analysis, IHCA was associated with increased survival to 30 days compared to OHCA (risk ratio [RR] = 1.41; 95% CI, 1.30; 1.54) and 1 year (RR = 1.46; 95% CI, 1.33; 1.61). Adjusting for age, sex, and comorbidities did not change the RR substantially. When cardiac arrest characteristics were added to the model, the RR decreased from 1.51 (95% CI, 1.39; 1.65) to 1.06 (95% CI, 0.93; 1.20) for survival to 30 days and from 1.66 (95% CI, 1.50; 1.84) to 1.09 (95% CI, 0.94; 1.26) for survival to 1 year. In all subgroup analyses based on cardiac arrest characteristics (e.g. witnessed status), the association between location and outcome was substantially mitigated compared to the primary analyses.

Conclusion : In this large, national study, we found that IHCA and OHCA patients were remarkably similar in demographics and most comorbidities. IHCA patients had better outcomes compared to OHCA patients, although these differences disappeared when comparing patients with similar cardiac arrest characteristics.

Conclusion (proposition de traduction) : Dans cette vaste étude nationale, nous avons constaté que les patients en arrêt cardiaque à l'hôpital et en préhospitalier étaient remarquablement similaires en termes de données démographiques et pour la plupart des comorbidités. Les patients en arrêt cardiaque à l'hôpital ont obtenu de meilleurs résultats par rapport aux patients en arrêt cardiaque extra-hospitalier, bien que ces différences aient disparu lors de la comparaison des patients présentant des caractéristiques d'arrêt cardiaque similaires.

Lactate and hypotension as predictors of mortality after in-hospital cardiac arrest.
Issa MS, Grossestreuer AV, Patel H, Ntshinga L, Coker A, Yankama T, Donnino MW, Berg KM. | Resuscitation. 2021 Jan;158:208-214
DOI: https://doi.org/10.1016/j.resuscitation.2020.10.018
Keywords: IHCA (in hospital cardiac arrest); Lactate; OHCA (out of hospital cardiac arrest); ROSC (return of spontaneous circulation); Vasopressors.

Clinical paper

Introduction : Guidance on post-cardiac arrest prognostication is largely based on data from out-of-hospital cardiac arrest (OHCA), despite clear differences between the OHCA and in-hospital cardiac arrest (IHCA) populations. Early prediction of mortality after IHCA would be useful to help make decisions about post-arrest care. We evaluated the ability of lactate and need for vasopressors after IHCA to predict hospital mortality.

Méthode : Single center retrospective observational study of adult IHCA patients who achieved sustained return of spontaneous circulation (ROSC), required mechanical ventilation peri-arrest and had a lactate checked within 2 h after ROSC. We evaluated the association of post-ROSC lactate and need for vasopressors with mortality using multivariate logistic regression.

Résultats : A total of 364 patients were included. Patients who received vasopressors within 3 h after ROSC had significantly higher mortality compared to patients who did not receive vasopressors (58% vs. 43%, p = 0.03). Elevated lactate level was associated with mortality (44% if lactate <5 mmol/L, 58% if lactate 5-10 mmol/L, and 73% if lactate >10 mmol/L, p < 0.01). A multivariable model with lactate group and post-ROSC vasopressor use as predictors demonstrated moderate discrimination (AUC 0.64 [95%CI:0.59-0.70]). Including other variables, the most parsimonious model included lactate, age, body mass index, race, and history of arrhythmia, cancer and/or liver disease (AUC 0.70 [95% CI: 0.64-0.75]).

Conclusion : Post-ROSC lactate and need for vasopressors may be helpful in stratifying mortality risk in patients requiring mechanical ventilation after IHCA.

Conclusion (proposition de traduction) : Le lactate post-retour à une circulation spontanée et le besoin de vasopresseurs peuvent être utiles pour stratifier le risque de mortalité chez les patients nécessitant une ventilation mécanique après un arrêt cardiaque à l'hôpital.

Bougie-assisted endotracheal intubation in the pragmatic airway resuscitation trial.
Bonnette AJ, Aufderheide TP, Jarvis JL, Lesnick JA, Nichol G, Carlson JN, Hansen M, Stephens SW, Colella MR, Wang HE. | Resuscitation. 2021 Jan;158:215-219
DOI: https://doi.org/10.1016/j.resuscitation.2020.11.003
Keywords: Airway management; Cardiopulmonary arrest; Emergency medical service; Intubation.

Clinical paper

Introduction : Paramedics may perform endotracheal intubation (ETI) while treating patients with out-of-hospital cardiac arrest (OHCA). The gum elastic Bougie (Bougie) is an intubation adjunct that may optimize intubation success. There are few reports of Bougie-assisted intubation in OHCA nor its association with outcomes. We compared intubation success rates and OHCA outcomes between Bougie-assisted and non-Bougie ETI in the out-of-hospital Pragmatic Airway Resuscitation Trial (PART).

Méthode : This was a secondary analysis of patients receiving ETI enrolled in the Pragmatic Airway Resuscitation Trial (PART), a multicenter clinical trial comparing intubation-first vs. laryngeal tube-first strategies of airway management in adult OHCA. The primary exposure was use of Bougie for ETI-assistance. The primary endpoint was first-pass ETI success. Secondary endpoints included overall ETI success, time to successful ETI, return of spontaneous circulation, 72-h survival, hospital survival and hospital survival with favorable neurologic status (Modified Rankin Score ≤3). We analyzed the data using Generalized Estimating Equations and Cox Regression, adjusting for known confounders.

Résultats : Of the 3004 patients enrolled in PART, 1227 received ETI, including 440 (35.9%) Bougie-assisted and 787 (64.1%) non-Bougie ETIs. First-pass ETI success did not differ between Bougie-assisted and non-Bougie ETI (53.1% vs. 42.8%; adjusted OR 1.12, 95% CI: 0.97-1.39). ETI overall success was slightly higher in the Bougie-assisted group (56.2% vs. 49.1%; adjusted OR 1.19, 95% CI: 1.01-1.32). Time to endotracheal tube placement or abandonment was longer for Bougie-assisted than non-Bougie ETI (median 13 vs. 11 min; adjusted HR 0.63, 95% CI: 0.45-0.90). While survival to hospital discharge was lower for Bougie-assisted than non-Bougie ETI (3.6% vs. 7.5%; adjusted OR 0.94, 95% CI: 0.92-0.96), there were no differences in ROSC, 72-h survival or hospital survival or hospital survival with favorable neurologic status.

Conclusion : While exhibiting slightly higher ETI overall success rates, Bougie-assisted ETI entailed longer airway placement times and potentially lower survival. The role of the Bougie assistance in ETI of OHCA remains unclear.

Conclusion (proposition de traduction) : Bien que présentant des taux de succès globaux d'intubation endotrachéale légèrement plus élevés, l'intubation endotrachéale avec un guide malléable impliquait des temps de mise en place plus longs et une survie potentiellement plus faible. Le rôle du guide malléable dans l'intubation endotrachéale des arrêts cardiaques extra-hospitaliers reste incertain.

Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopulmonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest.
Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, G Lurie K. | Resuscitation. 2021 Jan;158:220-227
DOI: https://doi.org/10.1016/j.resuscitation.2020.09.030
Keywords: Active compression–decompression CPR; Cardiac arrest; Cardiopulmonary resuscitation; Cerebral perfusion; Controlled sequential elevation; Head Up CPR; Head and thorax elevation; Impedance threshold device; Mechanical CPR.

Clinical paper

Introduction : Controlled sequential elevation of the head and thorax (CSE) during active compression decompression (ACD) cardiopulmonary resuscitation (CPR) with an impedance threshold device (ITD) has been shown to increase cerebral perfusion pressure and cerebral blood flow in previous animal studies as compared to the traditional supine position. The potential for this novel bundled treatment strategy to improve survival with intact neurological function is unknown

Méthode : Female farm pigs were sedated, intubated, and anesthetized. Central arterial and venous access were continuously monitored. Regional brain tissue perfusion (CerO2) was also measured transcutaneous. Ventricular fibrillation (VF) was induced and untreated for 10 min. Pigs were randomized to (1) Conventional CPR (C-CPR) flat or (2) ACD + ITD CSE CPR that included 2 min of ACD + ITD with the head and heart first elevated 10 and 8 cm, and then gradual elevation over 2 min to 22 and 9 cm, respectively. After 19 min of CPR, pigs were defibrillated and recovered. A veterinarian blinded to the intervention assessed cerebral performance category (CPC) at 24 h. A neurologically intact outcome was defined as a CPC score of 1 or 2. Categorical outcomes were analyzed by Fisher's exact test and continuous outcomes with an unpaired student's t-test.

Résultats : In 16 animals, return of spontaneous circulation rate was 8/8 (100%) with ACD + ITD CSE and 3/8 (25%) for C-CPR (p = 0.026). For the primary outcome of neurologically intact survival, 6/8 (75%) pigs had a CPC score 1 or 2 with ACD + ITD CSE versus 1/8 (12.5%) with C-CPR (p = 0.04). Coronary perfusion pressure (mmHg, mean ± SD) was higher with CSE at 18 min (41 ± 24 versus 10 ± 5, p = 0.004). rSO2 (%, mean ± SD) and ETCO2 (mmHg, mean ± SD) values were higher at 18 min with CSE (32 ± 9 versus 17 ± 2, p = 0.01, and 55 mmHg ± 10 versus 21 mmHg ± 4, p < 0.001), respectively.

Conclusion : The novel bundled resuscitation approach of CSE with ACD + ITD CPR increased favorable neurological survival versus C-CPR in a swine model of cardiac arrest.

Conclusion (proposition de traduction) : La nouvelle approche de réanimation associant l'élévation séquentielle contrôlée de la tête et du thorax avec la décompression active par compression + CPR avec un dispositif à seuil d'impédance a augmenté la survie neurologique favorable par rapport à la RCP conventionnelle dans un modèle porcin d'arrêt cardiaque.

Commentaire : 

Clinical decision rules for termination of resuscitation during in-hospital cardiac arrest: A systematic review of diagnostic test accuracy studies.
Lauridsen KG, Baldi E, Smyth M, Perkins GD, Greif R; Education Implementation and Team Task Force of the International Liaison Committee on Resuscitation (ILCOR). | Resuscitation. 2021 Jan;158:23-29
DOI: https://doi.org/10.1016/j.resuscitation.2020.10.036
Keywords: Advanced life support; Ethical issues; In-hospital cardiac arrest; Termination of resuscitation.

Reviews

Introduction : To assess whether any clinical decision rule for patients sustaining an in-hospital cardiac arrest (IHCA) can predict mortality or survival with poor neurological outcome.

Méthode : We searched online databases from inception through July 2020 for randomized controlled trials and non-randomized studies. Two reviewers assessed studies for inclusion. We followed PRISMA guidelines for Diagnostic Test Accuracy Studies, used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We assessed predictive values for no return of spontaneous circulation (ROSC), death before hospital discharge, and survival with unfavorable neurological outcome.

Résultats : Out of 6436 studies, 92 studies were selected for full-text screening. We included 3 observational studies describing the derivation and external validation for the UN10 rule (Unwitnessed arrest; Nonshockable rhythm; 10 min of resuscitation without ROSC) amongst patients suffering from IHCA. No studies were identified for clinical implementation. Positive Predicted Values (PPV) for death before hospital discharge for the three studies were 100% (95% CI: 97.1%-100%), 98.9% (95% CI: 96.5%-99.7%), and 93.7% (95% CI: 93.3%-94.0%). One study reported a PPV for prediction of survival with unfavorable neurological outcome, 95.2% (95% CI: 94.9%-95.6%). The level of evidence was rated as very low certainty.

Conclusion : We identified very low certainty evidence for one clinical decision rule (the UN-10 rule) that was unable to reliably predict mortality or survival with unfavorable neurological outcome for adults suffering from IHCA. We identified no evidence for children.

Conclusion (proposition de traduction) : Nous avons identifié des preuves de très faible certitude pour une règle de décision clinique (la règle UN-10) qui était incapable de prédire de manière fiable la mortalité ou la survie avec un résultat neurologique défavorable pour les adultes souffrant d'IHCA. Nous n'avons identifié aucune preuve pour les enfants.

Crowdsourcing to save lives: A scoping review of bystander alert technologies for out-of-hospital cardiac arrest.
Valeriano A, Van Heer S, de Champlain F, C Brooks S. | Resuscitation. 2021 Jan;158:94-121
DOI: https://doi.org/10.1016/j.resuscitation.2020.10.035
Keywords: Bystander intervention; Cardiopulmonary resuscitation; Crowdsourcing; Out-of-hospital cardiac arrest; Smartphone applications.

Reviews

Introduction : Out-of-hospital cardiac arrest (OHCA) constitutes a significant global health burden, with a survival rate of only 10-12%. Mobile phone technologies have been developed that crowdsource citizen volunteers to nearby OHCAs in order to initiate resuscitation prior to ambulance arrival. We performed a scoping review to map the available literature on these crowdsourcing technologies and compared their technical specifications.

Méthode : A search strategy was developed for five online databases. Two reviewers independently assessed all articles for inclusion and extracted relevant study information. Subsequently, we performed a supplementary internet search and consulted experts to identify all available bystander alert technologies and their specifications.

Résultats : We included 65 articles examining bystander alerting technologies from more than 15 countries. We also identified 25 unique technologies, of which 18 were described in the included literature. Technologies were text message-based systems (n = 3) or mobile phone applications (n = 22). Most (21/25) used global positioning systems to direct bystanders to victims and nearby AEDs. Response radii for alerts varied widely from 200 m to 10 km. Some technologies incorporated advanced features such as video-conferencing with ambulance dispatch and detailed alert settings. Not all systems required volunteers to have training in cardiopulmonary resuscitation. Only ten studies assessed impact on clinical outcomes. Key barriers discussed included false positive alerts, legal liability, and potential psychological impact on volunteers.

Conclusion : Our review provides a comprehensive overview of crowdsourcing technologies for bystander intervention in out-of-hospital cardiac arrest. Future work should focus on clinical outcomes and methods of addressing barriers to implementation.

