Comparison of the Loop Technique With Incision and Drainage for Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis.
Gottlieb M, Schmitz G, Peksa GD. | Acad Emerg Med. 2021 Mar;28(3):346-354
DOI: https://doi.org/10.1111/acem.14151
Keywords: Aucun

SYSTEMATIC REVIEWS (WITH OR WITHOUT META‐ANALYSES)

Introduction : Cutaneous abscesses are common presentations to the emergency department. While the primary treatment for most abscesses is conventional incision and drainage (CID), this is painful and can lead to multiple return visits. The loop drainage technique (LDT) has been proposed as an alternate, less-invasive approach to abscess management. The primary outcome of this study was to compare LDT with CID for skin and soft tissue abscesses.

Méthode : PubMed, Scopus, CINAHL, LILACS, Google Scholar, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all retrospective, prospective observational, and randomized controlled trials comparing treatment failures between LDT and CID among patients with skin and soft tissue abscesses. Data were dual extracted into a predefined worksheet and quality analysis was performed using the Cochrane Risk of Bias tool or the Newcastle-Ottawa scale. Data were summarized and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Subgroup analyses were performed for adult and pediatric patients.

Résultats : A total of 1,374 studies were identified with eight studies (n = 910 patients) selected for inclusion. Overall, CID failed in 69 of 487 patients (14.17%), while LDT failed in 35 of 423 patients (8.27%). There was an OR of 2.02 (95% CI = 1.29 to 3.18) in favor of higher failures in the CID group. This finding remained consistent with only randomized controlled trials (OR = 1.75, 95% CI = 1.07 to 2.86), but no difference was identified in the adult or pediatric subgroups.

Conclusion : The LDT was associated with reduced treatment failures when compared with CID. Future studies should further assess the impact on pain, cosmetic outcomes, and health care costs.

Conclusion (proposition de traduction) : La technique de drainage en boucle était associée à une réduction des échecs de traitement par rapport à l'incision et au drainage conventionnels. Les études futures devraient évaluer davantage l'impact sur la douleur, les résultats esthétiques et les coûts des soins de santé.

Commentaire :  Tiré de : Ladde JG, Baker S, Rodgers CN, Papa L. The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. Am J Emerg Med. 2015 Feb;33(2):271-6  .
Consulter également le texte : Prise en charge des infections cutanées bactériennes courantes. Méthode Recommandations pour la pratique clinique  . SPILF, SFD et HAS, Février 2019 (9.4 Prise en charge - page 95).

The Adjunctive Effect of Intravenous Magnesium Sulfate in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Randomized Controlled Clinical Trial.
Vafadar Moradi E, Pishbin E, Habibzadeh SR, Talebi Doluee M, Soltanifar A. | Acad Emerg Med. 2021 Mar;28(3):359-362
DOI: https://doi.org/10.1111/acem.14050
Keywords: Aucun

RESEARCH LETTERS

Editorial : Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death worldwide. Acute exacerbation of COPD (AECOPD) is a serious event during the natural course of the disease. Despite many clinical trials on the management of AECOPD, treatment has not changed significantly during the past decades. Intravenous (IV) magnesium sulfate (MgS04) has been proposed to enhance the bronchodilator effects of inhaled beta2-agonists. Magnesium is involved in many enzymatic processes. It relaxes bronchial smooth muscles through its calcium channel blocking properties and inhibitory effects on the release of acetylcholine from neuromuscular junctions. It also exerts antiinflammatory effects by attenuating the respiratory neutrophil burst and decreasing histamine release from mast cells. Some studies have proposed using MgSO4 for treatment of AECOPD via IV infusion or nebulization. The pretext for the use of MgSO4 in COPD was its reported efficacy in asthma exacerbation. Asthma and COPD represent overlapping clinical entities and they may co-occur, although they are clinically distinct diseases. There are several interventions which exert useful therapeutic effects for both asthma and COPD. However, there is still no conclusive evidence on MgSO4 for AECOPD. We conducted a randomized double-blind placebo controlled clinical trial to investigate the clinical benefits of IV MgSO4 as an adjuvant to standard treatment in patients with AECOPD.

Conclusion : The results of our trial supports the use of MgSO4 as an adjunct to standard treatment in AECOPD.

Conclusion (proposition de traduction) : Les résultats de notre essai soutiennent l’utilisation du MgSO⁴ comme adjuvant au traitement standard pour l’exacerbation aiguë de la maladie pulmonaire obstructive chronique (décompensation aigüe de BPCO).

Truchot J, Michelet D, Drummond D, Ceccald PF, Tesnières A, Plaisance P. | Ann Fr Med Urgence. 2021 March;11:87-92
DOI: https://doi.org/10.3166/afmu-2021-0316
Keywords: Cardiac arrest; Simulation; Pedagogy; Advance life support; Cardio pulmonary resuscitation

Original article

Introduction : La simulation est un outil d’enseignement en médecine qui a montré un bénéfice entre autres pour l’apprentissage de la réanimation cardiopulmonaire (RCP). Cependant, la RCP simulée peut différer grandement de la RCP en conditions réelles. Le but de cette étude exploratoire était d’identifier des éléments perturbateurs susceptibles d’intervenir lors d’une RCP.

Méthode : Il s’agit d’une étude transversale anonyme par questionnaire distribué par courrier électronique aux urgentistes de cinq services d’urgences à Paris. Le questionnaire comprenait des questions sur les éléments perturbateurs lors d’une RCP. D’autres questions ont exploré les différences perçues entre la RCP simulée et la RCP réelle. Les résultats sont exprimés sous forme de pourcentages et moyennes (± écart-type).

Résultats : Sur 100 médecins interrogés, 43 (43 %) réponses ont été analysées. Cinquante-trois pour cent étaient des femmes âgées en moyenne de 32 ± 3 ans. Les éléments perturbateurs de la RCP dans la vie réelle étaient principalement les interruptions de tâches provenant du personnel non médical (n = 16 ; 37 %), de la famille du patient (n = 5 ; 12 %), des autres spécialistes (n = 5 ; 12 %) et des appels téléphoniques (n = 2 ; 5 %). La saturation du flux patient des urgences (n = 12 ; 28 %) a également été mentionnée comme perturbateur. Les médecins ont aussi déclaré que certaines compétences techniques et non techniques étaient plus difficiles à réaliser dans la vie réelle que lors de simulations.

Conclusion (proposition de traduction) : Cette étude exploratoire a permis d’identifier des éléments perturbateurs rencontrés dans des cas réels de RCP qui pourront être intégrés aux sessions de simulation afin d’en augmenter le réalisme.

Assessment of the Thyromental Height Test as an Effective Airway Evaluation Tool.
Zimmerman B, Chason H, Schick A, Asselin N, Lindquist D, Musisca N. | Ann Emerg Med. 2021 March ;77(3):305-14
DOI: https://doi.org/10.1016/j.annemergmed.2020.10.010
Keywords: Aucun

Airway

Editorial : Airway assessment attempts to predict difficulty in multiple dimensions of airway management. This article will exclusively focus on anatomic difficulty in laryngoscopy and intubation. Other important dimensions not covered include face mask ventilation, extraglottic device placement, and cricothyrotomy

Introduction : L'évaluation des voies respiratoires tente de prédire la difficulté dans de multiples dimensions de la gestion des voies respiratoires. Cet article se concentre exclusivement sur les difficultés anatomiques de la laryngoscopie et de l'intubation. Les autres dimensions importantes non couvertes comprennent la ventilation du masque facial, le placement du dispositif extraglottique et la cricothyroïdotomie.

Conclusion : In conclusion, we should reevaluate our approach to teaching airway assessment to maximize patient and provider safety and minimize the difficulty of learning this critical skill.

Conclusion (proposition de traduction) : En conclusion, nous devrions réévaluer notre approche de l'enseignement de l'évaluation des voies respiratoires afin de maximiser la sécurité des patients et des prestataires et minimiser la difficulté d'apprendre cette compétence essentielle.

Inter-hospital transport of critically ill patients to manage the intensive care unit surge during the COVID-19 pandemic in France.
Painvin B, Messet H, Rodriguez M, Lebouvier T, Chatellier D, Soulat L, Ehrmann S, Thille AW, Gacouin A, Tadie JM. | Ann Intensive Care. 2021 Mar 31;11(1):54
DOI: https://doi.org/10.1186/s13613-021-00841-5  | Télécharger l'article au format  
Keywords: ARDS; COVID-19; Hospital transport; Intensive care unit; Mechanical ventilation; Mortality.

Research

Introduction : The COVID-19 pandemic led authorities to evacuate via various travel modalities critically ill ventilated patients into less crowded units. However, it is not known if interhospital transport impacts COVID-19 patient's mortality in intensive care units (ICUs). A cohort from three French University Hospitals was analysed in ICUs between 15th of March and the 15th of April 2020. Patients admitted to ICU with positive COVID-19 test and mechanically ventilated were recruited.

Résultats : Among the 133 patients included in the study, 95 (71%) were male patients and median age was 63 years old (interquartile range: 54-71). Overall ICU mortality was 11%. Mode of transport included train (48 patients), ambulance (6 patients), and plane plus helicopter (14 patients). During their ICU stay, 7 (10%) transferred patients and 8 (12%) non-transferred patients died (p = 0.71). Median SAPS II score at admission was 33 (interquartile range: 25-46) for the transferred group and 35 (27-42) for non-transferred patients (p = 0.53). SOFA score at admission was 4 (3-6) for the transferred group versus 3 (2-5) for the non-transferred group (p = 0.25). In the transferred group, median PaO2/FiO2 ratio (P/F) value in the 24 h before departure was 197 mmHg (160-250) and remained 166 mmHg (125-222) in the first 24 h post arrival (p = 0.13). During the evacuation 46 (68%) and 21 (31%) of the patients, respectively, benefited from neuromuscular blocking agents and from vasopressors. Transferred and non-transferred patients had similar rate of nosocomial infections, 37/68 (54%) versus 34/65 (52%), respectively (p = 0.80). Median length of mechanical ventilation was significantly increased in the transferred group compared to the non-transferred group, 18 days (11-24) and 14 days (8-20), respectively (p = 0.007). Finally, ICU and hospital length of stay did not differ between groups.

Conclusion : In France, inter-hospital evacuation of COVID-19 ventilated ICU patients did not appear to increase mortality and therefore could be proposed to manage ICU surges in the future.

Conclusion (proposition de traduction) : En France, l'évacuation interhospitalière des patients en USI ventilés pour COVID-19 n'a pas semblé augmenter la mortalité et pourrait donc être proposée pour gérer les surtensions en USI à l'avenir.

Ability of procalcitonin to distinguish between bacterial and nonbacterial infection in severe acute exacerbation of chronic obstructive pulmonary syndrome in the ICU.
Daubin C, Fournel F, Thiollière F, Daviaud F, Ramakers M, Polito A, Flocard B, Valette X, Du Cheyron D, Terzi N, Fartoukh M, Allouche S, Parienti JJ; from the PROCALCIVIR and BPCTrea study group. | Ann Intensive Care. 2021 Mar 6;11(1):39
DOI: https://doi.org/10.1186/s13613-021-00816-6  | Télécharger l'article au format  
Keywords: Antibiotic stewardship; Chronic obstructive pulmonary disease; Community-acquired pneumonia; Procalcitonin; Respiratory tract infection; Viral infection.

RESEARCH

Introduction : To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis.

Résultats : Regarding the entire cohort (n = 375), at any time, the PCT levels significantly differed between groups (Kruskal-Wallis test, p < 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (n = 94) than in patients without documented pathogens (n = 218) (p < 0.001). No significant difference was observed between patients with bacterial and viral infection (n = 63). For example, the median PCT-H0 levels were 0.64 ng/ml [0.22-0.87] in the bacterial group vs 0.24 ng/ml [0.15-0.37] in the viral group and 0.16 ng/mL [0.11-0.22] in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58-0.71) at H0, 0.64 [95% CI 0.57-0.70] at H6 and 0.63 (95% CI; 0.56-0.69) at H24, PCT had a low accuracy for predicting bacterial infection (BAC + group).

Conclusion : Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.

Conclusion (proposition de traduction) : Malgré des niveaux plus élevés de PCT dans l’exacerbation aiguë sévère de la BPCO causée par une infection bactérienne, le PCT n’a pas réussi à faire la distinction entre une infection bactérienne et une infection non bactérienne. La procalcitonine pourrait ne pas être suffisante comme marqueur autonome pour initier un traitement antibiotique dans ce contexte.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : La procalcitonine ne permet pas de guider la décision d’instaurer ou pas une antibiothérapie au cours des exacerbations aiguës de BPCO en réanimation  . Rédigé par le Dr Olivier Leroy, le 27 avril 2021.

The Correlation between Head of Bed Angle and Intra-Abdominal Pressure of Intubated Patients; a Pre-Post Clinical Trial.
Samimian S, Ashrafi S, Khaleghdoost Mohammadi T, Yeganeh MR, Ashraf A, Hakimi H, Dehghani M. | Arch Acad Emerg Med. 2021 Mar 6;9(1):e23
DOI: https://doi.org/10.22037/aaem.v9i1.1065  | Télécharger l'article au format  
Keywords: Compartment syndrome; Critical care; Head of Bed; Intra-abdominal Hypertension; Pressure; Supine Position.

Original/Research Article

Introduction : The recommended position for measuring Intra-Abdominal Pressure (IAP) is the supine position. However, patients put in this position are prone to Ventilator-associated pneumonia. This study was done to evaluate the relationship between bed head angle and IAP measurements of intubated patients in the intensive care unit.

Méthode : In this clinical trial, seventy-six critically ill patients under mechanical ventilation were enrolled. IAP measurement was performed every 8 hours for 24 hours using the KORN method in three different degrees of the head of bed (HOB) elevation (0°, 15°, and 30°). Bland-Altman analysis was performed to identify the bias and limits of agreement among the three HOBs. According to World Society of the Abdominal Compartment Syndrome (WSACS), we can consider two IAP techniques equivalent if a bias of <1 mmHg and limits of agreement of - 4 to +4 were found between them. Data were analyzed using SPSS statistical software (v. 19), and the significance level was considered as 0.05.

Résultats : The prevalence of intra-abdominal hypertension was 18.42%. Mean ± standard deviation (SD) of IAP were 8.44 ± 4.02 mmHg for HOB angle 0°, 9.58 ± 4.52 for HOB angle 15°, and 11.10 ± 4.73 for HOB angle 30o (p = 0.0001). The IAP measurement bias between HOB angle 0°and HOB angle 15° was 1.13 mmHg. This bias was 2.66 mmHg between HOB angle 0° and HOB angle 30°.

Conclusion : Elevation of HOB angle from 0 to 30 degree significantly increases IAP. It seems that the measurement of IAP at HOB angle 15° was more reliable than 30°.

Conclusion (proposition de traduction) : L'élévation de l'angle de la tête de lit de 0 à 30 degrés augmente considérablement la pression intra-abdominale. Il semble que la mesure de la pression intra-abdominale pour un angle de la tête du lit de 15° était plus fiable que 30°.

High flow oxygen and risk of mortality in patients with a suspected acute coronary syndrome: pragmatic, cluster randomised, crossover trial.
Stewart RAH, Jones P, Dicker B, Jiang Y, Smith T, Swain A, Kerr A, Scott T, Smyth D, Ranchord A, Edmond J, Than M, Webster M, White HD, Devlin G. | BMJ. 2021 Mar 2;372:n355
DOI: https://doi.org/10.1136/bmj.n355  | Télécharger l'article au format  
Keywords: Aucun

Research

Introduction : To determine the association between high flow supplementary oxygen and 30 day mortality in patients presenting with a suspected acute coronary syndrome (ACS).
Design: Pragmatic, cluster randomised, crossover trial.
Setting: Four geographical regions in New Zealand.
Participants: 40 872 patients with suspected or confirmed ACS included in the All New Zealand Acute Coronary Syndrome Quality Improvement registry or ambulance ACS pathway during the study periods. 20 304 patients were managed using the high oxygen protocol and 20 568 were managed using the low oxygen protocol. Final diagnosis of ST elevation myocardial infarction (STEMI) and non-STEMI were determined from the registry and ICD-10 discharge codes.
Interventions: The four geographical regions were randomly allocated to each of two oxygen protocols in six month blocks over two years. The high oxygen protocol recommended oxygen at 6-8 L/min by face mask for ischaemic symptoms or electrocardiographic changes, irrespective of the transcapillary oxygen saturation (SpO2). The low oxygen protocol recommended oxygen only if SpO2 was less than 90%, with a target SpO2 of less than 95%.

Méthode : 30 day all cause mortality determined from linkage to administrative data.

Résultats : Personal and clinical characteristics of patients managed under both oxygen protocols were well matched. For patients with suspected ACS, 30 day mortality for the high and low oxygen groups was 613 (3.0%) and 642 (3.1%), respectively (odds ratio 0.97, 95% confidence interval 0.86 to 1.08). For 4159 (10%) patients with STEMI, 30 day mortality for the high and low oxygen groups was 8.8% (n=178) and 10.6% (n=225), respectively (0.81, 0.66 to 1.00) and for 10 218 (25%) patients with non-STEMI was 3.6% (n=187) and 3.5% (n=176), respectively (1.05, 0.85 to 1.29).

Conclusion : In a large patient cohort presenting with suspected ACS, high flow oxygen was not associated with an increase or decrease in 30 day mortality.

Conclusion (proposition de traduction) : Dans une grande cohorte de patients suspect de présenter un syndrome coronarien aigu, l'oxygène à haut débit n'a pas été associé à une augmentation ou une diminution de la mortalité à 30 jours.

Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management.
Austin DR, Chang MG, Bittner EA. | Chest. 2021 Mar;159(3):1155-1165
DOI: https://doi.org/10.1016/j.chest.2020.09.083
Keywords: POCUS; airway management; emergency airway management; intubation; point-of-care ultrasound; ultrasound.

Review article

Editorial : Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.

Conclusion : Our review summarizing the emerging body of literature surrounding ultrasound in EAM suggests that POCUS has a role for reducing the high rate of complications, morbidity, and mortality related to EAM. Our algorithm for the incorporation of this emerging technology into the existing clinical practice of EAM may improve patient safety and serve as a framework for future validation studies.

Conclusion (proposition de traduction) : Notre revue résumant l'état de l'art sur l’échographie dans la gestion des voies aériennes d’urgence suggère que l’échographie au point d'intervention joue un rôle dans la réduction du taux élevé de complications, de morbidité et de mortalité liées à la gestion des voies aériennes d’urgence. Notre algorithme pour l’incorporation de cette nouvelle technologie dans la pratique clinique existante de la gestion des voies aériennes d’urgence pourrait améliorer la sécurité des patients et servir de cadre pour de futures études de validation.

Antibiotic Prescribing Choices and Their Comparative C. Difficile Infection Risks: A Longitudinal Case-Cohort Study.
Brown KA, Langford B, Schwartz KL, Diong C, Garber G, Daneman N. | Clin Infect Dis. 2021 Mar 1;72(5):836-844
DOI: https://doi.org/10.1093/cid/ciaa124
Keywords: Clostridioides difficile infection; CDI; antibiotics; cohort study; comparative effectiveness.

MAJOR ARTICLE

Introduction : Antibiotic use is the strongest modifiable risk factor for the development of Clostridioides difficile infection, but prescribers lack quantitative information on comparative risks of specific antibiotic courses. Our objective was to estimate risks of C. difficile infection associated with receipt of specific antibiotic courses.

Méthode : We conducted a longitudinal case-cohort analysis representing over 90% of Ontario nursing home residents, between 2012 and 2017. Our primary exposure was days of antibiotic receipt in the prior 90 days. Adjustment covariates included: age, sex, prior emergency department or acute care stay, Charlson comorbidity index, prior C. difficile infection, acid suppressant use, device use, and functional status. We examined incident C. difficile infection, including cases identified within the nursing home, and those identified during subsequent hospital admissions. Adjusted and unadjusted regression models were used to measure risk associated with 5- to 14-day courses of 18 different antibiotics.

Résultats : We identified 1708 cases of C. difficile infection (1.27 per 100 000 resident-days). Longer antibiotic duration was associated with increased risk: 10- and 14-day courses incurred 12% (adjusted relative risk [ARR] = 1.12, 95% confidence interval [CI]: 1.09, 1.14) and 27% (ARR = 1.27, 95% CI: 1.21,1.30) more risk compared to 7-day courses. Among 7-day courses with similar indications: moxifloxacin resulted in 121% more risk than amoxicillin (ARR = 2.21, 95% CI: 1.67, 3.08), ciprofloxacin engendered 89% more risk than nitrofurantoin (ARR = 1.89, 95% CI: 1.45, 2.68), and clindamycin resulted in 112% (ARR = 2.12, 95% CI: 1.32, 3.78) more risk than cloxacillin.

Conclusion : C. difficile infection risk increases with antibiotic duration, and there are wide disparities in risks associated with antibiotic courses used for similar indications.

Conclusion (proposition de traduction) : Le risque d'infection à C. difficile augmente avec la durée de l'antibiothérapie et il existe de grandes disparités dans les risques associés aux traitements antibiotiques utilisés pour des indications similaires.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Risque d’infection à Clostridioides difficile selon les antibiotiques et les durées de traitement  . Rédigé par le Dr Jean-Pierre Bru, le 11/03/2021.

High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome.
Santa Cruz R, Villarejo F, Irrazabal C, Ciapponi A. | Cochrane Database Syst Rev. 2021 Mar 30;3:CD009098
DOI: https://doi.org/10.1002/14651858.cd009098.pub3  | Télécharger l'article au format  
Keywords: Aucun

Intervention

Introduction : In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. This is an updated version of the review first published in 2013.
Objectives: To assess the benefits and harms of high versus low levels of PEEP in adults with ALI and ARDS.

Méthode : For our previous review, we searched databases from inception until 2013. For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and the Web of Science from inception until May 2020. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov; www.controlled-trials.com), and we screened the reference lists of included studies.
Selection criteria: We included randomised controlled trials that compared high versus low levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours.
Data collection and analysis: Two review authors assessed risk of bias and extracted data independently. We contacted investigators to identify additional published and unpublished studies. We used standard methodological procedures expected by Cochrane.

Résultats : We included four new studies (1343 participants) in this review update. In total, we included 10 studies (3851 participants). We found evidence of risk of bias in six studies, and the remaining studies fulfilled all criteria for low risk of bias. In eight studies (3703 participants), a comparison was made between high and low levels of PEEP, with the same tidal volume in both groups. In the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. In the main analysis, we assessed mortality occurring before hospital discharge only in studies that compared high versus low PEEP, with the same tidal volume in both groups. Evidence suggests that high PEEP may result in little to no difference in mortality compared to low PEEP (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.04; I² = 15%; 7 studies, 3640 participants; moderate-certainty evidence). In addition, high PEEP may result in little to no difference in barotrauma (RR 1.00, 95% CI 0.64 to 1.57; I² = 63%; 9 studies, 3791 participants; low-certainty evidence). High PEEP may improve oxygenation in patients up to the first and third days of mechanical ventilation (first day: mean difference (MD) 51.03, 95% CI 35.86 to 66.20; I² = 85%; 6 studies, 2594 participants; low-certainty evidence; third day: MD 50.32, 95% CI 34.92 to 65.72; I² = 83%; 6 studies, 2309 participants; low-certainty evidence) and probably improves oxygenation up to the seventh day (MD 28.52, 95% CI 20.82 to 36.21; I² = 0%; 5 studies, 1611 participants; moderate-certainty evidence). Evidence suggests that high PEEP results in little to no difference in the number of ventilator-free days (MD 0.45, 95% CI -2.02 to 2.92; I² = 81%; 3 studies, 1654 participants; low-certainty evidence). Available data were insufficient to pool the evidence for length of stay in the intensive care unit.

Conclusion : Moderate-certainty evidence shows that high levels compared to low levels of PEEP do not reduce mortality before hospital discharge. Low-certainty evidence suggests that high levels of PEEP result in little to no difference in the risk of barotrauma. Low-certainty evidence also suggests that high levels of PEEP improve oxygenation up to the first and third days of mechanical ventilation, and moderate-certainty evidence indicates that high levels of PEEP improve oxygenation up to the seventh day of mechanical ventilation. As in our previous review, we found clinical heterogeneity - mainly within participant characteristics and methods of titrating PEEP - that does not allow us to draw definitive conclusions regarding the use of high levels of PEEP in patients with ALI and ARDS. Further studies should aim to determine the appropriate method of using high levels of PEEP and the advantages and disadvantages associated with high levels of PEEP in different ARDS and ALI patient populations.

Conclusion (proposition de traduction) : Des preuves de certitude modérée montrent que des niveaux élevés comparés à de faibles niveaux de PEEP ne réduisent pas la mortalité avant la sortie de l'hôpital. Des preuves de faible certitude suggèrent que des niveaux élevés de PEEP entraînent peu ou pas de différence dans le risque de barotraumatisme. Des preuves de faible certitude suggèrent également que des niveaux élevés de PEEP améliorent l'oxygénation jusqu'aux premier et troisième jours de ventilation mécanique, et des preuves de certitude modérée indiquent que des niveaux élevés de PEEP améliorent l'oxygénation jusqu'au septième jour de ventilation mécanique. Comme dans notre revue précédente, nous avons trouvé une hétérogénéité clinique - principalement au sein des caractéristiques des participants et des méthodes de titrage de la PEEP - qui ne nous permet pas de tirer des conclusions définitives concernant l'utilisation de niveaux élevés de PEEP chez les patients présentant une lésion pulmonaire aiguë et un syndrome de détresse respiratoire aiguë. D'autres études devraient viser à déterminer la méthode appropriée d'utilisation de niveaux élevés de PEEP et les avantages et inconvénients associés à des niveaux élevés de PEEP dans différentes populations de patients atteints de syndrome de détresse respiratoire aiguë et de lésions pulmonaires aiguës.

High-flow nasal cannulae for respiratory support in adult intensive care patients.
Lewis SR, Baker PE, Parker R, Smith AF. | Cochrane Database Syst Rev. 2021 Mar 4;3:CD010172
DOI: https://doi.org/10.1002/14651858.cd010172.pub3  | Télécharger l'article au format  
Keywords: Aucun

Intervention

Introduction : High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review.
Objectives: To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU.

Méthode : We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches.
Selection criteria: We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU.
Data collection and analysis: We used standard methodological procedures as expected by Cochrane.

Résultats : We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evide

Conclusion : HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit peut conduire à moins d'échec du traitement par rapport à l'oxygénothérapie standard, mais fait probablement peu ou pas de différence en échec du traitement par rapport à la VNI ou NIPPV. Pour la plupart des autres résultats de la revue, nous n'avons trouvé aucune preuve d'une différence d'effet. Cependant, les preuves étaient souvent de faible ou très faible certitude. Nous avons trouvé un grand nombre d'études en cours ; les inclure dans les futures mises à jour pourrait accroître la certitude ou modifier la direction de ces effets.

Commentaire : L’utilisation de canules nasales à haut débit dans l'assistance respiratoire chez les patients adultes en soins intensifs   (traduction en français sur le site La Collaboration Cochrane  )

Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies.
Papoutsi E, Giannakoulis VG, Xourgia E, Routsi C, Kotanidou A, Siempos II. | Crit Care. 2021 Mar 25;25(1):121
DOI: https://doi.org/10.1186/s13054-021-03540-6  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; Acute respiratory failure; Coronavirus; Delayed; Intensive care unit; Pneumonia.

Research

Introduction : Although several international guidelines recommend early over late intubation of patients with severe coronavirus disease 2019 (COVID-19), this issue is still controversial. We aimed to investigate the effect (if any) of timing of intubation on clinical outcomes of critically ill patients with COVID-19 by carrying out a systematic review and meta-analysis.

Méthode : PubMed and Scopus were systematically searched, while references and preprint servers were explored, for relevant articles up to December 26, 2020, to identify studies which reported on mortality and/or morbidity of patients with COVID-19 undergoing early versus late intubation. "Early" was defined as intubation within 24 h from intensive care unit (ICU) admission, while "late" as intubation at any time after 24 h of ICU admission. All-cause mortality and duration of mechanical ventilation (MV) were the primary outcomes of the meta-analysis. Pooled risk ratio (RR), pooled mean difference (MD) and 95% confidence intervals (CI) were calculated using a random effects model.

Résultats : A total of 12 studies, involving 8944 critically ill patients with COVID-19, were included. There was no statistically detectable difference on all-cause mortality between patients undergoing early versus late intubation (3981 deaths; 45.4% versus 39.1%; RR 1.07, 95% CI 0.99-1.15, p = 0.08). This was also the case for duration of MV (1892 patients; MD - 0.58 days, 95% CI - 3.06 to 1.89 days, p = 0.65). In a sensitivity analysis using an alternate definition of early/late intubation, intubation without versus with a prior trial of high-flow nasal cannula or noninvasive mechanical ventilation was still not associated with a statistically detectable difference on all-cause mortality (1128 deaths; 48.9% versus 42.5%; RR 1.11, 95% CI 0.99-1.25, p = 0.08).

Conclusion : The synthesized evidence suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19. These results might justify a wait-and-see approach, which may lead to fewer intubations. Relevant guidelines may therefore need to be updated.

Conclusion (proposition de traduction) : Les preuves synthétisées suggèrent que le moment de l'intubation peut n'avoir aucun effet sur la mortalité et la morbidité des patients de réanimation atteints de la COVID-19. Ces résultats pourraient justifier une approche attentiste, ce qui peut conduire à moins d'intubations. Il se peut donc que les lignes directrices pertinentes doivent être mises à jour.

Decreased mortality in acute respiratory distress syndrome patients treated with corticosteroids: an updated meta-analysis of randomized clinical trials with trial sequential analysis.
Lin P, Zhao Y, Li X, Jiang F, Liang Z. | Crit Care. 2021 Mar 26;25(1):122
DOI: https://doi.org/10.1186/s13054-021-03546-0  | Télécharger l'article au format  
Keywords: Acute respiratory distress syndrome; Glucocorticoids; Meta-analysis; Randomized clinical trial.

Research

Introduction : The possible benefits associated with corticosteroid treatment in acute respiratory distress syndrome (ARDS) patients are not fully known. We conducted an updated meta-analysis to assess the effect of corticosteroids in the treatment of patients with ARDS.

Méthode : We systematically searched MEDLINE, Embase, and the Cochrane Library from inception to January 2021 via Ovid to identify randomized controlled trials evaluating the efficacy of glucocorticoids in the treatment of patients with ARDS. The primary outcome was hospital mortality. Secondary outcomes included the number of ventilator-free days at day 28, oxygenation improvement (PaO₂/FIO₂ ratios), and adverse events.

Résultats : Nine studies with 1371 participants were analyzed. The pooled analysis revealed that glucocorticoid use was associated with reduced mortality [relative risk (RR), 0.83; 95% confidence interval (CI) 0.74-0.93; P < 0.01; I2 = 37], and the statistical power was confirmed by trial sequential analysis. Glucocorticoids might also significantly increase the number of ventilator-free days at day 28 (mean deviation 3.66 days, 95% CI 2.64-4.68; P < 0.01) and improve oxygenation (standardized mean difference 4.17; 95% CI 2.32-6.02; P < 0.01). In addition, glucocorticoid use was not associated with increased risks of new infection (RR 0.84; 95% CI 0.70-1.01; P = 0.07) and hyperglycemia (RR 1.11; 95% CI 0.99-1.23; P = 0.06).

Conclusion : The use of glucocorticoids might result in reduced mortality in patients with ARDS. Glucocorticoids might be recommended as an adjunct to standard care for ARDS; however, the optimal dose and duration of steroid therapy remains unknown and further studies are needed.