Conclusion (proposition de traduction) : Notre revue fournit un aperçu complet des technologies de production participative pour l'intervention des témoins en cas d'arrêt cardiaque hors de l'hôpital. Les travaux futurs devraient se concentrer sur les résultats cliniques et les méthodes pour éliminer les obstacles à la mise en œuvre.

Association between the body mass index and outcomes of patients resuscitated from out-of-hospital cardiac arrest: a prospective multicentre registry study.
Lee H, Oh J, Kang H, Lim TH, Ko BS, Choi HJ, Park SM, Jo YH, Lee JS, Park YS, Yoon YH, Kim SJ, Min YG; Korean Cardiac Arrest Research Consortium (KoCARC) Investigators. | Scand J Trauma Resusc Emerg Med. 2021 Jan 28;29(1):24
DOI: https://doi.org/10.1186/s13049-021-00837-x  | Télécharger l'article au format  
Keywords: Body mass index; Obesity; Out-of-hospital cardiac arrest.

Original research

Introduction : The effects of the body mass index (BMI) on outcomes of patients resuscitated from cardiac arrest are controversial. Therefore, the current study investigated the association between the BMI and the favourable neurologic outcomes and survival to discharge of patients resuscitated from out-of-hospital cardiac arrest (OHCA).

Méthode : This multicentre, prospective, nationwide OHCA registry-based study was conducted using data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC). We enrolled hospitals willing to collect patient height and weight and included patients who survived to the hospital between October 2015 and June 2018. The included patients were categorised into the underweight (< 18.5 kg/m²), normal weight (≥18.5 to < 25 kg/m²), overweight (≥25 to < 30 kg/m²), and obese groups (≥30 kg/m²) according to the BMI per the World Health Organization (WHO) criteria. The primary outcome was a favourable neurologic outcome; the secondary outcome was survival to discharge. Univariate and multivariate analyses were performed to investigate the association between BMI and outcomes.

Résultats : Nine hospitals were enrolled; finally, 605 patients were included in our analysis and categorised per the WHO BMI classification. Favourable neurologic outcomes were less frequent in the underweight BMI group than in the other groups (p = 0.002); survival to discharge was not significantly different among the BMI groups (p = 0.110). However, the BMI classification was not associated with favourable neurologic outcomes or survival to discharge after adjustment in the multivariate model.

Conclusion : The BMI was not independently associated with favourable neurologic and survival outcomes of patients surviving from OHCA.

Conclusion (proposition de traduction) : L'IMC n'était pas associé de manière indépendante à des résultats neurologiques et de survie favorables chez les patients survivant d'un arrêt cardiaque hors hôpital.

Shock Severity and Hospital Mortality In Out of Hospital Cardiac Arrest Patients Treated With Targeted Temperature Management.
Tabi M, Burstein BJ, Ahmed A, Dezfulian C, Kashani KB, Jentzer JC. | Shock. 2021 Jan 1;55(1):48-54
DOI: https://doi.org/10.1097/shk.0000000000001600
Keywords: Aucun

Clinical Science Aspects

Introduction : Shock in patients resuscitated after out of hospital cardiac arrest (OHCA) is associated with an increased risk of mortality. We sought to determine the associations between lactate level, mean arterial pressure (MAP), and vasopressor/inotrope doses with mortality.

Méthode : Retrospective cohort study of adult patients with OHCA of presumed cardiac etiology treated with targeted temperature management (TTM) between December 2005 and September 2016. Multivariable logistic regression was performed to determine predictors of hospital death.

Résultats : Among 268 included patients, the median age was 64 (55, 71.8) years, including 27% females. OHCA was witnessed in 89%, OHCA rhythm was shockable in 87%, and bystander CPR was provided in 64%. Vasopressors were required during the first 24 h in 60%. Hospital mortality occurred in 104 (38.8%) patients. Higher initial lactate, peak Vasoactive-Inotropic Score (VIS), and lower mean 24-h MAP were associated with higher hospital mortality (all P < 0.001). After multivariable regression, both higher initial lactate (adjusted OR 1.15 per 1 mmol/L higher, 95% CI 1.00-1.31, P = 0.03) and higher peak VIS (adjusted OR 1.20 per 10 units higher, 95% CI 1.10-1.54, P = 0.003) were associated with higher hospital mortality, but mMAP was not (P = 0.92). However, patients with a mMAP < 70 mm Hg remained at higher risk of hospital mortality after multivariable adjustment (adjusted OR 9.30, 95% CI 1.39-62.02, P = 0.02).

Conclusion : In patients treated with TTM after OHCA, greater shock severity, as reflected by higher lactate levels, mMAP < 70 mmHg, and higher vasopressor requirements during the first 24 h was associated with an increased rate of hospital mortality.

Conclusion (proposition de traduction) : Chez les patients traités avec une gestion ciblée de la température après arrêt cardiaque extra-hospitalier, une plus grande gravité du choc, reflétée par des taux de lactate plus élevés, une pression artérielle moyenne < 70 mmHg et des besoins plus élevés en vasopresseurs au cours des 24 premières heures, a été associée à une augmentation du taux de mortalité hospitalière.

Is Tranexamic Acid Associated With Mortality or Multiple Organ Failure Following Severe Injury?.
Richards JE, Fedeles BT, Chow JH, Morrison JJ, Renner C, Trinh AT, Schlee CS, Koerner K, Grissom TE, Betzold RD, Scalea TM, Kozar RA. | Shock. 2021 Jan 1;55(1):55-60
DOI: https://doi.org/10.1097/shk.0000000000001608
Keywords: Aucun

Clinical Science Aspects

Introduction : Tranexamic acid (TXA) administration is recommended in severely injured trauma patients. We examined TXA administration, admission fibrinolysis phenotypes, and clinical outcomes following traumatic injury and hypothesized that TXA was associated with increased multiple organ failure (MOF).

Méthode : Two-year, single-center, retrospective investigation. Inclusion criteria were age ≥ 18 years, Injury Severity Score (ISS) >16, admitted from scene of injury, thromboelastography within 30 min of arrival. Fibrinolysis was evaluated by lysis at 30 min (LY30) and fibrinolysis phenotypes were defined as: Shutdown: LY30 ≤ 0.8%, Physiologic: LY30 0.81-2.9%, Hyperfibrinolysis: LY30 ≥ 3.0%. Primary outcomes were 28-day mortality and MOF. The association of TXA with mortality and MOF was assessed among the entire study population and in each of the fibrinolysis phenotypes.

Résultats : Four hundred twenty patients: 144/420 Shutdown (34.2%), 96/420 Physiologic (22.9%), and 180/410 Hyperfibrinolysis (42.9%). There was no difference in 28-day mortality by TXA administration among the entire study population (P = 0.52). However, there was a significant increase in MOF in patients who received TXA (11/46, 23.9% vs 16/374, 4.3%; P < 0.001). TXA was associated MOF (OR: 3.2, 95% CI 1.2-8.9), after adjusting for confounding variables. There was no difference in MOF in patients who received TXA in the Physiologic (1/5, 20.0% vs 7/91, 7.7%; P = 0.33) group. There was a significant increase in MOF among patients who received TXA in the Shutdown (3/11, 27.3% vs 5/133, 3.8%; P = 0.001) and Hyperfibrinolysis (7/30, 23.3% vs 5/150, 3.3%; P = 0.001) groups.

Conclusion : Administration of TXA following traumatic injury was associated with MOF in the fibrinolysis shutdown and hyperfibrinolysis phenotypes and warrants continued evaluation.

Conclusion (proposition de traduction) : L’administration d’acide tranexamique à la suite d’une blessure traumatique était associée à une défaillance multiviscérale lors de l’arrêt de la fibrinolyse et les phénotypes d’hyperfibrinolyse et justifie une évaluation continue.

Utilization and extravasation of peripheral norepinephrine in the emergency department.
Nguyen TT, Surrey A, Barmaan B, Miller S, Oswalt A, Evans D, Dhindsa H. | Am J Emerg Med. 2021 Jan;39:55-59
DOI: https://doi.org/10.1016/j.ajem.2020.01.014
Keywords: Extravasation; Norepinephrine; Peripheral vasopressors.

Original Contribution

Introduction : Vasopressors are typically administered through central venous catheters (CVC) due to a historical risk of extravasation with peripheral administration. However, CVC insertion is a time-consuming process that may delay vasopressor administration and is associated with complications. The Virginia Commonwealth University Health System (VCUHS) Emergency Department (ED) implemented a protocol that recommends peripheral norepinephrine (pNE) be administered through an 18 gauge or larger at or above the antecubital fossa or the external jugular vein with a maximum dose of 20 μg/min. This study characterizes the use and incidence of extravasation in all adult patients who received pNE initiated in the VCUHS ED.

Méthode : This was an observational, retrospective cohort study in adult patients from March 2016 to March 2019. Of the 331 patients that were screened, 177 met inclusion criteria. Data were analyzed using descriptive statistics.

Résultats : Patients had a median age of 60 years and 59% were male. The median APACHE II score was 25 with an overall hospital mortality of 27%. A majority of patients received pNE for distributive shock (63%). Approximately 69% received pNE through an antecubital infusion site. The median total pNE duration was 62 min (IQR 32, 142). Eighty-four percent of patients received a central line. Only 2.3% of patients had confirmed extravasation in addition to another 2.3% where extravasation could not be excluded, for a total rate of 4.5%. None had subsequent extremity injury.

Conclusion : Administration of pNE according to the VCUHS ED protocol resulted in a low extravasation rate.

Conclusion (proposition de traduction) : L'administration de noradrénaline par voie veineuse périphérique selon le protocole du service d'urgence du système de santé de l'Université du Commonwealth de Virginie a entraîné un faible taux d'extravasation.

Do manual chest compressions provide substantial ventilation during prehospital cardiopulmonary resuscitation?.
Vanwulpen M, Wolfskeil M, Duchatelet C, Hachimi-Idrissi S. | Am J Emerg Med. 2021 Jan;39:129-131
DOI: https://doi.org/10.1016/j.ajem.2020.09.037
Keywords: Advanced cardiac life support; Artificial respiration; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest.

Brief Reports

Introduction : Chest compressions have been suggested to provide passive ventilation during cardiopulmonary resuscitation. Measurements of this passive ventilatory mechanism have only been performed upon arrival of out-of-hospital cardiac arrest patients in the emergency department. Lung and thoracic characteristics rapidly change following cardiac arrest, possibly limiting the effectiveness of this mechanism after prolonged resuscitation efforts. Goal of this study was to quantify passive inspiratory tidal volumes generated by manual chest compression during prehospital cardiopulmonary resuscitation.

Méthode : A flowsensor was used during adult out-of-hospital cardiac arrest cases attended by a prehospital medical team. Adult, endotracheally intubated, non-traumatic cardiac arrest patients were eligible for inclusion. Immediately following intubation, the sensor was connected to the endotracheal tube. The passive inspiratory tidal volumes generated by the first thirty manual chest compressions performed following intubation (without simultaneous manual ventilation) were calculated.

Résultats : 10 patients (5 female) were included, median age was 64 years (IQR 56, 77 years). The median compression frequency was 111 compression per minute (IQR 107, 116 compressions per minute). The median compression depth was 5.6 cm (IQR 5.4 cm, 6.1 cm). The median inspiratory tidal volume generated by manual chest compressions was 20 mL (IQR 13, 28 mL).

Conclusion : Using a flowsensor, passive inspiratory tidal volumes generated by manual chest compressions during prehospital cardiopulmonary resuscitation, were quantified. Chest compressions alone appear unable to provide adequate alveolar ventilation during prehospital treatment of cardiac arrest.

Conclusion (proposition de traduction) : À l'aide d'un capteur de débit, les volumes courants inspiratoires passifs générés par les compressions thoraciques manuelles pendant la réanimation cardio-pulmonaire préhospitalière ont été quantifiés. Les compressions thoraciques seules semblent incapables de fournir une ventilation alvéolaire adéquate pendant le traitement préhospitalier de l'arrêt cardiaque.

Noninvasive ventilation for acute hypoxemic respiratory failure in patients with COVID-19.
Avdeev SN, Yaroshetskiy AI, Tsareva NA, Merzhoeva ZM, Trushenko NV, Nekludova GV, Chikina SY. | Am J Emerg Med. 2021 Jan;39:154-157
DOI: https://doi.org/10.1016/j.ajem.2020.09.075  | Télécharger l'article au format  
Keywords: Acute respiratory failure; COVID-19; Noninvasive ventilation.

Brief Report

Introduction : Noninvasive ventilation (NIV) is known to reduce intubation in patients with acute hypoxemic respiratory failure (AHRF). We aimed to assess the outcomes of NIV application in COVID-19 patients with AHRF.

Méthode : In this retrospective cohort study, patients with confirmed diagnosis of COVID-19 and AHRF receiving NIV in general wards were recruited from two university-affiliated hospitals. Demographic, clinical, and laboratory data were recorded at admission. The failure of NIV was defined as intubation or death during the hospital stay.

Résultats : Between April 8 and June 10, 2020, 61 patients were enrolled into the final cohort. NIV was successful in 44 out of 61 patients (72.1%), 17 patients who failed NIV therapy were intubated, and among them 15 died. Overall mortality rate was 24.6%. Patients who failed NIV were older, and had higher respiratory rate, PaCO2, D-dimer levels before NIV and higher minute ventilation and ventilatory ratio on the 1-st day of NIV. No healthcare workers were infected with SARS-CoV-2 during the study period.

Conclusion : NIV is feasible in patients with COVID-19 and AHRF outside the intensive care unit, and it can be considered as a valuable option for the management of AHRF in these patients.

Conclusion (proposition de traduction) : La VNI est réalisable chez les patients présentant une pneumopathie COVID-19 en SDRA en dehors de l'unité de soins intensifs, et elle peut être considérée comme une option précieuse pour la gestion du SDRA chez ces patients.