Conclusion (proposition de traduction) : L'utilisation de glucocorticoïdes peut permettre une réduction de la mortalité chez les patients en SDRA. Les glucocorticoïdes peuvent être recommandés en complément des soins standard dans le SDRA ; cependant, la dose et la durée optimales de la corticothérapie restent inconnues et des études complémentaires sont nécessaires.

Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update.
Vallet H, Schwarz GL, Flaatten H, de Lange DW, Guidet B, Dechartres A. | Crit Care Med . 2021 Feb 1;49(2):324-334
DOI: https://doi.org/10.1097/ccm.0000000000004772  | Télécharger l'article au format  
Keywords: Aucun

Online Special Article

Introduction : The coronavirus disease 2019 pandemic continues to affect millions worldwide. Given the rapidly growing evidence base, we implemented a living guideline model to provide guidance on the management of patients with severe or critical coronavirus disease 2019 in the ICU.

Méthode : The Surviving Sepsis Campaign Coronavirus Disease 2019 panel has expanded to include 43 experts from 14 countries; all panel members completed an electronic conflict-of-interest disclosure form. In this update, the panel addressed nine questions relevant to managing severe or critical coronavirus disease 2019 in the ICU. We used the World Health Organization's definition of severe and critical coronavirus disease 2019. The systematic reviews team searched the literature for relevant evidence, aiming to identify systematic reviews and clinical trials. When appropriate, we performed a random-effects meta-analysis to summarize treatment effects. We assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach, then used the evidence-to-decision framework to generate recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility.

Résultats : The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued nine statements (three new and six updated) related to ICU patients with severe or critical coronavirus disease 2019. For severe or critical coronavirus disease 2019, the panel strongly recommends using systemic corticosteroids and venous thromboprophylaxis but strongly recommends against using hydroxychloroquine. In addition, the panel suggests using dexamethasone (compared with other corticosteroids) and suggests against using convalescent plasma and therapeutic anticoagulation outside clinical trials. The Surviving Sepsis Campaign Coronavirus Diease 2019 panel suggests using remdesivir in nonventilated patients with severe coronavirus disease 2019 and suggests against starting remdesivir in patients with critical coronavirus disease 2019 outside clinical trials. Because of insufficient evidence, the panel did not issue a recommendation on the use of awake prone positioning.

Conclusion : The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued several recommendations to guide healthcare professionals caring for adults with critical or severe coronavirus disease 2019 in the ICU. Based on a living guideline model the recommendations will be updated as new evidence becomes available.

Conclusion (proposition de traduction) : Le panel d'experts de la campagne Surviving Sepsis Coronavirus Diease 2019 a émis plusieurs recommandations pour guider les professionnels de la santé qui s'occupent d'adultes atteints d'une maladie à coronavirus 2019 critique ou grave en unité de soins intensifs. Sur la base d'un modèle de lignes directrices évolutives, les recommandations seront mises à jour à mesure que de nouvelles données seront disponibles.

Commentaire : Voir l'infographie   de la mise à jour.

Intravenous access placement and fluid administration appropriateness in the emergency department.
Salvetti M, Paini A, Colonetti E, Mutti C,1 Bonetti S, Broggi A, Bertacchini F, Muiesan ML. | Emerg Care J. 2021;17:9150
DOI: https://doi.org/10.4081/ecj.2021.9150
Keywords: Aucun

ORIGINAL ARTICLES

Editorial : The aim of this study is to assess practice and effectiveness of Peripheral Venous Catheter (PVC) insertion and intravenous fluid administration in the Emergency Department (ED). A prospective study was conducted at a single primary ED in Brescia, Italy. 455 participants were included in the analysis. PVC were placed in 88 % of patients, 18 gauge catheters were the most frequently used (63%). In 360 patients PVC placement required one attempt. In 99 % of patients PVCs were used at least once. Fluid administration was considered appropriate in 23 patients. Out of 402 PVC placements, 244 were not necessary (in 225 patients PVCs were used only for blood samples withdrawal, and in 16 patients they were used for blood samples withdrawal, and inappropriate fluid administration). We concluded that a large number of PVC placements in the ED was potentially avoidable, and, when PVCs were used for IV fluid administration, the indication was often inappropriate. Physicians should carefully assess the real need of PVC placement in patients admitted to the ED and critically assess some issues of everyday practice, like PVC placement or IV fluids prescription, with evaluation of cost savings.

Conclusion : Our study results show that a significant amount PVC placements in and ED are potentially avoidable. These results support the hypothesis that the decision to place a PVC is not always made upon “a priori” standardized criteria, but it is more often made out of clinicians’ (both nurses and physicians) habit or experience, and may represent an idle “just in case” placement.
Modern medicine relies on new tools, procedures, diagnostic tests and therapies, and, especially in rich countries, these are prescribed without carefully weighing costs and benefits. Physicians should carefully assess the real needs of patients before prescriptions and reassess some critical issues of everyday practice, like PVC placement or intravenous fluids administration in the ED.

Conclusion (proposition de traduction) : Les résultats de notre étude montrent qu'une quantité importante de poses de cathéters veineux périphériques dans le service des urgences est potentiellement évitable. Ces résultats sont en faveur de l'hypothèse selon laquelle la décision de placer un cathéter veineux périphérique n'est pas toujours prise sur des critères normalisés « a priori », mais elle est plus souvent prise à partir de l'habitude ou de l'expérience des cliniciens (infirmiers et médecins), et peut représenter un placement inactif « au cas où ».
La médecine moderne repose sur de nouveaux outils, procédures, tests diagnostiques et thérapeutiques et, en particulier dans les pays riches, ceux-ci sont prescrits sans peser soigneusement les coûts et les avantages. Les médecins devraient soigneusement évaluer les besoins réels des patients avant les ordonner et réévaluer certains problèmes critiques de la pratique quotidienne, comme la pose d'un cathéter veineux périphérique ou la perfusion de liquides intraveineux au service des urgences.

Propofol Target-Controlled Infusion in Emergency Department Sedation (ProTEDS): a multicentre, single-arm feasibility study.
Burton FM, Lowe DJ, Millar J, Corfield AR, Watson MJ, Sim MAB. | Emerg Med J. 2021 Mar;38(3):205-210
DOI: https://doi.org/10.1136/emermed-2020-209686  | Télécharger l'article au format  
Keywords: airway; analgesia/pain control; emergency department management; fractures and dislocations; safety.

Original research

Introduction : Procedural sedation is a core skill of the emergency physician. Bolus administration of propofol is widely used in UK EDs. Titrated to an end point of sedation, it has a rapid effect but has been associated with adverse incidents. The use of a target-controlled infusion (TCI) of propofol is not routine but may reduce the incidence of adverse incidents.The primary aims of this single-arm feasibility study were patient satisfaction and to establish recruitment rates for a randomised controlled trial comparing propofol TCI to bolus administration.

Méthode : Four EDs in Scotland, UK, participated. Patients aged 18-65 years, with anterior shoulder dislocation, weight ≥ 50kg, fasted ≥ 90 min were screened. Patients underwent reduction of their dislocated shoulder using TCI propofol. The primary end point was patient satisfaction recorded on a Visual Analogue Scale.

Résultats : Between 3 April 2017 and 31 December 2018, 25 patients were recruited with a recruitment rate of 20% for the 16-month recruitment window, with a temporary pause to allow amendment of drug dosage.Two patients were excluded. Twenty achieved adequate sedation, defined as a Modified Observer's Assessment of Alertness/Sedation Scale (OAA/S) 3. Successful reduction was achieved in all adequately sedated. Patient satisfaction was documented in 14 patients, mean±SD of 97±9 and time to sedation was 25±8 min. No adverse events were recorded using the Society of Intravenous Anaesthesia adverse event reporting tool.

Conclusion : Propofol TCI was acceptable as a method of procedural sedation for patients. The lower than expected recruitment rates highlight the need for dedicated research support.

Conclusion (proposition de traduction) : La perfusion contrôlée par la cible de propofol était acceptable comme méthode de sédation procédurale pour les patients. Les taux de recrutement inférieurs aux prévisions soulignent la nécessité d'un soutien dédié à la recherche.

Oxygen therapy and inpatient mortality in COPD exacerbation.
Echevarria C, Steer J, Wason J, Bourke S. | Emerg Med J. 2021 Mar;38(3):170-177
DOI: https://doi.org/10.1136/emermed-2019-209257
Keywords: COPD; death/mortality; resuscitation.

RESPIRATORY

Introduction : In hospitalised patients with exacerbation of Chronic Obstructive Pulmonary Disease, European and British guidelines endorse oxygen target saturations of 88%-92%, with adjustment to 94%-98% if carbon dioxide levels are normal. We assessed the impact of admission oxygen saturation level and baseline carbon dioxide on inpatient mortality.

Méthode : Patients were identified from the prospective Dyspnoea, Eosinopenia, Consolidation, Acidaemia and Atrial Fibrillation (DECAF) derivation study (December 2008-June 2010) and the mixed methods DECAF validation study (January 2012 to May 2014). In six UK hospitals, of 2645 patients with COPD exacerbation, 1027 patients were in receipt of supplemental oxygen at admission. All had a clinical history of COPD and obstructive spirometry. These patients were subdivided into the following groups: admission oxygen saturations of 87% or less, 88%-92%, 93%-96% or 97%-100%. Inpatient mortality was calculated for each group and expressed as ORs. The DECAF score and National Early Warning Score 2 (excluding oxygen saturation) were used in binary logistic regression to adjust for baseline risk.

Résultats : In patients with COPD receiving supplemental oxygen, oxygen saturations above 92% were associated with higher mortality and an adverse dose-response. Compared with the 88%-92% group, the adjusted risk of death (OR) in the 93%-96% and 97%-100% groups was 1.98 (95% CI 1.09 to 3.60, p=0.025) and 2.97 (95% CI 1.58 to 5.58, p=0.001). In the subgroup with normocapnia, the mortality signal remained significant in both the 93%-96% and 97%-100% groups.

Conclusion : Inpatient mortality was lowest in those with oxygen saturations of 88%-92%. Even modest elevations in oxygen saturations above this range (93%-96%) were associated with an increased risk of death. A similar mortality trend was seen in both patients with hypercapnia and normocapnia. This shows that the practice of setting different target saturations based on carbon dioxide levels is not justified. Treating all patients with COPD with target saturations of 88%-92% will simplify prescribing and should improve outcome.

Conclusion (proposition de traduction) : La mortalité des patients hospitalisés était la plus faible chez ceux dont la saturation en oxygène était entre 88 % et 92 %. Même des élévations modestes des saturations en oxygène au-dessus de cette plage (93 %-96 %) étaient associées à un risque accru de décès. Une tendance de mortalité similaire a été observée chez les patients souffrant d'hypercapnie et de normocapnie. Cela montre que la pratique consistant à fixer des saturations cibles différentes en fonction des niveaux de dioxyde de carbone n'est pas justifiée. Traiter tous les patients atteints de BPCO avec des saturations cibles entre 88 % et 92 % simplifiera la prescription et devrait améliorer les résultats.

Comparison of the efficacy of ketamine- propofol versus sodium thiopental-fentanyl in sedation: a randomised clinical trial.
Bahreini M, Talebi Garekani M, Sotoodehnia M, Rasooli F. | Emerg Med J. 2021 Mar;38(3):211-216
DOI: https://doi.org/10.1136/emermed-2020-209542
Keywords: anaesthesia - general; analgesia/pain control; clinical assessment, effectiveness; safety.

SEDATION

Introduction : Many sedative regimens have been studied with controversial efficiencies. This study tried to assess the desirable and adverse effects of sodium thiopental-fentanyl (TF) with ketamine-propofol (KP) for procedural sedation and analgesia in the emergency department.

Méthode : After signing written consent, patients were enrolled in this randomised double-blind trial to receive either KP or TF to reach the desired sedation level. The respiratory and haemodynamic complications, nausea and vomiting, recovery agitation, patient recall and satisfaction, provider satisfaction and recovery time were compared.

Résultats : Of the participants, 47 in the KP group and 49 in the TF group were enrolled. The mean and SD scores were 6.91±1.93 and 8.34±1.25 for patients' satisfaction and 7.55±1.54 and 8.65±1.00 for satisfaction of physicians performing the procedures in TF and KP groups, respectively (p=0.000). Moreover, 39 (79.59%) and 18 (38.29%) of patients declared that they had recalled the procedures in the TF and KP groups, respectively (p=0.000). Transient hypoxia was reported in 2.1% and 8.1% in the KP and TF groups leading to perform 4.2% vs 8.1% airway manoeuvres, respectively, without the need for endotracheal intubation or further admission.

Conclusion : KP and TF combinations were effectively comparable although KP resulted in higher patient and provider satisfaction. This study did not detect a difference regarding adverse respiratory or haemodynamic effects. It is estimated that the TF combination can be potent and efficacious with possible low adverse events in procedural sedation.

Conclusion (proposition de traduction) : Les associations kétamine-propofol et thiopental-fentanyl étaient effectivement comparables, bien que la kétamine-propofol ait entraîné une plus grande satisfaction des patients et des praticiens. Cette étude n'a pas détecté de différence concernant les effets indésirables respiratoires ou hémodynamiques. On estime que l'association thiopental-fentanyl peut être puissante et efficace avec d'éventuels effets indésirables faibles lors de la sédation procédurale.

Prioritising intubator safety in a pandemic: the details matter .
Barnicle R, Bracey A, Zahid B, Davic A, Weingart S. | Emerg Med J. 2021 Mar;38(3):217-219
DOI: https://doi.org/10.1136/emermed-2020-210362  | Télécharger l'article au format  
Keywords: airway; emergency department; infectious diseases; respiratory; safety; viral.

Report from the front

Editorial : Our ED-intensive care unit has instituted a new protocol meant to maximise the safety of physicians, nurses and respiratory therapists involved with endotracheal intubation of patients known or suspected of being infected with the novel SARS-CoV-2. The level of detail involved with this checklist is a deviation from standard intubation practices and is likely unfamiliar to most emergency physicians. However, the two-person system used in our department removes the cognitive burden such complexity would otherwise demand and minimises the number of participants that would typically be exposed during endotracheal intubation. We share this checklist to demonstrate to other departments how adopting international airway guidelines to a specific institution can be achieved in order to promote healthcare worker safety.

Conclusion : The granular COVID-19 protected intubation checklist prioritises staff safety by emphasising conscientious attention to detail and largely follows recommendations from the Safe Airway Society. The ‘buddy’ system we employ allows us to benefit from the increase in detail while mitigating the down- side of increased cognitive load. In submitting this checklist, we are assuming that other departments will face similar obstacles when additional COVID-19 surges occur.

Conclusion (proposition de traduction) : La liste de contrôle granulaire (la « granularité » fait référence à un niveau méticuleux de détails logistiques) de l’intubation protégée contre la COVID-19 donne la priorité à la sécurité du personnel en mettant l'accent sur une attention consciencieuse aux détails et suit largement les recommandations de la Safe Airway Society. Le système de « coopération » que nous utilisons nous permet de bénéficier de l’augmentation du niveau de détails tout en atténuant l’inconvénient de l’augmentation de la charge cognitive. En soumettant cette liste de contrôle, nous présumons que d'autres départements seront confrontés à des obstacles similaires en cas d’augmentation de la COVID-19.