Elevated D-dimer levels on admission are associated with severity and increased risk of mortality in COVID-19: A systematic review and meta-analysis.
Gungor B, Atici A, Baycan OF, Alici G, Ozturk F, Tugrul S, Asoglu R, Cevik E, Sahin I, Barman HA. | Am J Emerg Med. 2021 Jan;39:173-179
DOI: https://doi.org/10.1016/j.ajem.2020.09.018  | Télécharger l'article au format  
Keywords: Aucun

Review

Introduction : In this systematic review and meta-analysis, we aimed to investigate the correlation of D-dimer levels measured on admission with disease severity and the risk of death in patients with coronavirus disease 2019 (COVID-19) pneumonia.

Méthode : We performed a comprehensive literature search from several databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. Quality assessment was performed using the Newcastle-Ottawa quality assessment scale (NOS). D-dimer levels were pooled and compared between severe/non-severe and surviving/non-surviving patient groups. Weighted mean difference (WMD), risk ratios (RRs) and 95% confidence intervals (CIs) were analyzed.

Résultats : Thirty-nine studies reported on D-dimer levels in 5750 non-severe and 2063 severe patients and 16 studies reported on D-dimer levels in 2783 surviving and 697 non-surviving cases. D-dimer levels were significantly higher in patients with severe clinical status (WMD: 0.45 mg/L, 95% CI: 0.34-0.56; p < 0.0001). Non-surviving patients had significantly higher D-dimer levels compared to surviving patients (WMD: 5.32 mg/L, 95% CI: 3.90-6.73; p < 0.0001). D-dimer levels above the upper limit of normal (ULN) was associated with higher risk of severity (RR: 1.58, 95% CI: 1.25-2.00; p < 0.0001) and mortality (RR: 1.82, 95% CI: 1.40-2.37; p < 0.0001).

Conclusion : Increased levels of D-dimer levels measured on admission are significantly correlated with the severity of COVID-19 pneumonia and may predict mortality in hospitalized patients.

Conclusion (proposition de traduction) : L'augmentation des taux de D-dimères mesurés à l'admission est significativement corrélée à la gravité de la pneumopathie COVID-19 et peut prédire la mortalité chez les patients hospitalisés.

Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis.
Sahu AK, Suresh S, Mathew R, Aggarwal P, Nayer J. | Am J Emerg Med. 2021 Jan;39:190-196
DOI: https://doi.org/10.1016/j.ajem.2020.09.058  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Chest compression; Personal protective equipment.

Review

Introduction : To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study.

Méthode : This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model.

Résultats : Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: -0.47 to -0.10) and CC depth (SMD: -0.26, 95%CI: -0.44 to -0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78).

Conclusion : The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated.

Conclusion (proposition de traduction) : L'utilisation d'un EPI compromet considérablement la qualité des compressions thoraciques pendant la RCP, et de nouvelles méthodes de compression thoracique doivent être étudiées.

Comparing Diazepam Plus Fentanyl With Midazolam Plus Fentanyl in the Moderate Procedural Sedation of Anterior Shoulder Dislocations: A Randomized Clinical Trial.
Afzalimoghaddam M, Khademi MF, Mirfazaelian H, Payandemehr P, Karimialavijeh E, Jalali A. | J Emerg Med. 2021 Jan;60(1):1-7
DOI: https://doi.org/10.1016/j.jemermed.2020.09.030  | Télécharger l'article au format  
Keywords: conscious sedation; diazepam; fentanyl; midazolam; shoulder dislocation.

Original Contribution

Introduction : The reduction of shoulder dislocation requires adequate procedural sedation and analgesia. The mixture of midazolam and fentanyl is reported in the literature, but long-acting benzodiazepines in conjunction with fentanyl are lacking.

Méthode : This was a randomized controlled clinical trial conducted from April 2019 to December 2019 in the emergency department of a university-affiliated hospital in Tehran, Iran. Participants were adult patients (aged 18-65 years) with anterior shoulder dislocation. Group A (n = 42) received diazepam 0.1 mg/kg plus fentanyl 1 μg/kg IV and group B received midazolam 0.1 mg/kg plus fentanyl 1 μg g/kg IV. Main outcomes measured were onset of muscle relaxation, time taken to reduction, total procedure time, number of the reduction attempts, patient recovery time, the occurrence of the adverse effects, amount of the pain reported by the patients using visual analog scale, and patients and physicians overall satisfaction with the procedure using a Likert scale question.

Résultats : Eighty-one patients were included. The mean ± standard deviation time of the onset of the muscle relaxation and time taken to reduction was shorter in the diazepam plus fentanyl group (p = 0.016 and p = 0.001, respectively). Adverse effects and pain relief were not statistically different between the two groups. Patient recovery time and total procedure time was shorter in the midazolam plus fentanyl group (p = 0.008 and p = 0.02, respectively). The overall satisfaction of patients and physicians was higher in the diazepam plus fentanyl group.

Conclusion : As compared with midazolam plus fentanyl, diazepam plus fentanyl was superior in terms of the onset of the muscle relaxation, patient and physician satisfaction, and time taken to reduction.

Conclusion (proposition de traduction) : Par rapport au midazolam associé au fentanyl, le diazépam associé au fentanyl était supérieur en termes de début de relaxation musculaire, de satisfaction du patient et du médecin et de temps nécessaire à la réduction.

Recognition and Differential Diagnosis of Hereditary Angioedema in the Emergency Department.
Pines JM, Poarch K, Hughes S. | J Emerg Med. 2021 Jan;60(1):35-43
DOI: https://doi.org/10.1016/j.jemermed.2020.09.044  | Télécharger l'article au format  
Keywords: angioedema; bradykinin-mediated; diagnosis; hereditary angioedema; histamine-mediated; pathophysiology; treatment.

Clinical Reviews in Emergency Medicine

Introduction : Angioedema (AE) is a clinical syndrome marked by localized swelling of the subcutaneous layer of the skin or the submucosal layer of the respiratory or gastrointestinal tracts. While AE is commonly mediated by histamine (allergic AE), some types result from excessive bradykinin activity, including hereditary AE (HAE), acquired AE, and angiotensin-converting enzyme inhibitor-induced AE. These are less common but important to consider given different treatment requirements and potentially serious outcomes, including death from laryngeal swelling.

Méthode : This review describes the pathophysiology and clinical features of AE as well as the diagnosis and treatment of AE in the emergency department (ED).

Discussion : Bradykinin-mediated AE does not respond to antihistamines and corticosteroids. By contrast, several targeted, effective therapies are available, including C1-inhibitor (C1-INH) concentrates, which replace the missing protein activity underlying some bradykinin-mediated AE, and medications that directly lessen bradykinin activity (eg, ecallantide and icatibant). Urticaria is generally absent in bradykinin-mediated AE and serves as a primary differentiating factor in the clinical diagnosis. Relevant laboratory assessments may include C1-INH levels, C1-INH function, and C4 complement. Patients with HAE or a family member can communicate their known diagnosis when presenting to the ED, and some may even bring their own medication(s) with them. Patients newly diagnosed with HAE in the ED should be referred for specialized outpatient care upon ED discharge.

Conclusion : There is a great need for ED clinicians to be aware of HAE, its differential diagnosis, and appropriate treatment to ensure that patients receive optimal and timely treatment.

Conclusion (proposition de traduction) : Il est nécessaire que les cliniciens des services d'urgence soient informés sur l'angio-œdème héréditaire, sur son diagnostic différentiel et son traitement approprié pour s'assurer que les patients bénéficient d'un traitement optimal et rapide.

What is the Role of Sugammadex in the Emergency Department?.
Lentz S, Morrissette KM, Porter BA, DeWitt KM, Koyfman A, Long B. | J Emerg Med. 2021 Jan;60(1):44-53
DOI: https://doi.org/10.1016/j.jemermed.2020.08.006  | Télécharger l'article au format  
Keywords: airway management; neuromuscular blockade; rapid sequence intubation; rocuronium; sugammadex.

Clinical Reviews in Emergency Medicine

Introduction : Sugammadex is a medication newly available to many emergency physicians. It effectively, and within minutes, reverses neuromuscular blockade in patients who have received rocuronium or vecuronium. The role of sugammadex for the reversal of neuromuscular blockade after rapid sequence intubation in the emergency department (ED) is evolving, and limited emergency medicine-specific literature exists.

Méthode : This narrative review evaluates the role of sugammadex for the reversal of neuromuscular blockade in the ED.

Discussion : The basic pharmacology, duration of action, adverse effects, and important medication and disease interactions specific to sugammadex are well described. Case reports suggest sugammadex can reverse neuromuscular blockade to facilitate an urgent, neurologic examination by an emergency physician or consultant. Multiple case reports of failure to improve airway patency with the use of sugammadex, even when neuromuscular blockade is completely reversed, and concern for added difficulty of definitive airway management in a patient with spontaneous movement suggest that sugammadex should largely be omitted from failed or difficult airway management strategies. Instead, it is important to focus on the ability to oxygenate and ventilate, including progression to surgical airway or jet ventilation if needed.

Conclusion : Sugammadex is an effective, rapid reversal agent for rocuronium and has the potential use to facilitate an urgent neurologic examination shortly after administration of rocuronium. Its routine inclusion in a failed or difficult emergency airway is not supported by available literature.

Conclusion (proposition de traduction) : Le sugammadex est un agent de réversion rapide et efficace du rocuronium et peut être utilisé pour faciliter un examen neurologique urgent peu de temps après l’administration du rocuronium. Son utilisation systématique dans l'échec de la gestion des voies aériennes ou l'abord des voies aériennes difficiles en urgence n'est pas étayée par la littérature disponible.

Removal of the Prehospital Tourniquet in the Emergency Department.
Levy MJ, Pasley J, Remick KN, Eastman AL, Margolis AM, Tang N, Goolsby CA. | J Emerg Med. 2021 Jan;60(1):98-102
DOI: https://doi.org/10.1016/j.jemermed.2020.10.018  | Télécharger l'article au format  
Keywords: prehospital tourniquet; stop the Bleed; tourniquet conversion; tourniquet removal.

Techniques and Procedures

Introduction : Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place.

Discussion : An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient.

Conclusion : These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.

Conclusion (proposition de traduction) : Ces étapes décrites aideront les cliniciens en médecine d'urgence à évaluer et à gérer de manière appropriée les patients présentant des garrots en place. Le retrait du garrot doit être effectué de manière systématique avec des plans en place pour traiter immédiatement les complications.

Association of timing of initiation of pharmacologic venous thromboembolism prophylaxis with outcomes in trauma patients.
Hecht JP, Han EJ, Cain-Nielsen AH, Scott JW, Hemmila MR, Wahl WL. | J Trauma Acute Care Surg. 2021 Jan 1;90(1):54-63
DOI: https://doi.org/10.1097/ta.0000000000002912
Keywords: Aucun

AAST 2020 PODIUM PAPERS

Introduction : Patients are at a high risk for developing venous thromboembolism (VTE) following traumatic injury. We examined the relationship between timing of initiation of pharmacologic prophylaxis with VTE complications.

Méthode : Trauma quality collaborative data from 34 American College of Surgeons Committee on Trauma-verified levels I and II trauma centers were analyzed. Patients were excluded if they were on anticoagulant therapy at the time of injury, had hospitalization <48 hours, or received no or nonstandard pharmacologic VTE prophylaxis (heparin drip). Patient comparison groups were based on timing of initiation of VTE prophylaxis relative to hospital presentation (0 to <24 hours, 24 to <48 hours, ≥48 hours). Risk-adjusted rates of VTE events were calculated accounting for patient factors including type of pharmacologic agent in addition to standard trauma patient confounders. A sensitivity analysis was performed excluding patients who received blood in the first 4 hours and/or patients with a significant traumatic brain injury.

Résultats : Within the 79,386 patients analyzed, there were 1,495 (1.9%) who experienced a VTE complication and 1,437 (1.8%) who died. After adjusting for type of prophylaxis and patient factors, the risk of a VTE event was significantly increased in the 24- to <48-hour (odds ratio, 1.26; 95% confidence interval, 1.09-1.47; p = 0.002) and ≥48-hour (odds ratio, 2.35; 95% confidence interval, 2.04-2.70; p < 0.001) cohorts relative to patients initiated at 0 to <24 hours. These VTE event findings remained significant after exclusion of perceived higher-risk patients in a sensitivity analysis.

Conclusion : Early initiation of pharmacologic VTE prophylaxis in stable trauma patients is associated with lower rates of VTE.

Conclusion (proposition de traduction) : L'initiation précoce de la prophylaxie pharmacologique de la thrombophlébite chez les patients traumatisés stables est associée à des taux plus faibles de thrombophlébite.

Mean arterial pressure maintenance following spinal cord injury: Does meeting the target matter?.
Weinberg JA, Farber SH, Kalamchi LD, Brigeman ST, Bohl MA, Varda BM, Sioda NA, Radosevich JJ, Chapple KM, Snyder LA. | J Trauma Acute Care Surg. 2021 Jan 1;90(1):97-106
DOI: https://doi.org/10.1097/ta.0000000000002953
Keywords: Aucun

AAST 2020 PODIUM PAPERS

Introduction : Neurosurgical guidelines recommend maintaining mean arterial pressure (MAP) between 85 and 90 mm Hg following acute spinal cord injury (SCI). In our hospital, SCI patients receive orders for MAP targeting for 72 hours following admission, but it is unclear how often the patient's MAP meets the target and whether or not this affects outcome. We hypothesized that the proportion of MAP measurements ≥85 mm Hg would be associated with neurologic recovery.

Méthode : Spinal cord injury patients with blunt mechanism of injury admitted between 2014 and 2019 were identified from the registry of a level 1 trauma center. Proportion of MAP values ≥85 mm Hg was calculated for each patient. Neurologic improvement, as measured by positive change in American Spinal Injury Association (ASIA) impairment scale by ≥1 level from admission to discharge was evaluated with respect to proportion of elevated MAP values.