Annweiler C, Souberbielle JC. | Geriatr Psychol Neuropsychiatr Vieil. 2021 Mar;19(1):20-29
DOI: https://doi.org/10.1684/pnv.2020.0907
Keywords: ovid-19, SARS-Cov-2, vitamine D, supplémentation, recommandations

Gériatrie et gérontologie. Synthèses

Editorial : Après 12 mois de circulation virale, le SARS-CoV-2 a infecté des millions de personnes dans le monde, faisant des centaines de milliers de morts. En l’absence de traitement curatif, préventif ou vaccinal efficace et accessible à ce jour contre le Covid-19, recourir à des médicaments déjà existants pourrait aider à enrayer la pandémie. La vitamine D est un candidat possible discuté dans de nombreuses publications. Des essais cliniques randomisés montrent que la supplémentation en vitamine D réduit significativement le risque d’infections respiratoires. Il existe également de nombreux arguments suggérant que l’hypovitaminose D constitue un facteur de risque indépendant (et facilement modifiable) des formes graves de Covid-19 et de mortalité par Covid-19. La supplémentation en vitamine D est une mesure simple, sans risque, peu coûteuse et remboursée par l’assurance maladie, qui est efficace pour corriger l’hypovitaminose D retrouvée chez 40 à 50 % de la population française et chez plus de 80 % des adultes atteints de Covid-19. Dans ce papier de position, nous proposons des schémas simples de supplémentation vitaminique D chez l’adulte en l’absence ou en cas de Covid-19.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care.
Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. | Intensive Care Med. 2021 Apr;47(4):369-421
DOI: https://doi.org/10.1007/s00134-021-06368-4  | Télécharger l'article au format  
Keywords: Cardiac arrest; Guidelines; Post resuscitation care; Prognostication.

Conference Reports and Expert Panel

Editorial : The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

Conclusion : In 2015 the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) collaborated to produce their first combined post-resuscitation care guidelines, which were co-published in Resuscitation and Intensive Care Medicine. These post-resuscitation care guidelines have been extensively updated for 2020 and incorporate the science that has been published since 2015. The topics covered include the post-cardiac arrest syndrome, control of oxygenation and ventilation, haemodynamic targets, coronary reperfusion, targeted temperature management, control of seizures, prognostication, rehabilitation, and long-term outcome.

Conclusion (proposition de traduction) : En 2015, le Conseil européen de réanimation (ERC) et la Société européenne de médecine de soins intensifs (ESICM) ont collaboré pour produire leurs premières lignes directrices combinées sur les soins post-réanimation, qui ont été co-publiées dans Resuscitation and Intensive Care Medicine. Ces directives de soins post-réanimation ont été largement mises à jour pour 2020 et intègrent l'état de la science publiée depuis 2015. Les sujets abordés incluent le syndrome post-arrêt cardiaque, le contrôle de l'oxygénation et de la ventilation, les cibles hémodynamiques, la reperfusion coronaire, la gestion ciblée de la température, contrôle des crises, pronostic, rééducation et issue à long terme.

Commentaire :  Post resuscitation care algorithm

Short vs long-course antibiotic therapy in pyelonephritis: a comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign.
Erba L, Furlan L, Monti A, Marsala E, Cernuschi G, Solbiati M, Bracco C, Bandini G, Pecorino Meli M, Casazza G, Montano N, Sbrojavacca R, Costantino G. | Intern Emerg Med. 2021 Mar;16(2):313-323
DOI: https://doi.org/10.1007/s11739-020-02401-4
Keywords: Antibiotic treatment; Choosing wisely; Guidelines; Pyelonephritis; Systematic review; Urinary tract infection.

IM - ORIGINAL

Introduction : The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies.

Méthode : We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence.

Résultats : We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53-0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75-1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs.

Conclusion : Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.

Conclusion (proposition de traduction) : Un traitement antibiotique de courte durée est au moins aussi efficace que des traitements plus longs pour le succès microbiologique et clinique du traitement de la pyélonéphrite aiguë non compliquée.

Lung ultrasound as diagnostic tool for SARS-CoV-2 infection.
Bosso G, Allegorico E, Pagano A, Porta G, Serra C, Minerva V, Mercurio V, Russo T, Altruda C, Arbo P, De Sio C, Dello Vicario F, Numis FG. | Intern Emerg Med. 2021 Mar;16(2):471-476
DOI: https://doi.org/10.1007/s11739-020-02512-y  | Télécharger l'article au format  
Keywords: LUS score; Lung ultrasound; P/F ratio; SARS-CoV-2.

EM - ORIGINAL

Editorial : The aim of this study was to explore the role of lung ultrasound (LUS) in the diagnosis of SARS-CoV-2 infection and to verify its utility in the prediction of lung disease's severity and outcome. Fifty-three consecutive patients presenting to the Emergency Department of Santa Maria delle Grazie Hospital with high suspicion of SARS-CoV-2 infection underwent diagnostic test for SARS-CoV-2 on samples obtained from nasopharyngeal swab as well as complete proper diagnostic work-up that included clinical evaluation, laboratory tests, blood gas analyses, chest CT and LUS. A semiquantitative analysis of B-lines distribution was performed to calculate the LUS score. Patients were divided into two groups according to the results of both SARS-CoV-2 diagnostic test and other exams (Group A = pneumonia due to SARS-CoV2 infection vs Group B = no SARS-CoV2 infection and another definite diagnosis). LUS showed an excellent accuracy in predicting the diagnosis of SARS-CoV-2 infection (area under the ROC curve of 0.92 with a sensibility of 73% and a specificity of 89% a the cut-off of 12.5). LUS score was more impaired in SARS-CoV-2 patients (18.1 ± 6.0 vs 7.6 ± 5.9, p < 0.00001) and it is significantly negatively correlated with PF ratio values (r = - 0.719, p < 0.0001). An intrahospital mortality rate of 46% was found; patients with adverse outcome had significant higher value of LUS, PF, LDH, and APACHE II score. None of these parameters was predictive of mortality. LUS is a useful tool for the early detection of SARS-CoV-2 infection and for the evaluation of the disease severity, but does not predict mortality. Further studies with repeated evaluations of LUS score are needed to further explore the role of LUS in the assessment of severity in SARS-CoV-2 disease and in the monitoring of the response to treatments.

Conclusion : In conclusion, LUS is applying not only in the early detec- tion of Sars-CoV-2 infection preceding the nasopharyngeal swab results but also in evaluating the disease severity and monitoring the clinical course. Further studies with repeated evaluations of LUS score can effectively track the course of Sars-CoV-2 disease and its modifications in response to different medical treatment or ventilator support to better characterize its prognostic value.

Conclusion (proposition de traduction) : En conclusion, l'échographie pulmonaire s'applique non seulement à la détection précoce de l'infection à Sars-CoV-2 précédant les résultats de l'écouvillon nasopharyngé, mais également à l'évaluation de la gravité de la maladie et au suivi de l'évolution clinique. D'autres études avec des évaluations répétées du score échographique pulmonaire peuvent suivre efficacement l'évolution de la maladie à Sars-CoV-2 et ses modifications en réponse à différents traitements médicaux ou assistance respiratoire afin de mieux caractériser sa valeur pronostique.

Post-ROSC peripheral perfusion index discriminates 30-day survival after out-of-hospital cardiac arrest.
Savastano S, Baldi E, Contri E, De Pirro A, Sciutti F, Compagnoni S, Fracchia R, Primi R, Frigerio L, Gentile FR, Visconti LO, Palo A. | Intern Emerg Med. 2021 Mar;16(2):455-462
DOI: https://doi.org/10.1007/s11739-020-02430-z
Keywords: Out-of-hospital cardiac arrest; Perfusion index; Prognostication.

EM - ORIGINA

Introduction : Prognostication after an out-of-hospital cardiac arrest (OHCA) remains a challenge. The peripheral-derived perfusion index (PI) is a simple and non-invasive way to assess perfusion. We sought to assess whether the PI was able to discriminate the prognosis of patients resuscitated from an OHCA.

Méthode : All the reports generated by the manual monitor/defibrillator (Corpuls 3 by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) used for all the OHCAs who achieved ROSC treated by our Emergency Medical Service from January 2015 to December 2018 were reviewed. The mean PI value of each minute after ROSC was automatically provided by the device and the mean value of 30 min of monitoring (MPI₃₀) was calculated. Pre-hospital data were collected according to the Utstein 2014 recommendations.

Résultats : Among 1,909 resuscitation attempts, ROSC was achieved in 346 and it was possible to calculate an MPI₃₀ in 164. MPI₃₀ was higher in the patients who survived at 30 days [1.6 (95% CI 1.2-2.1) vs 1 (95% CI 0.8-1.3), p = 0.0017]. At the multivariable Cox regression model, after correction for shockable rhythm, witnessed status, bystander CPR, age, and blood pressure, MPI₃₀ was found to be an independent predictor of both 30-day mortality [RR 0.83 (95% CI 0.69-0.99), p = 0.036] and 30-day mortality or poor neurologic outcome [RR 0.85 (95% CI 0.72-0.99), p = 0.04]. Overall 30-day survival with good neurologic outcome was significantly different in the three tertiles [T1: 0.1-0.8; T2: 0.9-1.8 and T3: 1.82-7.8, log-rank p = 0.007].

Conclusion : The post-ROSC peripheral perfusion index was found to be an independent predictor of 30-day mortality or poor neurologic outcome. It could help prognostication in OHCA patients.

Conclusion (proposition de traduction) : L'indice de perfusion périphérique post-RACS s'est avéré être un prédicteur indépendant de la mortalité à 30 jours ou d'un mauvais résultat neurologique. Cela pourrait aider au pronostic chez les patients en arrêt cardiaque extra-hospitalier.

Efficacy and safety of colchicine for secondary prevention of coronary heart disease: a systematic review and meta-analysis.
Xiang Z, Yang J, Yang J, Zhang J, Fan Z, Yang C, Di L, Ma C, Wu J, Huang Y. | Intern Emerg Med. 2021 Mar;16(2):487-496
DOI: https://doi.org/10.1007/s11739-020-02606-7
Keywords: Colchicine; Coronary heart disease (CHD); Meta-analysis; Secondary prevention.

CE-Systematic reviews and meta-analysis

Introduction : To evaluate the efficacy and safety of colchicine for secondary prevention of coronary heart disease (CHD), relevant randomized controlled trials (RCTs) were identified by searching several databases from the creation date to August 31, 2020 and were reviewed.

Résultats : Eight eligible trials of colchicine therapy involving a total of 11, 463 patients were included (5, 776 subjects received colchicine, while 5, 687 subjects were in the respective control arms), and the outcome was reported as risk ratio (RR) and 95% confidence interval (CI), as the relative measure of association. Overall, the incidences of major adverse cardiovascular events (MACEs) (RR 0.70; 95% CI 0.61-0.80), myocardial infarction (MI) (RR 0.77; 95% CI 0.64-0.94), emergency readmission due to CHD (RR 0.70; 95% CI 0.58-0.86), and ischemic stroke (RR 0.49; 95% CI 0.30-0.79) were lower in the colchicine group than in the placebo arm. We did not find a significant reduction in the incidence of all-cause mortality (RR 1.03; 95% CI 0.80-1.32). Although the incidence of diarrhea in the colchicine treatment group was higher than that in the placebo arms (RR 2.53; 95% CI 1.17, 5.48), the symptoms disappeared rapidly after drug withdrawal, and no serious adverse reactions occurred.

Conclusion : In summary, colchicine is an accessible, safe, and effective drug that could be successfully utilized for the secondary prevention of CHD. The tolerability and benefits should be confirmed in in-depth clinical trials.

Conclusion (proposition de traduction) : En résumé, la colchicine est un médicament accessible, sûr et efficace qui pourrait être utilisé avec succès pour la prévention secondaire de la maladie coronarienne. La tolérabilité et les bénéfices doivent être confirmés lors d'essais cliniques approfondis.

Martin PV, Fogelman J, Travers S, Martin AC. | JEUR. 2021 March:33(1):12-20
DOI: https://doi.org/10.1016/j.jeurea.2021.01.003
Keywords: Echocardiography, Dyspnea, Filling pressures, Tamponade, Acute pulmonary heart

Cardiologie

Editorial : The emergency physician can have at his fingertips a new powerful diagnostic method, echocardiography. Often considered complex and within the field of specialty, and despite a recommended use by the French Society of Emergency Medicine [1,2], it is slow to develop in emergency services. This article proposes a simplified method of analysis for the use of the emergency physician by explaining the theoretical bases of echocardiography by specifying the key parameters of knowing how to interpret. This method can be used daily in the patient's bed to quickly provide a diagnostic orientation to go further in the analysis of cardiac function.

Conclusion (proposition de traduction) : L’urgentiste peut avoir à sa portée un nouveau moyen diagnostic performant qu’est l’échocardiographie. Souvent considérée comme complexe et relevant du domaine de la spécialité, et malgré une utilisation recommandée par la Société française de médecine d’urgence [1,2], elle tarde à se développer dans les services d’urgences. Cet article propose une méthode d’analyse simplifiée à l’usage de l’urgentiste en expliquant les bases théoriques de l’échocardiographie en précisant les paramètres clefs à savoir interpréter. Cette méthode pourra être utilisée au quotidien au lit du patient pour rapidement apporter une orientation diagnostique en permettant d’aller plus loin dans l’analyse de la fonction cardiaque.

Pouymayou J, Piano V, Astruc N. | JEUR. 2021 March:33(1):21-25
DOI: https://doi.org/10.1016/j.jeurea.2021.01.004
Keywords: Weak opioids, Strong Opioids, QTc Prolongation, Cardiovascular risk

Cardio

Editorial : Opioids, used in pain management or in opioid substitution, have broadened the evidence for their usefulness. However, theses molecules must be used carefully, choosing wisely their indication and taking in account their side effect profile. Recent publications have also focused on the opioids cardiovascular risk and more specifically on the risk of QTc prolongation. An increase in QTc interval can expose some patients to Torsades de Pointes, to ventricular fibrillation and, for the more severe cases, to death from cardiac arrest. In a literature review published in 2018, authors have distinguished opioids in 3 categories, depending of their risk on QTc Prolongation: methadone (most risky molecule), oxycodone and tramadol (intermediate risk molecules), buprenorphine and morphine (least risky molecules). Despite contradictory data, the cardiovascular risk must be taken in account when choosing which opioid to prescribe. In clinical practice, it seems preferable to use the least risky molecules like morphine. It is also suggested to avoid as much as possible combination with other drugs prolonging QTc interval and avoid opioids metabolized by cytochrome, such as oxycodone. The presence of risk factors should not be a brake to opioid analgesics if their prescription is essential for the patients. In France, with the future commercialization of methadone in pain management, it can be useful to remind: to realize an electrocardiogram at the initiation and another after 30 days of treatment for patients having a significant risk; to realize annual complementary electrocardiogram or when the methadone dose exceed 120mg per day.

Conclusion (proposition de traduction) : Les opioïdes, qu’ils soient prescrits dans la prise en charge de la douleur ou dans la substitution opiacée, ont fait largement la preuve de leur utilité. Toutefois, un usage prudent de ces molécules doit se faire en posant judicieusement l’indication et en prenant en en compte de l’ensemble de leurs effets indésirables. Des publications récentes se sont également penchées sur les risques cardiovasculaires et plus particulièrement sur le risque d’allongement du QT. Une modification à la hausse de ce paramètre cardiaque peut exposer certains patients à des risques de Torsades de Pointes, de fibrillation ventriculaire et, dans les cas les plus graves, à une mort par arrêt cardiaque. Dans une revue de la littérature datée de 2018, des auteurs se sont intéressés au risque d’allongement du QT en lien avec différents opioïdes en distinguant 3 niveaux de risque : méthadone (molécule la plus à risque), oxycodone et tramadol (molécules à risque intermédiaire), buprénorphine et morphine (molécules les moins à risque). Malgré des données parfois contradictoires, le risque cardiovasculaire apparaît comme un critère de choix des opioïdes que nous prescrivons. En pratique, il semble préférable de privilégier les molécules les moins à risque, comme la morphine. Il est suggéré d’éviter autant que possible les associations avec d’autres médicaments allongeant l’intervalle QT et d’éviter les molécules opioïdes dont le métabolisme par les cytochromes est variable, comme l’oxycodone. La présence de facteurs de risque ne doit pas être un frein à l’utilisation d’opioïdes antalgiques si leur prescription s’avère indispensable pour les patients. Avec la mise à disposition prochaine de la méthadone dans le domaine de la douleur, il peut être utile de rappeler la pertinence de réaliser avec cette molécule : un ECG à l’admission et un autre dans les 30 jours qui suivent seulement pour les patients qui présentent un risque significatif ; des ECG annuels complémentaires ou lorsque la posologie dépasse 120mg de méthadone par jour.