Résultats : A total of 136 SCI patients were evaluated. Average proportion of elevated MAP values was 75%. Admission ASIA grades were as follows: A, 30 (22.1%); B, 20 (14.7%); C, 28 (20.6%); and D, 58 (42.6%). One hundred six patients (77.9%) required vasopressors to elevate MAP (ASIA A, 86.7%; B, 95.0%; C, 92.9%; D, 60.3%). Forty patients (29.4%) were observed to have improvement in ASIA grade by discharge (admission ASIA A, 15%; B, 33%; C, 40%; D, 13%). The proportion of elevated MAP values was higher for patients with neurologic improvement (0.81 ± 0.15 vs. 0.72 ± 0.25, p = 0.014). Multivariate modeling demonstrated a significant association between proportion of elevated MAP values and neurologic improvement (p = 0.028). An interaction revealed this association to be moderated by vasopressor dose (p = 0.032).

Conclusion : The proportion of MAP measurements ≥85 mm Hg was determined to be an independent predictor of neurologic improvement. Increased vigilance regarding MAP maintenance above 85 mm Hg is warranted to optimize neurologic recovery following SCI.

Conclusion (proposition de traduction) : La proportion de mesures de MAP ≥ 85 mmHg a été déterminée comme étant un prédicteur indépendant de l'amélioration neurologique. Une vigilance accrue concernant le maintien de la MAP au-dessus de 85 mmHg est justifiée pour optimiser la récupération neurologique après une lésion de la moelle épinière.

Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures.
Schwed AC, Wagenaar A, Reppert AE, Gore AV, Pieracci FM, Platnick KB, Lawless RA, Campion EM, Coleman JJ, Cohen MJ, Moore EE, Burlew CC. | J Trauma Acute Care Surg. 2021 Jan 1;90(1):137-142
DOI: https://doi.org/10.1097/ta.0000000000002947
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Use of the focused assessment with sonography for trauma (FAST) examination in patients with pelvic fractures has been reported as unreliable. We hypothesized that FAST is a reliable method for detecting clinically significant intra-abdominal hemorrhage in patients with pelvic fractures.

Méthode : All patients with pelvic fractures over a 10-year period were reviewed at a Level I trauma center. The predictive ability of FAST was assessed by calculating the sensitivity, specificity, positive predictive value and negative predictive value against the criterion standard of either computed tomography (CT) or laparotomy findings. The FAST examination was considered "false negative" if findings at laparotomy indicated traumatic intra-abdominal hemorrhage. Likewise, the FAST examination was considered "false positive" if either CT or findings at laparotomy indicated no intra-abdominal hemorrhage. Hemodynamic instability scores were calculated for all patients.

Résultats : There were 1,456 patients with pelvic fractures and an initial FAST reviewed; 1,219 (83.7%) underwent FAST and either CT or operative exploration. Median age was 43 years (interquartile range, 26-56 years) and mean Injury Severity Score was 18.5 ± 12.3. The sensitivity and specificity for FAST in this group of patients with pelvic fracture was 85.4% and 98.1%, respectively. The positive predictive value and negative predictive value were 78.4% and 98.8%, respectively. Of 21 patients with a false-positive FAST, 15 (71.4%) were confirmed with a negative CT scan, and 6 (28.6%) underwent laparotomy without findings of intra-abdominal hemorrhage. Of 13 patients with a false-negative FAST, all were identified with positive findings at the time of laparotomy. The specificity of the FAST examination remained high regardless of hemodynamic instability score grade.

Conclusion : The false positive rate of FAST examination for intra-abdominal hemorrhage is 1.1%. These data suggest that a positive FAST in this clinical scenario should be considered to represent intra-abdominal fluid. This series contradicts prior reports that FAST is unreliable in patients with pelvic fracture.

Conclusion (proposition de traduction) : Le taux de faux positifs d'examen FAST dans l'hémorragie intra-abdominale est de 1,1 %. Ces données suggèrent qu'une FAST positif dans ce scénario clinique devrait être considéré comme représentant du liquide intra-abdominal. Cette série contredit les rapports antérieurs selon lesquels la FAST n'est pas fiable chez les patients présentant une fracture pelvienne.

Commentaire : FAST : Focused Abdominal Sonography for Trauma

Traumatic brain injury induced temperature dysregulation: What is the role of β blockers?.
Asmar S, Bible L, Chehab M, Tang A, Khurrum M, Castanon L, Ditillo M, Douglas M, Joseph B. | J Trauma Acute Care Surg. 2021 Jan 1;90(1):177-184
DOI: https://doi.org/10.1097/ta.0000000000002975
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ββ) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ββ on PTH in critically-ill TBI patients.

Méthode : We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ββ were excluded. Patients were stratified into (ββ+) and (ββ-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed.

Résultats : We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ββ + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ββ-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ββ+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ββ in terms of reducing the time interval between febrile episodes (p = 0.582).

Conclusion : Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ββ may be a potential therapeutic modality in PTH.

Conclusion (proposition de traduction) : Les bêtabloquants atténuent l'hyperthermie post-traumatique en diminuant la fréquence des épisodes fébriles, en augmentant l'intervalle de temps entre les épisodes fébriles et en réduisant l'élévation maximale de la température. Les bêtabloquants peuvent être une modalité thérapeutique potentielle dans dans l'hyperthermie post-traumatique..

Prognostic significance of preinjury anticoagulation in patients with traumatic brain injury: A systematic review and meta-analysis.
Lim XT, Ang E, Lee ZX, Hajibandeh S, Hajibandeh S. | J Trauma Acute Care Surg. 2021 Jan 1;90(1):191-201
DOI: https://doi.org/10.1097/ta.0000000000002976
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Traumatic brain injury (TBI) is a leading cause of injury-related deaths and neurological disability globally. Considering the widespread anticoagulant use among the aging population, we aimed to perform a systematic review and meta-analysis to evaluate the prognostic significance of preinjury anticoagulation in TBI patients.

Méthode : This systematic review was conducted according to a predefined protocol (International Prospective Register of Systematic Reviews CRD42020192323). In compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology standards, a structured electronic database search was undertaken to identify all observational studies comparing preinjury anticoagulation with no preinjury anticoagulation in TBI patients. The primary outcome measure was overall mortality. The secondary outcome measures comprised in-hospital mortality, length of hospital stay, length of intensive care unit stay, need for neurosurgical procedure, and number of patients discharged home. All outcome data were analyzed using random effects modeling.

Résultats : Twelve comparative studies enrolling a total of 4,417 patients were included. Preinjury anticoagulation was associated with higher risk of overall mortality (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.63-3.50, p < 0.00001), in-hospital mortality (OR, 2.47; 95% CI, 1.56-3.93, p = 0.0001), and longer length of intensive care unit stay (mean difference, 1.06; 95% CI, 0.54-1.57; p < 0.0001) compared with no preinjury anticoagulation. No statistical difference was observed in length of hospital stay (mean difference, -2.15; 95% CI, -5.36 to 1.05, p = 0.19), need for neurosurgical procedure (OR, 1.30; 95% CI, 0.70-2.44; p = 0.41), and discharged home (OR, 0.76; 95% CI, 0.55-1.04; p = 0.09) between the two groups.