Diagnostic Accuracy of Ultrasound Measurements of Anterior Neck Soft Tissue in Determining a Difficult Airway.
Srinivasarangan M, Akkamahadevi P, Balkal VC, Javali RH. | J Emerg Trauma Shock. 2021 Jan-Mar;14(1):33-37
DOI: https://doi.org/10.4103/jets.jets_12_20  | Télécharger l'article au format  
Keywords: Anterior neck soft tissue; difficult airway; difficult intubation; point-of-care ultrasound.

Original article

Introduction : Airway management in the emergency department is challenging because conventional screening tools cannot be applied. Therefore, a rapid noninvasive means of identifying a difficult airway will be advantageous for emergency physicians.
Aims: The aim of this study is to examine the association between ultrasound measurements of anterior neck soft tissue and difficult airway as judged by the Cormack Lehane grading.
Settings and design: A prospective study was done for 18 months on patients requiring intubation presenting to the emergency medicine department.

Méthode : Ultrasound measurements of anterior neck soft tissue were obtained in 60 cases at the levels of thyrohyoid membrane, hyoid bone, and vocal cords. Another examiner who was blinded to the ultrasound measurements performed endotracheal intubation and noted Cormack-Lehane grading.
Statistical analysis used: Descriptive statistics such as mean, standard deviation, frequency, and percentage were used. Inferential statistics such as Student's t-test and receiver operating characteristic (ROC) curve analysis were done using the SPSS software version 22.

Résultats : The thickness of anterior neck soft tissues at the level of hyoid bone in difficult patients was 0.73 cm (95% confidence interval = 0.65-0.80) compared to easy patients 0.47 cm (95% confidence interval = 0.44-0.51) with a P = 0.001 and at the level of thyrohyoid membrane in difficult patients it was 1.83 cm (95% confidence interval = 1.7-1.89) compared to easy patients 1.46 cm (95% confidence interval = 1.41-1.51) with a P = 0.001. Area under the ROC curve was significant at all the three levels with the highest at the level of thyrohyoid membrane 0.99 and least at the level of vocal cords 0.79, the area under the curve was 0.92 at the level of hyoid bone.

Conclusion : Sonographic measurements of the anterior neck soft tissue can be used as a screening tool by an emergency physician to detect difficult intubation.

Conclusion (proposition de traduction) : Les mesures échographiques des tissus mous à la face antérieure du cou peuvent être utilisées comme outil de dépistage par un médecin urgentiste pour détecter une intubation difficile.

Predictors of failure with high-flow nasal oxygen therapy in COVID-19 patients with acute respiratory failure: a multicenter observational study.
Mellado-Artigas R, Mujica LE, Ruiz ML, Ferreyro BL, Angriman F, Arruti E, Torres A, Barbeta E, Villar J, Ferrando C; COVID-19 Spanish ICU Network. | J Intensive Care. 2021 Mar 5;9(1):23
DOI: https://doi.org/10.1186/s40560-021-00538-8  | Télécharger l'article au format  
Keywords: COVID-19; High-flow nasal oxygen therapy; Hypoxemic respiratory failure; Invasive mechanical ventilation.

Research

Introduction : We aimed to describe the use of high-flow nasal oxygen (HFNO) in patients with COVID-19 acute respiratory failure and factors associated with a shift to invasive mechanical ventilation.

Méthode : This is a multicenter, observational study from a prospectively collected database of consecutive COVID-19 patients admitted to 36 Spanish and Andorran intensive care units (ICUs) who received HFNO on ICU admission during a 22-week period (March 12-August 13, 2020). Outcomes of interest were factors on the day of ICU admission associated with the need for endotracheal intubation. We used multivariable logistic regression and mixed effects models. A predictive model for endotracheal intubation in patients treated with HFNO was derived and internally validated.

Résultats : From a total of 259 patients initially treated with HFNO, 140 patients (54%) required invasive mechanical ventilation. Baseline non-respiratory Sequential Organ Failure Assessment (SOFA) score [odds ratio (OR) 1.78; 95% confidence interval (CI) 1.41-2.35], and the ROX index calculated as the ratio of partial pressure of arterial oxygen to inspired oxygen fraction divided by respiratory rate (OR 0.53; 95% CI: 0.37-0.72), and pH (OR 0.47; 95% CI: 0.24-0.86) were associated with intubation. Hospital site explained 1% of the variability in the likelihood of intubation after initial treatment with HFNO. A predictive model including non-respiratory SOFA score and the ROX index showed excellent performance (AUC 0.88, 95% CI 0.80-0.96).

Conclusion : Among adult critically ill patients with COVID-19 initially treated with HFNO, the SOFA score and the ROX index may help to identify patients with higher likelihood of intubation.

Conclusion (proposition de traduction) : Chez les patients adultes de réanimation atteints de la COVID-19 initialement traités par oxygénothérapie nasale à haut débit, le score SOFA et l'indice ROX peuvent aider à identifier les patients présentant une probabilité plus élevée d'intubation.

Commentaire : L'index ROX [(SpO₂/FiO₂) /fréquence respiratoire] permet de prédire le succès ou l'échec d'une traitement de détresse respiratoire aiguë par haut débit nasal (type Optiflow™) dans le cadre d'une pneumopathie.
Un index ROX ≥ 4,88 à h2, h6 ou h12 du traitement est prédictif d'un succès du traitement par haut débit nasal.
Un index ROX ≤ 2,85 à h2, 3,47 à h6 ou 3,85 à h12 est prédictif d'un échec du traitement par haut débit nasal et d'une nécessité d'intubation.

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review.
Mendelson SJ, Prabhakaran S. | JAMA. 2021 Mar 16;325(11):1088-1098
DOI: https://doi.org/10.1001/jama.2020.26867
Keywords: Aucun

Review

Introduction : Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually.

Méthode : Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic…

Conclusion : Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.

Conclusion (proposition de traduction) : La bi-thérapie antiplaquettaire initiée dans les 24 heures suivant l'apparition des symptômes et poursuivie pendant 3 semaines réduit le risque d'accident vasculaire cérébral chez certains patients présentant un AIT à haut risque et un accident vasculaire cérébral mineur. Pour certains patients présentant un AVC ischémique aigu invalidant, la thrombolyse dans les 4,5 heures et la thrombectomie mécanique dans les 24 heures suivant l'apparition des symptômes améliorent les résultats fonctionnels.

Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial.
Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, Montomoli J, Falò G, Tonetti T, Cutuli SL, Pintaudi G, Tanzarella ES, Piervincenzi E, Bongiovanni F, Dell'Anna AM, Delle Cese L, Berardi C, Carelli S, Bocci MG, Montini L, Bello G, Natalini D, De Pascale G, Velardo M, Volta CA, Ranieri VM, Conti G, Maggiore SM, Antonelli M; COVID-ICU Gemelli Study Group. | JAMA. 2021 Mar 25
DOI: https://doi.org/10.1001/jama.2021.4682
Keywords: Aucun

Original Investigation

Introduction : High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19.
Objective : To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone.
Design, setting, and participants: Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200).
Interventions: Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55).

Méthode : The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay.

Résultats : Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, -2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, -21% [95% CI, -38% to -3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, -1% [95% CI, -17% to 15%]; P > .99).

Conclusion : Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation.

Conclusion (proposition de traduction) : Parmi les patients atteints de COVID-19 et d'hypoxémie modérée à sévère, le traitement par ventilation non invasive par casque, comparé à l'oxygène nasal à haut débit, n'a entraîné aucune différence significative du nombre de jours sans assistance respiratoire dans les 28 jours. Des recherches supplémentaires sont nécessaires pour déterminer les effets sur d'autres résultats, y compris la nécessité d'une intubation endotrachéale.

Commentaire : Analyse de l'article, Covid-19 : Covid-19 : la newsletter du Pr Adnet (N°45 - 29 mars)  .
La Covid-19 sévère se caractérise par une atteinte pulmonaire avec une hypoxémie importante. Lorsque les moyens d’oxygénation classique (lunettes, masques) deviennent insuffisants – et dans l’espoir de ne pas recourir à l’intubation et à la ventilation mécanique invasive – l’étape intermédiaire consiste à proposer une oxygénation à haut débit (OHD) ou, pour certains médecins, à la ventilation non invasive (VNI).
Dans une étude originale, randomisée (JAMA, 25 mars 2021) des chercheurs ont comparé les deux méthodes chez des patients Covid-19+ sévères (N=109) : VNI-helmet, caractérisée par l’utilisation d’un masque scaphandre (N=54) vs. OHD (N=55).
• Les patients étaient hypoxémiques, caractérisés par un rapport PaO2/FiO2≤200.
• Le critère d’évaluation principal était le nombre de jours sans support ventilatoire (OHD ou VNI) évalué au 28e jour après inclusion.
• Les résultats n’ont pas montré de différence significative entre les deux groupes : 20 jours dans le groupe VNI et 18 dans le groupe OHD (différence moyenne 2 jours (IC95%[-2-6]).
• Cependant, parmi les critères secondaires, on remarque qu’il y a eu moins d’intubation dans le groupe VNI : 30% vs. 51%.
• La mortalité hospitalière dans les deux groupes ne différait pas significativement (24% dans le groupe VNI vs. 25%).
Bon, les deux approches semblent pouvoir être proposées aux patients en échec d’oxygénation classique.

Diagnosis and Treatment of Irritable Bowel Syndrome: A Review.
Camilleri M | JAMA. 2021 Mar 2;325(9):865-877
DOI: https://doi.org/10.1001/jama.2020.22532
Keywords: Aucun

Review

Introduction : The prevalence of irritable bowel syndrome (IBS) in the United States is between 7% and 16%, most common in women and young people, with annual direct costs estimated at more than $1 billion dollars in the United States. Traditionally, the diagnosis of IBS has been based on the positive identification of symptoms that correlate with several different syndromes associated with disorders such as IBS diarrhea, IBS constipation, functional diarrhea, functional constipation, chronic functional abdominal pain, or bloating. Several peripheral and central mechanisms initiate gastrointestinal motor and sensory dysfunctions leading to IBS symptoms. Those dysfunctions may require evaluation in patients whose symptoms do not respond to first-line treatments.

Méthode : Validation studies of consensus symptom-based criteria have identified deficiencies that favor a simpler identification of the predominant symptoms of abdominal pain, bowel dysfunction, and bloating and exclusion of alarm symptoms such as unintentional weight loss, rectal bleeding, or recent change in bowel function. Symptom-based diagnosis of IBS is enhanced with additional history for symptoms of somatoform and psychological disorders and alarm symptoms, physical examination including digital rectal examination, and screening tests to exclude organic disease (by measuring hemoglobin and C-reactive protein concentrations). The initial treatment plan should include patient education, reassurance, and first-line treatments such as fiber and osmotic laxatives for constipation, opioids for diarrhea, antispasmodics for pain and for management of associated psychological disorders. For patients who do not respond to those IBS treatments, testing for specific functional disorders may be required in a minority of patients with IBS. These disorders include rectal evacuation disorder, abnormal colonic transit, and bile acid diarrhea. Their identification is followed by individualized treatment, such as pelvic floor retraining for rectal evacuation disorders, sequestrants for bile acid diarrhea, and secretory agents for constipation, although there is only limited evidence that this individualized management approach is effective.

Conclusion : Advances in the identification of specific dysfunctions as causes of individual symptoms in the "IBS spectrum" leads to the potential to enhance the diagnosis and management of symptoms for the majority of patients for whom first-line therapies of IBS and management of comorbid psychological disorders are insufficient.

Conclusion (proposition de traduction) : Les progrès dans l'identification des dysfonctionnements spécifiques en tant que causes des symptômes individuels dans le « spectre du syndrome du côlon irritable » permettent d'améliorer le diagnostic et la prise en charge des symptômes pour la majorité des patients pour lesquels les traitements de première intention du syndrome du côlon irritable et la prise en charge des troubles psychologiques et des comorbidités sont insuffisants.

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries.
Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, Lascarrou JB, Szuldrzynski K, Camporota L, Pelosi P, Sorbello M, Higgs A, Greif R, Putensen C, Agvald-Öhman C, Chalkias A, Bokums K, Brewster D, Rossi E, Fumagalli R, Pesenti A, Foti G, Bellani G; INTUBE Study Investigators. | JAMA. 2021 Mar 23;325(12):1164-1172
DOI: https://doi.org/10.1001/jama.2021.1727
Keywords: Aucun

Original Investigation

Introduction : Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events.
Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients.
Design, setting, and participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents.
Exposures: Tracheal intubation.

Méthode : The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality.

Résultats : Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%.

Conclusion : In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.

Conclusion (proposition de traduction) : Dans cette étude observationnelle des pratiques d'intubation chez des patients gravement malades à partir d'un échantillon de commodité de 197 sites dans 29 pays, des événements indésirables majeurs associés à l'intubation - en particulier l'instabilité cardiovasculaire - ont été fréquemment observés.

Vaccination and non-pharmaceutical interventions for COVID-19: a mathematical modelling study.
Moore S, Hill EM, Tildesley MJ, Dyson L, Keeling MJ. | Lancet Infect Dis. 2021 Mar 18:S1473-3099(21)00143-2
DOI: https://doi.org/10.1016/s1473-3099(21)00143-2  | Télécharger l'article au format  
Keywords: Aucun

ARTICLE

Introduction : The dynamics of vaccination against SARS-CoV-2 are complicated by age-dependent factors, changing levels of infection, and the relaxation of non-pharmaceutical interventions (NPIs) as the perceived risk declines, necessitating the use of mathematical models. Our aims were to use epidemiological data from the UK together with estimates of vaccine efficacy to predict the possible long-term dynamics of SARS-CoV-2 under the planned vaccine rollout.

Méthode : In this study, we used a mathematical model structured by age and UK region, fitted to a range of epidemiological data in the UK, which incorporated the planned rollout of a two-dose vaccination programme (doses 12 weeks apart, protection onset 14 days after vaccination). We assumed default vaccine uptake of 95% in those aged 80 years and older, 85% in those aged 50-79 years, and 75% in those aged 18-49 years, and then varied uptake optimistically and pessimistically. Vaccine efficacy against symptomatic disease was assumed to be 88% on the basis of Pfizer-BioNTech and Oxford-AstraZeneca vaccines being administered in the UK, and protection against infection was varied from 0% to 85%. We considered the combined interaction of the UK vaccination programme with multiple potential future relaxations (or removals) of NPIs, to predict the reproduction number (R) and pattern of daily deaths and hospital admissions due to COVID-19 from January, 2021, to January, 2024.

Résultats : We estimate that vaccination alone is insufficient to contain the outbreak. In the absence of NPIs, even with our most optimistic assumption that the vaccine will prevent 85% of infections, we estimate R to be 1·58 (95% credible intervals [CI] 1·36-1·84) once all eligible adults have been offered both doses of the vaccine. Under the default uptake scenario, removal of all NPIs once the vaccination programme is complete is predicted to lead to 21 400 deaths (95% CI 1400-55 100) due to COVID-19 for a vaccine that prevents 85% of infections, although this number increases to 96 700 deaths (51 800-173 200) if the vaccine only prevents 60% of infections. Although vaccination substantially reduces total deaths, it only provides partial protection for the individual; we estimate that, for the default uptake scenario and 60% protection against infection, 48·3% (95% CI 48·1-48·5) and 16·0% (15·7-16·3) of deaths will be in individuals who have received one or two doses of the vaccine, respectively.

Conclusion : For all vaccination scenarios we investigated, our predictions highlight the risks associated with early or rapid relaxation of NPIs. Although novel vaccines against SARS-CoV-2 offer a potential exit strategy for the pandemic, success is highly contingent on the precise vaccine properties and population uptake, both of which need to be carefully monitored.

Conclusion (proposition de traduction) : Pour tous les scénarios de vaccination que nous avons étudiés, nos prédictions mettent en évidence les risques associés à un relâchement précoce ou rapide des interventions non pharmaceutiques (ndlr : mesures barrière). Bien que les nouveaux vaccins contre le SRAS-CoV-2 offrent une stratégie de sortie potentielle de la pandémie, le succès dépend fortement des propriétés précises du vaccin et de l'adoption par la population, qui doivent tous deux être soigneusement surveillés.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : Quand les effets bénéfiques de la vaccination COVID 19 permettront-ils de lever les mesures barrières est la question à laquelle cette étude anglaise essaie de répondre ?  . Rédigé par le Dr Jacques Gaillat, le 31 mars 2021.

Change in Cardiopulmonary Resuscitation Performance Over Time During Simulated Pediatric Cardiac Arrest and the Effect of Just-in-Time Training and Feedback.
Duff JP, Bhanji F, Lin Y, Overly F, Brown LL, Bragg EA, Kessler D, Tofil NM, Bank I, Hunt EA, Nadkarni V, Cheng A; INSPIRE CPR Investigators. | Pediatr Emerg Care. 2021 Mar 1;37(3):133-137
DOI: https://doi.org/10.1097/pec.0000000000002359
Keywords: Aucun

Original Article

Introduction : Effective cardiopulmonary resuscitation (CPR) is critical to ensure optimal outcomes from cardiac arrest, yet trained health care providers consistently struggle to provide guideline-compliant CPR. Rescuer fatigue can impact chest compression (CC) quality during a cardiac arrest event, although it is unknown if visual feedback or just-in-time training influences change of CC quality over time. In this study, we attempt to describe the changes in CC quality over a 12-minute simulated resuscitation and examine the influence of just-in-time training and visual feedback on CC quality over time.

Méthode : We conducted secondary analysis of data collected from the CPRCARES study, a multicenter randomized trial in which CPR-certified health care providers from 10 different pediatric tertiary care centers were randomized to receive visual feedback, just-in-time CPR training, or no intervention. They participated in a simulated cardiac arrest scenario with 2 team members providing CCs. We compared the quality of CCs delivered (depth and rate) at the beginning (0-4 minutes), middle (4-8 minutes), and end (8-12 minutes) of the resuscitation.

Résultats : There was no significant change in depth over the 3 time intervals in any of the arms. There was a significant increase in rate (128 to 133 CC/min) in the no intervention arm over the scenario duration (P < 0.05).

Conclusion : There was no significant drop in CC depth over a 12-minute cardiac arrest scenario with 2 team members providing compressions.

Conclusion (proposition de traduction) : Il n'y avait pas de baisse significative de la profondeur de compression thoracique sur un scénario d'arrêt cardiaque de 12 minutes avec 2 membres de l'équipe fournissant des compressions.

Retrospective Comparison of Intranasal Fentanyl and Inhaled Nitrous Oxide to Intravenous Ketamine and Midazolam for Painful Orthopedic Procedures in a Pediatric Emergency Department.
Míguez MC, Ferrero C, Rivas A, Lorente J, Muñoz L, Marañón R. | Pediatr Emerg Care. 2021 Mar 1;37(3):e136-e140
DOI: https://doi.org/10.1097/pec.0000000000001788
Keywords: Aucun

Original article

Introduction : To compare the efficacy and adverse events of 2 pharmacological strategies: intranasal fentanyl and nitrous oxide (FN) inhaled against intravenous ketamine and midazolam (KM) as procedural sedation and analgesia (PSA) in painful orthopedic procedures in the pediatric emergency department (ED).

Méthode : This is an observational retrospective cohort study. Patients were included that submitted to PSA for carrying out a painful orthopedic procedure in the ED of a tertiary hospital over a period of 2 years. The main outcome variable was efficacy and adverse events of the PSA procedure.

Résultats : Eighty-three patients were included. Fifty-two patients received FN and 31 KM. The PSA strategy was considered efficacious in 82.7% of the patients in the KM group and 80.6% in the FN cohort. No differences between both strategies were found (P = 0.815). Seventeen children showed early adverse events, 2 in the FN cohort and 15 in the KM group (relative risk of the KM strategy, 23.48; 95% confidence interval (CI), 3.24-169.99). The average of satisfaction obtained by the families was of 10 (CI, 10-10) in the KM cohort and of 9 (CI, 8-9.5) in the FN group (P = 0.152). The length of stay in the ED was longer in the KM cohort (P < 0.001). Hospital admission rate differences were not statistically different (9.6% vs 22.6%, P = 0.144) in the KM versus FN cohort.

Conclusion : Both PSA strategies presented similar efficacy. The FN strategy was associated with a lower risk of adverse events and shorter ED length of stay than KM in this ED setting.

Conclusion (proposition de traduction) : Les stratégies de sédation procédurale et d'analgésie ont présenté une efficacité similaire. La stratégie d'utilisation du fentanyl intra nasale et de protoxyde d'azote inhalé était associée à un risque plus faible d'événements indésirables et à une durée de séjour plus courte au service des urgences que l'utilisation de kétamine et midazolam par voie intraveineuse dans ce service d'urgence.

Time to Return of Spontaneous Circulation and Survival: When to Transport in out-of-Hospital Cardiac Arrest?.
de Graaf C, Donders DNV, Beesems SG, Henriques JPS, Koster RW. | Prehosp Emerg Care. 2021 Mar-Apr;25(2):171-181
DOI: https://doi.org/10.1080/10903127.2020.1752868  | Télécharger l'article au format  
Keywords: out-of-hospital cardiac arrrest; return of spontaneous circulation; survival; timing; transport.

Original Contribution

Introduction : n out-of-hospital cardiac arrest (OHCA), 10-50% of patients have return of spontaneous circulation (ROSC) before hospital arrival. It is important to investigate the relation between time-to-ROSC and survival to determine the optimal timing of transport to the hospital in patients without ROSC.

Méthode : We analyzed data of OHCA patients with a presumed cardiac cause (excluding traumatic and other obvious non-cardiac causes) and ROSC before hospital arrival from the Amsterdam Resuscitation Study (ARREST) database. ROSC included those patients whose ROSC was persistent or transient before or during transport, lasting ≥1 min. Of these data, we analyzed the association between the time of emergency medical services (EMS) arrival until ROSC (time-to-ROSC) and 30-day survival.

Résultats : Of 3632 OHCA patients with attempted resuscitation, 810 patients with prehospital ROSC were included. Of these, 332 (41%) survived 30 days. Survivors had a significant shorter time-to-ROSC compared to non-survivors of median 5 min (IQR 2,10) vs. median 12 min (IQR 9,17) (p < 0.001). Of the survivors, 90% achieved ROSC within 15 min compared to 22 min of non-survivors. In a multivariable model adjusted for known system determinants time-to-ROSC per minute was significantly associated with 30-day survival (OR 0.89; 95%CI 0.86-0.91). A ROC curve showed 8 min as the time-to-ROSC with the best test performance (sensitivity of 0.72 and specificity of 0.77).

Conclusion : In OHCA patients with prehospital ROSC survival significantly decreases with increasing time-to-ROSC. Of all patients, 90% of survivors had achieved ROSC within the first 15 min of EMS resuscitation. The optimal time for the decision to transport is between 8 and 15 min after EMS arrival.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque extra-hospitalier avec retour à une circulation spontanée préhospitalier, la survie diminue de manière significative avec l'augmentation du temps de retour à une circulation spontanée. De tous les patients, 90 % des survivants avaient obtenu un retour à une circulation spontanée dans les 15 premières minutes de réanimation par les services médicaux d'urgence. Le moment optimal pour la décision de transport se situe entre 8 et 15 min après l'arrivée des services médicaux d'urgence.

Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: A systematic review and meta-analysis.
McFadden P, Reynolds JC, Madder RD, Brown M. | Resuscitation. 2021 Mar;160:20-36
DOI: https://doi.org/10.1016/j.resuscitation.2020.11.039  | Télécharger l'article au format  
Keywords: cardiac arrest; coronary angiography; diagnostic test accuracy; electrocardiogram; revascularization; systematic review.

Review

Introduction : Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an acute-appearing coronary lesion and revascularization.

Méthode : We searched PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science through February 18, 2020. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using QUADAS-2. We estimated sensitivity (Sn), specificity (Sp), and likelihood ratios (LR) for all reported ECG features to indicate all reported reference standards. Random-effects meta-analysis pooled comparable studies without critical risk of bias. GRADE methodology evaluated the certainty of evidence.

Résultats : Overall, 48 studies reported 94 combinations of ECG features and reference standards with wide variation in their definitions. Most studies had risks of bias from selection for coronary angiography and blinding to the ECG and/or reference standard. Meta-analysis combined 6 studies for STE and acute coronary lesion (Sn 0.70 [95% CI 0.54-0.82]; Sp 0.85 [95% CI 0.78-0.90]; LR + 4.7 [95% CI 3.3-6.7]; LR- 0.4 [95% CI 0.2-0.6]) and 4 studies for STE and revascularization (Sn 0.53 [95% CI 0.47-0.58]; Sp 0.86 [95% CI 0.80-0.91]; LR + 3.9 [95% CI 2.8-5.5]; LR- 0.5 [95% CI 0.5-0.6]). Overall certainty of evidence was low with substantial heterogeneity.

Conclusion : Based on low certainty evidence, STE had good classification for acute coronary lesion and fair classification for revascularization. STE was more specific than sensitive for these outcomes and no single ECG feature excluded them. Uniform definitions and terminology would greatly facilitate the interpretation of subsequent studies.

Conclusion (proposition de traduction) : Sur la base de preuves de faible certitude, l'élévation du segment ST avait une bonne classification pour les lésions coronaires aiguës et une classification juste pour la revascularisation. L'élévation du segment ST était plus spécifique que sensible pour ces résultats et aucune caractéristique ECG ne les excluait. Des définitions et une terminologie uniformes faciliteraient grandement l'interprétation des études ultérieures.

Pediatric timing of epinephrine doses: A systematic review.
Ohshimo S, Wang CH, Couto TB, Bingham R, Mok YH, Kleinman M, Aickin R, Ziegler C, DeCaen A, Atkins DL, Maconochie I, Rabi Y, Morrison L; International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force. | Resuscitation. 2021 Mar;160:106-117
DOI: https://doi.org/10.1016/j.resuscitation.2021.01.015
Keywords: Children; Good neurological outcome; Hospital discharge; Infant; ROSC; Survival.

Review

Introduction : To evaluate the optimal timing and doses of epinephrine for Infants and children suffering in-hospital or out-of-hospital cardiac arrest.

Méthode : We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for human randomized clinical trials and observational studies including comparative cohorts. Two investigators reviewed relevance of studies, extracted the data, conducted meta-analyses and assessed the risk of bias using the GRADE and CLARITY frameworks. Authors of the eligible studies were contacted to obtain additional data. Critically important outcomes included return of spontaneous circulation, survival to hospital discharge and survival with good neurological outcome.

Résultats : We identified 7 observational studies suitable for meta-analysis and no randomized clinical trials. The overall certainty of evidence was very low. For the critically important outcomes, the earlier administration of epinephrine was favorable for both in-hospital and out-of-hospital cardiac arrest. Because of a limited number of eligible studies and the presence of severe confounding factors, we could not determine the optimal interval of epinephrine administration.

Conclusion : Earlier administration of the first epinephrine dose could be more favorable in non-shockable pediatric cardiac arrest. The optimal interval for epinephrine administration remains unclear.

Conclusion (proposition de traduction) : L'administration précoce de la première dose d'adrénaline pourrait être plus favorable en cas d'arrêt cardiaque pédiatrique non choquable. L'intervalle optimal pour l'administration d'adrénaline reste incertain.

Duration of exposure to a prehospital advanced airway and neurological outcome for out-of-hospital cardiac arrest: A retrospective cohort study.
Benoit JL, Stolz U, McMullan JT, Wang HE. | Resuscitation. 2021 Mar;160:59-65
DOI: https://doi.org/10.1016/j.resuscitation.2021.01.009
Keywords: Advanced cardiac life support; Emergency medical services; Endotracheal intubation; Mechanical ventilation; Out-of-hospital cardiac arrest; Return of spontaneous circulation; Supraglottic airway.

Clinical paper

Introduction : Out-of-hospital cardiac arrest (OHCA) studies have focused on the benefits and harms of placing an intra-arrest advanced airway, but few studies have evaluated the benefits and harms after successful placement. We hypothesize that increased time in the tumultuous prehospital environment after intra-arrest advanced airway placement results in reduced patient survival.

Méthode : This was a secondary analysis of adult, non-traumatic, OHCA patients with an advanced airway placed in the PRIMED trial. The exposure variable was the time interval between successful advanced airway placement and Emergency Department (ED) arrival. The outcome was cerebral performance category (CPC) 1 or 2 at hospital discharge. Multivariable logistic regression, adjusted for Utstein variables and resuscitation-associated time intervals, was used to estimate adjusted odds ratios (aOR).

Résultats : The cohort of complete cases included 4779 patients. The median time exposed to a prehospital advanced airway was 27 min (IQR 20-35). The total prehospital time was 39.4 min (IQR 32.3-48.1). An advanced airway was placed intra-arrest in 3830 cases (80.1%) and post-return of spontaneous circulation (post-ROSC) in 949 cases (19.9%). Overall, 486 (10.2%) of the cohort achieved the CPC outcome, but this was higher in the post-ROSC (21.7%) versus intra-arrest (7.5%) cohort. CPC was not associated with the time interval from advanced airway placement to ED arrival in the intra-arrest airway cohort (aOR 0.98, 95%CI 0.94-1.01).

Conclusion : In OHCA patients who receive an intra-arrest advanced airway, longer time intervals exposed to a prehospital advanced airway are not associated with reduced patient survival.

Conclusion (proposition de traduction) : Chez les patients en arrêt cardiaque extra-hospitalier qui ont été intubé pour un arrêt cardiaque extra-hospitalier, des durée plus longs d'utilisation de l'intubation préhospitalière n'est pas associés à une réduction de la survie du patient.

Commentaire : Cette étude justifie l'intubation précoce du patient malgré les conditions défavorables du transport pré-hospitalier de ces patients intubés.

Long term outcomes of participants in the PARAMEDIC2 randomised trial of adrenaline in out-of-hospital cardiac arrest.
Haywood KL, Ji C, Quinn T, Nolan JP, Deakin CD, Scomparin C, Lall R, Gates S, Long J, Regan S, Fothergill RT, Pocock H, Rees N, O'Shea L, Perkins GD. | Resuscitation. 2021 Mar;160:84-93
DOI: https://doi.org/10.1016/j.resuscitation.2021.01.019
Keywords: Adrenaline; Cardiac arrest; Cognitive; Drugs; Functional; Health related quality of life; Long term.

Clinical paper

Introduction : We recently reported early outcomes in patients enrolled in a randomised trial of adrenaline in out-of-hospital cardiac arrest: the PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) trial. The purpose of the present paper is to report long-term survival, quality of life, functional and cognitive outcomes at 3, 6 and 12-months.

Méthode : PARAMEDIC2 was a pragmatic, individually randomised, double blind, controlled trial with an economic evaluation. Patients were randomised to either adrenaline or placebo. This paper reports results on the modified Rankin Scale scores at 6-months, survival at 6 and 12-months, as well as other cognitive, functional and quality of life outcomes collected at 3 and 6 months (Two Simple Questions, the Mini Mental State Examination, the Informant Questionnaire on Cognitive Decline Evaluation for Cardiac Arrest, Hospital Anxiety and Depression Scale, the Post Traumatic Stress Disorder Checklist - Civilian Version, Short-Form 12-item Health Survey and the EuroQoL EQ-5D-5L).