Conclusion : Preinjury anticoagulation is a powerful prognosticator of mortality in TBI patients. This highlights the need for dedicated triage and trauma team activation protocols considering earlier intervention and more aggressive imaging in all anticoagulated patients. Future studies should focus on strategies that can potentially reduce the risk of mortality in this population. The prognostic significance of direct oral anticoagulants versus warfarin remains unanswered.

Conclusion (proposition de traduction) : L'anticoagulation pré-lésionnelle est un puissant pronostic de la mortalité chez les patients traumatisés crâniens. Cela met en évidence la nécessité de protocoles d'activation de l'équipe de triage et de traumatologie dédiés en tenant compte d'une intervention plus précoce et d'une imagerie plus agressive chez tous les patients anticoagulés. Les études futures devraient se concentrer sur les stratégies susceptibles de réduire le risque de mortalité dans cette population. La signification pronostique des anticoagulants oraux directs par rapport à la warfarine reste sans réponse.

Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial.
Post R, Germans MR, Tjerkstra MA, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Willems PWA, Wolfs JFC, deBeer FC, Kieft H, Nanda D, van der Pol B, Roks G, de Beer F, Halkes PHA, Reichman LJA, Brouwers PJAM, van den Berg-Vos RM, Kwa VIH, van der Ree TC, Bronner I, van de Vlekkert J, Bienfait HP, Boogaarts HD, Klijn CJM, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWEM, Vandertop WP, Verbaan D; ULTRA Investigators. | Lancet. 2021 Jan 9;397(10269):112-118
DOI: https://doi.org/10.1016/s0140-6736(20)32518-6
Keywords: Aucun

Article

Introduction : In patients with aneurysmal subarachnoid haemorrhage, short-term antifibrinolytic therapy with tranexamic acid has been shown to reduce the risk of rebleeding. However, whether this treatment improves clinical outcome is unclear. We investigated whether ultra-early, short-term treatment with tranexamic acid improves clinical outcome at 6 months.

Méthode : In this multicentre prospective, randomised, controlled, open-label trial with masked outcome assessment, adult patients with spontaneous CT-proven subarachnoid haemorrhage in eight treatment centres and 16 referring hospitals in the Netherlands were randomly assigned to treatment with tranexamic acid in addition to care as usual (tranexamic acid group) or care as usual only (control group). Tranexamic acid was started immediately after diagnosis in the presenting hospital (1 g bolus, followed by continuous infusion of 1 g every 8 h, terminated immediately before aneurysm treatment, or 24 h after start of the medication, whichever came first). The primary endpoint was clinical outcome at 6 months, assessed by the modified Rankin Scale, dichotomised into a good (0-3) or poor (4-6) clinical outcome. Both primary and safety analyses were according to intention to treat.

Résultats : Between July 24, 2013, and July 29, 2019, we enrolled 955 patients; 480 patients were randomly assigned to tranexamic acid and 475 patients to the control group. In the intention-to-treat analysis, good clinical outcome was observed in 287 (60%) of 475 patients in the tranexamic acid group, and 300 (64%) of 470 patients in the control group (treatment centre adjusted odds ratio 0·86, 95% CI 0·66-1·12). Rebleeding after randomisation and before aneurysm treatment occurred in 49 (10%) patients in the tranexamic acid and in 66 (14%) patients in the control group (odds ratio 0·71, 95% CI 0·48-1·04). Other serious adverse events were comparable between groups.

Conclusion : In patients with CT-proven subarachnoid haemorrhage, presumably caused by a ruptured aneurysm, ultra-early, short-term tranexamic acid treatment did not improve clinical outcome at 6 months, as measured by the modified Rankin Scale.

Conclusion (proposition de traduction) : Chez les patients présentant une hémorragie sous-arachnoïdienne retrouvée à la tomodensitométrie, vraisemblablement causée par un anévrisme rompu, un traitement ultra-précoce et à court terme par acide tranexamique n'a pas amélioré le résultat clinique à 6 mois, tel que mesuré par l'échelle de Rankin modifiée.

Sotagliflozin in Patients with Diabetes and Recent Worsening Heart Failure.
Bhatt DL, Szarek M, Steg PG, Cannon CP, Leiter LA, McGuire DK, Lewis JB, Riddle MC, Voors AA, Metra M, Lund LH, Komajda M, Testani JM, Wilcox CS, Ponikowski P, Lopes RD, Verma S, Lapuerta P, Pitt B; SOLOIST-WHF Trial Investigators. | N Engl J Med. 2021 Jan 14;384(2):117-128
DOI: https://doi.org/10.1056/nejmoa2030183
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of hospitalization for heart failure or death from cardiovascular causes among patients with stable heart failure. However, the safety and efficacy of SGLT2 inhibitors when initiated soon after an episode of decompensated heart failure are unknown.

Méthode : We performed a multicenter, double-blind trial in which patients with type 2 diabetes mellitus who were recently hospitalized for worsening heart failure were randomly assigned to receive sotagliflozin or placebo. The primary end point was the total number of deaths from cardiovascular causes and hospitalizations and urgent visits for heart failure (first and subsequent events). The trial ended early because of loss of funding from the sponsor.

Résultats : A total of 1222 patients underwent randomization (608 to the sotagliflozin group and 614 to the placebo group) and were followed for a median of 9.0 months; the first dose of sotagliflozin or placebo was administered before discharge in 48.8% and a median of 2 days after discharge in 51.2%. Among these patients, 600 primary end-point events occurred (245 in the sotagliflozin group and 355 in the placebo group). The rate (the number of events per 100 patient-years) of primary end-point events was lower in the sotagliflozin group than in the placebo group (51.0 vs. 76.3; hazard ratio, 0.67; 95% confidence interval [CI], 0.52 to 0.85; P<0.001). The rate of death from cardiovascular causes was 10.6 in the sotagliflozin group and 12.5 in the placebo group (hazard ratio, 0.84; 95% CI, 0.58 to 1.22); the rate of death from any cause was 13.5 in the sotagliflozin group and 16.3 in the placebo group (hazard ratio, 0.82; 95% CI, 0.59 to 1.14). Diarrhea was more common with sotagliflozin than with placebo (6.1% vs. 3.4%), as was severe hypoglycemia (1.5% vs. 0.3%). The percentage of patients with hypotension was similar in the sotagliflozin group and the placebo group (6.0% and 4.6%, respectively), as was the percentage with acute kidney injury (4.1% and 4.4%, respectively). The benefits of sotagliflozin were consistent in the prespecified subgroups of patients stratified according to the timing of the first dose.

Conclusion : In patients with diabetes and recent worsening heart failure, sotagliflozin therapy, initiated before or shortly after discharge, resulted in a significantly lower total number of deaths from cardiovascular causes and hospitalizations and urgent visits for heart failure than placebo.

Conclusion (proposition de traduction) : Chez les patients diabétiques et présentant une aggravation récente de l'insuffisance cardiaque, le traitement par la sotagliflozine, initié avant ou peu après la sortie de l'hôpital, a entraîné un nombre total de décès de causes cardiovasculaires et d'hospitalisations et de visites urgentes pour insuffisance cardiaque significativement inférieur à celui du placebo.