Résultats : 8014 patients were randomised with confirmed trial drug administration. At 6-months, 78 (2.0%) of the patients in the adrenaline group and 58 (1.5%) of patients in the placebo group had a favourable neurological outcome (adjusted odds ratio 1.35 [95% confidence interval: 0.93, 1.97]). 117 (2.9%) patients were alive at 6-months in the adrenaline group compared with 86 (2.2%) in the placebo group (1.43 [1.05, 1.96], reducing to 107 (2.7%) and 80 (2.0%) respectively at 12-months (1.38 [1.00, 1.92]). Measures of 3 and 6-month cognitive, functional and quality of life outcomes were reduced, but there was no strong evidence of differences between groups.

Conclusion : Adrenaline improved survival through to 12-months follow-up. The study did not find evidence of improvements in favourable neurological outcomes.

Conclusion (proposition de traduction) : L'adrénaline a amélioré la survie jusqu'à 12 mois de suivi. L'étude n'a pas trouvé de preuves d'amélioration des résultats neurologiques favorables.

The use of personal protection equipment does not impair the quality of cardiopulmonary resuscitation: A prospective triple-cross over randomised controlled non-inferiority trial.
Kienbacher CL, Grafeneder J, Tscherny K, Krammel M, Fuhrmann V, Niederer M, Neudorfsky S, Herbich K, Schreiber W, Herkner H, Roth D. | Resuscitation. 2021 Mar;160:79-83
DOI: https://doi.org/10.1016/j.resuscitation.2021.01.021  | Télécharger l'article au format  
Keywords: COVID-19; Cardiopulmonary resuscitation; Chest compressions; Emergency medical services; Manikin; Personal protective equipment; Simulation.

Simulation and Education

Introduction : Prior studies suggest that the use of personal protective equipment might impair the quality of critical care. We investigated the influence of personal protective equipment on out-of-hospital cardiopulmonary resuscitation.

Méthode : Randomised controlled non-inferiority triple-crossover study. Forty-eight emergency medical service providers, randomized into teams of two, performed 12 min of basic life support (BLS) on a manikin after climbing 3 flights of stairs. Three scenarios were completed in a randomised order: Without personal protective equipment, with personal protective equipment including a filtering face piece (FFP) 2 mask with valve, and with personal protective equipment including an FFP2 mask without valve. The primary outcome was mean depth of chest compressions with a pre-defined non-inferiority margin of 3.5 mm. Secondary outcomes included other measurements of CPR quality, providers' subjective exhaustion levels, and providers' vital signs, including end-tidal CO2.

Résultats : Differences regarding the primary outcome were well below the pre-defined non-inferiority margins for both control vs. personal protective equipment without valve (absolute difference 1 mm, 95% CI [-1, 2]) and control vs. personal protective equipment with valve (absolute difference 1 mm, [-0.2, 2]). This was also true for secondary outcomes regarding quality of chest compressions and providers' vital signs including etCO2. Subjective physical strain after BLS was higher in the personal protective equipment groups (Borg 4 (SD 3) without valve, 4 (SD 2) with valve) than in the control group (Borg 3 (SD 2)).

Conclusion : PPE including masks with and without expiration valve is safe for use without concerns regarding the impairment of CPR quality.

Conclusion (proposition de traduction) : Les EPI, y compris les masques avec et sans valve d'expiration, peuvent être utilisés en toute sécurité sans craindre de détériorer la qualité de la RCP.

Coulm B | Sages-Femmes. 2021 March-april;2(52);43-46
DOI: http://dx.doi.org/10.1016/j.sagf.2021.01.011
Keywords: medication, nausea, pregnancy, treatment, vomiting

Clinique

Editorial : Les nausées et les vomissements gravidiques sont des troubles fonctionnels fréquents de la grossesse. Généralement bénins, ils disparaissent spontanément à la fin du premier trimestre. Ils peuvent parfois être invalidants et ne pas être soulagés par des mesures non pharmacologiques. Ces problèmes ne doivent pas être banalisés par les professionnels. L’instauration d’une prise en charge adaptée, médicamenteuse si nécessaire, doit être proposée.

Conclusion (proposition de traduction) : Les NVG sont des troubles fréquents en cours de grossesse. S’ils sont le plus souvent sans danger pour la mère et le fœtus, ils peuvent s’avérer invalidants et impacter la qualité de vie de la patiente. De ce fait, quand ils sont évoqués en consultation, ils ne doivent pas être banalisés, d’autant plus qu’une pathologie sous-jacente peut être à l’origine des vomissements, particulièrement s’ils perdurent (importance du diagnostic différentiel). Il convient de proposer une prise en charge adéquate. En cas d’échec des méthodes non pharmacologiques mises en place, différents médicaments ayant fait preuve de leur efficacité et de leur innocuité en cours de grossesse peuvent être prescrits.

Commentaire : 

Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy.
Knapp J, Eberle B, Bernhard M, Theiler L, Pietsch U, Albrecht R. | Scand J Trauma Resusc Emerg Med. 2021 Mar 17;29(1):49
DOI: https://doi.org/10.1186/s13049-021-00863-9  | Télécharger l'article au format  
Keywords: Airway; HEMS; Intubation; Prehospital emergency medicine; Videolaryngoscopy.

Original research

Introduction : Tracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative.

Méthode : We conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider's level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy.

Résultats : FPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers' expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified.

Conclusion : Airway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Conclusion (proposition de traduction) : La gestion des voies aériennes à l'aide du vidéolaryngoscope C-MAC avec lame Macintosh dans un groupe d'opérateurs ayant une expérience mitigée a montré un succès d'intubation au premier essai élevé et des taux globaux de réussite de l'intubation. L'enregistrement vidéo des intubations d'urgence peut améliorer l'éducation et le contrôle de la qualité.

Cerebral fat embolism after traumatic bone fractures: a structured literature review and analysis of published case reports.
Vetrugno L, Bignami E, Deana C, Bassi F, Vargas M, Orsaria M, Bagatto D, Intermite C, Meroi F, Saglietti F, Sartori M, Orso D, Robiony M, Bove T. | Scand J Trauma Resusc Emerg Med. 2021 Mar 12;29(1):47
DOI: https://doi.org/10.1186/s13049-021-00861-x  | Télécharger l'article au format  
Keywords: Cerebral fat embolism; Fat embolism syndrome; Patent foramen ovale.

Review

Introduction : The incidence of cerebral fat embolism (CFE) ranges from 0.9-11%, with a mean mortality rate of around 10%. Although no univocal explanation has been identified for the resulting fat embolism syndrome (FES), two hypotheses are widely thought: the 'mechanical theory', and the 'chemical theory'. The present article provides a systematic review of published case reports of FES following a bone fracture.

Méthode : We searched MEDLINE, Web of Science and Scopus to find any article related to FES. Inclusion criteria were: trauma patients; age ≥ 18 years; and the clinical diagnosis of CFE or FES. Studies were excluded if the bone fracture site was not specified.

Résultats : One hundred and seventy studies were included (268 cases). The male gender was most prominent (81.6% vs. 18.4%). The average age was 33 years (±18). The mean age for males (29 ± 14) was significantly lower than for females (51 ± 26) (p < 0.001). The femur was the most common fracture site (71% of cases). PFO was found in 12% of all cases. Univariate and multivariate regression analyses showed the male gender to be a risk factor for FES: RR 1.87 and 1.41, respectively (95%CI 1.27-2.48, p < 0.001; 95%CI 0.48-2.34, p < 0.001).

Conclusion : FES is most frequent in young men in the third decades of life following multiple leg fractures. FES may be more frequent after a burst fracture. The presence of PFO may be responsible for the acute presentation of cerebral embolisms, whereas FES is mostly delayed by 48-72 h.

Conclusion (proposition de traduction) : Le syndrome d'embolie graisseuse est le plus fréquent chez les jeunes hommes dans la troisième décennie de la vie après de multiples fractures de la jambe. Le syndrome d'embolie graisseuse peut être plus fréquent après une fracture comminutive. La présence d'un foramen ovale perméable peut être responsable de la présentation d'embolies cérébrales aiguë, alors que le syndrome d'embolie graisseuse est le plus souvent retardé de 48 à 72 h.

Vacuum mattress or long spine board: which method of spinal stabilisation in trauma patients is more time consuming? A simulation study.
Roessler MS, Riffelmann M, Kunze-Szikszay N, Lier M, Schmid O, Haus H, Schneider S, Heuer JF. | Scand J Trauma Resusc Emerg Med. 2021 Mar 11;29(1):46
DOI: https://doi.org/10.1186/s13049-021-00854-w  | Télécharger l'article au format  
Keywords: Long spine board; Prehospital trauma treatment; Spinal stabilisation; Vacuum mattress.

Original research

Introduction : Spinal stabilisation is recommended for prehospital trauma treatment. In Germany, vacuum mattresses are traditionally used for spinal stabilisation, whereas in anglo-american countries, long spine boards are preferred. While it is recommended that the on-scene time is as short as possible, even less than 10 minutes for unstable patients, spinal stabilisation is a time-consuming procedure. For this reason, the time needed for spinal stabilisation may prevent the on-scene time from being brief. The aim of this simulation study was to compare the time required for spinal stabilisation between a scoop stretcher in conjunction with a vacuum mattress and a long spine board.

Méthode : Medical personnel of different professions were asked to perform spinal immobilizations with both methods. A total of 172 volunteers were immobilized under ideal conditions as well as under realistic conditions. A vacuum mattress was used for 78 spinal stabilisations, and a long spinal board was used for 94. The duration of the procedures were measured by video analysis.

Résultats : Under ideal conditions, spinal stabilisation on a vacuum mattress and a spine board required 254.4 s (95 % CI 235.6-273.2 s) and 83.4 s (95 % CI 77.5-89.3 s), respectively (p < 0.01). Under realistic conditions, the vacuum mattress and spine board required 358.3 s (95 % CI 316.0-400.6 s) and 112.6 s (95 % CI 102.6-122.6 s), respectively (p < 0.01).

Conclusion : Spinal stabilisation for trauma patients is significantly more time consuming on a vacuum mattress than on a long spine board. Considering that the prehospital time of EMS should not exceed 60 minutes and the on-scene time should not exceed 30 minutes or even 10 minutes if the patient is in extremis, based on our results, spinal stabilisation on a vacuum mattress may consume more than 20 % of the recommended on-scene time. In contrast, stabilisation on a spine board requires only one third of the time required for that on a vacuum mattress. We conclude that a long spine board may be feasible for spinal stabilisation for critical trauma patients with timesensitive life threatening ABCDE-problems to ensure the shortest possible on-scene time for prehospital trauma treatment, not least if a patient has to be rescued from an open or inaccessible terrain, especially that with uneven overgrown land.

Conclusion (proposition de traduction) : La stabilisation de la colonne vertébrale pour les patients traumatisés prend beaucoup plus de temps sur un matelas à dépression que sur un plan dur vertébral. Considérant que le temps préhospitalier des services médicaux d'urgence ne doit pas dépasser 60 minutes et le temps sur place ne doit pas dépasser 30 minutes voire 10 minutes si le patient est in détresse vitale, d'après nos résultats, la stabilisation vertébrale sur matelas à dépression peut consommer plus de 20 % du temps de présence recommandé. En revanche, la stabilisation sur une plan dur vertébral ne nécessite qu'un tiers du temps requis pour celle sur un matelas à dépression. Nous concluons qu'un plan dur vertébral pourrait être réalisable pour la stabilisation de la colonne vertébrale chez les patients souffrant de problèmes d’ABCDE menaçant leur pronostic vital, afin de garantir le plus court délai possible sur place pour le traitement préhospitalier, surtout si un patient doit être secouru dans un terrain ouvert ou inaccessible, surtout sur un terrain accidenté envahi par la végétation.

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies.
Hsieh YL, Wu MC, Wolfshohl J, d'Etienne J, Huang CH, Lu TC, Huang EP, Chou EH, Wang CH, Chen WJ. | Scand J Trauma Resusc Emerg Med. 2021 Mar 8;29(1):44
DOI: https://doi.org/10.1186/s13049-021-00858-6  | Télécharger l'article au format  
Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Intraosseous; Intravenous; Meta-analysis; Systematic review.

Original research

Introduction : This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).

Méthode : We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I² statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.

Résultats : Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33; I², 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42-11.02, p: 0.02). That is, when the studies not accounting for the variable of "time to intervention" in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.

Conclusion : The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

Conclusion (proposition de traduction) : La méta-analyse n'a révélé aucune association significative entre les types d'accès vasculaire et les résultats neurologiques à la sortie de l'hôpital parmi les résultats après un arrêt cardiaque en dehors de l'hôpital. Le délai d'intervention a été identifié comme un modérateur important des résultats dans cette méta-analyse d'études observationnelles. Ces résultats appellent à la nécessité de futurs essais cliniques pour étudier l'effet impartial de l'utilisation de la voie intra-osseuse sur les résultats après un arrêt cardiaque RCP en dehors de l'hôpital.

Monitoring tissue oxygenation index using near-infrared spectroscopy during pre-hospital resuscitation among out-of-hospital cardiac arrest patients: a pilot study.
Tsukuda J, Fujitani S, Rahman M, Morisawa K, Kawaguchi T, Taira Y. | Scand J Trauma Resusc Emerg Med. 2021 Mar 4;29(1):42
DOI: https://doi.org/10.1186/s13049-021-00857-7  | Télécharger l'article au format  
Keywords: Cardiopulmonary resuscitation; Out‐of‐hospital cardiac arrest.

Original research

Introduction : Tissue oxygenation index (TOI) using the near infrared spectroscopy (NIRS) has been demonstrated as a useful indicator to predict return of spontaneous circulation (ROSC) among out-of-hospital cardiac arrest (OHCA) patients in hospital setting. However, it has not been widely examined based on pre-hospital setting.

Méthode : In this prospective observational study, we measured TOI in pre-hospital setting among OHCA patients receiving cardio-pulmonary resuscitation (CPR) during ambulance transportation between 2017 and 2018. Throughout the pre-hospital CPR procedure, TOI was continuously measured. The study population was divided into two subgroups: ROSC group and non-ROSC group.

Résultats : Of the 81 patients included in the final analysis, 26 achieved ROSC and 55 did not achieve ROSC. Patients in the ROSC group were significantly younger, had higher ∆TOI (changes in TOI) (5.8 % vs. 1.3 %; p < 0.01), and were more likely to have shockable rhythms and event witnessed than patients in the non-ROSC group. ∆TOI cut-off value of 5 % had highest sensitivity (65.4 %) and specificity (89.3 %) for ROSC. Patients with a cut-off value ≤-2.0 % did not achieve ROSC and while all OHCA patient with a cut-off value ≥ 8.0 % achieved ROSC. In addition, ROSC group had stronger positive correlation between mean chest compression rate and ∆TOI (r = 0.82) than non-ROSC group (r = 0.50).

Conclusion : This study suggests that ∆ TOI could be a useful indicator to predict ROSC in a pre-hospital setting.

Conclusion (proposition de traduction) : Cette étude suggère que le ∆ TOI pourrait être un indicateur utile pour prédire la RACS en milieu préhospitalier.

Shock Index and Postpartum Hemorrhage in Vaginal Deliveries: A Multicenter Retrospective Study.
Ushida T, Kotani T, Imai K, Nakano-Kobayashi T, Nakamura N, Moriyama Y, Yoshida S, Yamashita M, Kajiyama H, Kikkawa F. | Shock. 2021 Mar 1;55(3):332-337
DOI: https://doi.org/10.1097/shk.0000000000001634
Keywords: Aucun

Clinical Science Aspects

Introduction : Shock index (SI), calculated by dividing heart rate by systolic blood pressure, is used to detect hemodynamic instability and hypovolemia. In obstetric practice, limited evidence is available regarding its usefulness in detecting postpartum hemorrhage (PPH). We aimed to evaluate the usefulness of SI in detecting PPH in vaginal deliveries using clinical data from 12 primary maternity care units in Japan.

Méthode : In this multicenter retrospective study, a total of 30,820 women who delivered vaginally at term at 12 primary maternity care units from January 2012 to December 2018 were included. Systolic and diastolic blood pressures and heart rate were measured at five different time points from admission to postpartum 2 h, and postpartum blood loss was measured. We evaluated the trend of average SI and the performance of each vital sign for detection of PPH.

Résultats : The trend of average SI during labor and the immediate postpartum period was approximately 0.7 in women with blood loss of <500 mL. SI from the time of delivery of the placenta increased with an increase in blood loss. SI had the highest area under the receiver operating characteristic curve of 0.699 [95% confidence interval (CI), 0.682-0.716] and 0.758 (95% CI, 0.729-0.788) for PPH of ≥1,000 and ≥1,500 mL, respectively. However, both sensitivity of SI (1.0) for PPH (≥1,000 mL; 29.9%, and ≥1,500 mL; 40.5%, respectively) and correlation between maximum SI and blood loss (coefficient of correlation, 0.263) were low.

Conclusion : SI is a better parameter for PPH detection in vaginal deliveries than other vital signs. However, clinical judgment must incorporate other vital signs and symptoms associated with hypovolemic shock due to the low sensitivity of SI.

Conclusion (proposition de traduction) : Le Shock Index est un meilleur paramètre pour la détection des hémorragies du post-partum lors d'accouchements par voie basse que les autres signes vitaux. Cependant, le jugement clinique doit intégrer d'autres signes vitaux et symptômes associés au choc hypovolémique en raison de la faible sensibilité du Shock Index.

D-Dimer as Predictor of Large Vessel Occlusion in Acute Ischemic Stroke.
Ramos-Pachón A, López-Cancio E, Bustamante A, Pérez de la Ossa N, Millán M, Hernández-Pérez M, Garcia-Berrocoso T, Cardona P, Rubiera M, Serena J, Ustrell X, Garcés M, Terceño M, Dávalos A, Montaner J. | Stroke. 2021 Mar;52(3):852-858
DOI: https://doi.org/10.1161/strokeaha.120.031657
Keywords: biomarkers; patients; reperfusion; stroke; thrombectomy.

Original Contributions

Introduction : Improving prehospital triage of large vessel occlusion (LVO) would reduce time to reperfusion therapies. We aimed to study early predictors of LVO in acute ischemic stroke to identify candidates for endovascular treatment.

Méthode : The Stroke-Chip was a prospective observational study conducted at 6 Stroke Centers in Catalonia. Blood samples were obtained in the first 6 hours from symptom onset of consecutive patients. Stroke severity was evaluated with National Institutes of Health Stroke Scale (NIHSS) and LVO was assessed. Independent association of multiple blood biomarkers with LVO was evaluated using logistic regression models adjusted by covariates. Sensitivity, specificity, and predictive values were assessed for NIHSS and the combination of NIHSS and selected serum biomarkers levels.

Résultats : One thousand three hundred eight suspected strokes were enrolled for a 17-month period. LVO was not assessed in 131 patients. One thousand one hundred seventy-seven patients were selected for analysis (mean age 69.3 years, 56% men, median baseline NIHSS of 6, and median time to blood collection 2.5 hours). LVO was detected in 262 patients. LVO patients were older, had higher baseline NIHSS, history of atrial fibrillation, and lower time from stroke onset to admission. After logistic regression analysis, D-dimer remained an independent predictor of LVO (odds ratio, 1.59 [1.31-1.92]). Specificity and positive predictive value to exclude or detect LVO were higher when using combined D-dimer levels and NIHSS score assessment rather than NIHSS alone.

Conclusion : Early D-dimer levels are an independent predictor of LVO and may be useful to better optimize prehospital patient transport to the appropriate stroke center.

Conclusion (proposition de traduction) : Les taux précoces de D-dimères sont un prédicteur indépendant de l'occlusion des gros vaisseaux et peuvent être utiles pour mieux optimiser le transport des patients préhospitaliers vers le centre d'AVC approprié.

Thrombus Composition and Efficacy of Thrombolysis and Thrombectomy in Acute Ischemic Stroke.
Jolugbo P, Ariëns RAS. | Stroke. 2021 Mar;52(3):1131-1142
DOI: https://doi.org/10.1161/strokeaha.120.032810  | Télécharger l'article au format  
Keywords: blood platelets; extracellular traps; fibrin; ischemic stroke; thrombectomy.

Topical Review

Editorial : Thrombi retrieved from patients with acute ischemic stroke are highly heterogeneous. Recent data suggest that thrombus composition may impact on mechanical thrombectomy, the number of recanalization manoeuvres, resistance to retrieval, and on thrombolytic potential. Our aim was to summarize evidence describing the impact of thrombus composition on efficacy of mechanical thrombectomy and thrombolysis in patients with acute ischemic stroke. The scoping review methodology guided by the Joanna Briggs Institute, an adaption of the Arksey and O'Malley, was followed. Comprehensive searches were conducted in MEDLINE, EMBASE, SCOPUS, and Web of Science. Articles were classified into 4 key themes: (1) composition of stroke thrombi, (2) thrombus composition and mechanical thrombectomy, (3) thrombus composition and thrombolytic therapy, and (4) novel imaging and endovascular approaches. Our search identified 698 articles published from 1987 to June 2020. Additional articles were extracted from reference lists of the selected articles. Overall, 95 topic-specific articles identified for inclusion published in 40 different journals were included. Reports showed that thrombus composition in stroke was highly heterogeneous, containing fibrin, platelets, red blood cells, VWF (von Willebrand Factor), and neutrophil extracellular traps. Thrombi could roughly be divided into fibrin- and red blood cell-rich clots. Fibrin-rich clots were associated with increased recanalization manoeuvres, longer procedure time, and less favorable clinical outcomes compared with red blood cell-rich clots. Advances in detection or treatment of thrombi that take into account clot heterogeneity may be able to improve future endovascular and thrombolytic treatment of stroke.

Conclusion : In recent years, research characterising thrombi in AIS has shown that the histological, biochemical and structural composition of the clot has a significant impact on treatment success rates. RBC-rich thrombi are typically associated with favourable outcomes such as higher recanalization success, shorter intervention time and increased tPA sensitivity. Fibrin- rich thrombi on the other hand have a less favourable outcome, mostly due to their increased stiffness and resistance to both mechanical thrombectomy and thrombolysis. Future developments to better identify and remove occlusive thrombi through early vessel signs, innovative imaging and diagnostic methods to determine clot composition, and adjuvant treatments are likely to be key for future improvements in AIS treatment, care and outcomes.

Conclusion (proposition de traduction) : Ces dernières années, la recherche caractérisant les thrombus dans l'AVC ischémique aigu a montré que la composition histologique, biochimique et structurelle du caillot a un impact significatif sur les taux de succès du traitement. Les thrombus riches en globules rouges sont généralement associés à des résultats favorables tels qu'un succès de recanalisation plus élevé, un temps d'intervention plus court et une sensibilité accrue au rtPA. Les thrombi riches en fibrine, quant à eux, ont un résultat moins favorable, principalement en raison de leur rigidité et de leur résistance accrues à la fois à la thrombectomie mécanique et à la thrombolyse. Les développements futurs pour mieux identifier et éliminer les thrombus occlusifs grâce aux signes précoces des vaisseaux, aux méthodes d'imagerie et de diagnostic innovantes pour déterminer la composition du caillot et aux traitements adjuvants seront probablement essentiels pour les améliorations futures du traitement, des soins et des résultats de l'AVC ischémique aigu.

Isopropyl alcohol nasal inhalation for nausea in the triage of an adult emergency department.
Candemir H, Akoglu H, Sanri E, Onur O, Denizbasi A. | Am J Emerg Med. 2021 Mar;41:9-13
DOI: https://doi.org/10.1016/j.ajem.2020.12.052
Keywords: Aromatherapy; Inhalation; Isopropyl alcohol; Triage.

Original Contribution

Introduction : Nausea and vomiting (N&V) are among the most common complaints in the emergency department (ED). However, low acuity is assigned to most of these patients at the triage, and waiting for long hours without medication decreases patient safety and satisfaction. We aimed to compare the inhalation of isopropyl alcohol (IPA) with placebo (P) to treat nausea at the triage area of an ED.

Méthode : In this prospective, randomized and placebo-controlled trial, we used a convenience sample of consecutive adult (ages 18-65) patients presented to the triage area of the ED with the complaint of N&V, and we randomized them to inhale IPA or P embedded gauzes. We used an 11-point (0-10) numeric rating scale (NRS) to evaluate the degree of N&V before the inhalation, at the baseline, and at 2, 4 and 10 min after the inhalation.

Résultats : We randomized 118 patients (IPA, n = 62; P, n = 56, intent-to-treat), three patients left the ED without being seen, and 115 patients completed the study. IPA and P groups were similar according to age, sex, comorbidities, and vital signs. We found that patients in the IPA group had significantly lower mean NRS starting with the 2nd minute (robust two-way mixed ANOVA between-subjects, p = 0.008). We also observed a significant within-subjects effect in the IPA group. The mean NRS value was decreased at each consecutive time point in the IPA group (all pairwise comparisons, p < 0.001).

Conclusion : In this study, IPA was significantly more effective than P for N&V at the triage. Moreover, patients in the IPA group had less need for rescue treatment.

Conclusion (proposition de traduction) : Dans cette étude, l'inhalation d'alcool isopropylique était significativement plus efficace que le placebo pour les nausées et les vomissements lors du triage. De plus, les patients dans le groupe de l'inhalation d'alcool isopropylique avaient moins besoin d'un traitement de secours.

Problems with interpreting troponins in chronic kidney disease patients for ruling out acute coronary syndrome.
Kansara T, Majmundar M, Basman C, Visco F. | Am J Emerg Med. 2021 Mar;41:14-15
DOI: https://doi.org/10.1016/j.ajem.2020.12.051
Keywords: Acute coronary syndrome; Chronic kidney disease; Troponin.

Original Contribution

Editorial : Chest pain is one of the most common reasons for emergency department visits worldwide, and troponins play a central role in diagnosing acute coronary syndrome (ACS) in these patients. Hence, the tests for these molecules are imperative in triage for ACS. Presently, multiple high-sensitivity troponin tests are available, including those for troponin T and I. However, in the presence of physiological and pathological alterations such as chronic kidney disease (CKD) and muscle dysfunction, these tests lose their sensitivity and specificity, especially if not interpreted in the right clinical background. Further, no guidelines exist for interpreting the results in patients with CKD. We identified studies that compared the relative efficacy, sensitivity, and specificity of tests for troponin T and I in patients with CKD to understand the practical problems in the clinical interpretation of these results in the specific setting of CKD and highlight the measures to be taken into consideration.

Barriers to point-of-care ultrasound utilization during cardiac arrest in the emergency department: a regional survey of emergency physicians.
Singh MR, Jackson JS, Newberry MA, Riopelle C, Tran VH, PoSaw LL. | Am J Emerg Med. 2021 Mar;41:28-34
DOI: https://doi.org/10.1016/j.ajem.2020.12.040
Keywords: Barriers; Cardiac arrest; Emergency department; Point-of-care ultrasound; Training.

Original Contribution

Introduction : Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED).

Méthode : Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers.

Résultats : 206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was "No structured curriculum to educate physicians on POCUS." The top-ranked personal barriers were "I do not feel comfortable with my POCUS skills" and "I do not have sufficient time to dedicate to learning POCUS." The top-ranked barriers for resident physicians were "Time to retrieve and operate the machine" and "Chaotic milieu."

Conclusion : While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

Conclusion (proposition de traduction) : Bien que notre étude démontre que la plupart des médecins séniors et juniors utilisent l'échographie au point d'intervention lors d'un arrêt cardiaque, il existe des obstacles à une mise en œuvre de haute qualité. Les principaux obstacles pour les médecins séniors sont liés à la formation en échographie au point d'intervention, tandis que les principaux obstacles pour les juniors sont liés à la logistique et aux machines. Les interventions visant à surmonter ces obstacles pourraient conduire à l'optimisation des performances de l'échographie au point d'intervention lors d'un arrêt cardiaque aux urgences.

Lidocaine versus dexketoprofen in treatment of tension-type headache: A double-blind randomized controlled trial.
Akbas I, Kocak AO, Akgol Gur ST, Oral Ahiskalioglu E, Dogruyol S, Dolanbay T, Demir M, Cakir Z. | Am J Emerg Med. 2021 Mar;41:125-129
DOI: https://doi.org/10.1016/j.ajem.2020.12.057
Keywords: Aucun

Original contribution

Editorial : Tension-type headache, with a life time prevalence in the general population ranging between 30% and 78%, can be episodic or chronic. Episodic tension-type headache, which can be infrequent episodic or frequent, has a high socio-economic impact. Tension-type headache was reported as the third most prevalent disorder among all dis- eases in Global Burden of Diseases Study in 2016, and headache composes one of the most common reasons for visiting primary care and emergency departments (EDs). ED boarding is one of the main factors for overcrowding in EDs, but ED alone could not solve the underlying clinical disease and could only mitigate the basic complaint which the patient has. The ED management of headache ideally focuses on controlling pain. Although the use of nerve block has been propagated in occipital and cervical pain syndromes, systemic use of non-steroidal anti-inflammatory drugs and acetaminophen are the first choice in the pharmacological management of tension-type headache. However, it is mentioned that overuse or misuse of non-steroidal anti-inflammatory drugs can lead the severe gastrointestinal, cardiovascular, and renal side effects.

Conclusion : Headache disorders, which are among the most prevalent disorder worldwide, deserve greater attention in hospitals and compose an important part of ED admission. The intravenous administration of lidocaine with minimal side effects seems to be useful for tension-type headache in the EDs. More comprehensive and randomize controlled clinical researches are needed to generalize that the intravenous lidocaine treatment is effective for pain relief in patients with headache disorders.

Conclusion (proposition de traduction) : Les maux de tête, qui sont parmi les troubles les plus répandus dans le monde, méritent une plus grande attention dans les hôpitaux et constituent une part importante de l'admission aux urgences. L'administration intraveineuse de lidocaïne avec des effets secondaires minimes semble être utile pour les céphalées de tension dans les services d'urgence. Des recherches cliniques contrôlées plus complètes et randomisées sont nécessaires pour généraliser que le traitement intraveineux de lidocaïne est efficace pour le soulagement de la douleur chez les patients souffrant de maux de tête.

The reverse vagal manoeuvre: A new tool for treatment of supraventricular tachycardia?.
Gaudart P, Cazes N, Simon K, Larger D, Deharo JC. | Am J Emerg Med. 2021 Mar;41:66-69
DOI: https://doi.org/10.1016/j.ajem.2020.12.061
Keywords: Modified Valsalva manoeuvre; Reverse Valsalva manoeuvre; Supraventricular tachycardia; Vagal manoeuvre.

Brief Reports

Editorial : Supraventricular tachycardia is a common cardiac arrhytmia with recurrent episodes. The rapid resolution of supraventricular tachycardia remains a challenge. Vagal manoeuvres are simple and non-invasive but yield positive results in less than half the cases. Currently, the modified Valsalva manoeuvre appears to be the most effective technique. We have tested the effectiveness of the reverse Valsalva manoeuvre without swallowing as new vagal manoeuvre for the treatment of supraventricular tachycardia. This new technique is easy to perform and can be carried out alone by the patient. We report in this series 11 cases of supraventricular tachycardia, 10 of which were effectively reduced after the completion of the reverse Valsava manoeuvre. The very encouraging results of this series of cases will have to be quickly evaluated by a randomised controlled trial. This new technique, which is simple to learn and carry out, could be easily taught throughout the world, including in regions with few health-care resources.

Conclusion : The reverse Valsalva manoeuvre without swallowing is describedhere for thefirst time as a vagal manoeuvre in the context of arrestingSVT. This manoeuvre holds much research interest. The rVM should becompared with the currently used vagal manoeuvres for treating SVTto determine whether it can be an alternative method or whether, be-cause of its greater effectiveness and simplicity of teaching and execu-tion, it should become the method of choice in thefirst-line treatmentof SVT.

Conclusion (proposition de traduction) : La manœuvre de Valsalva « inversée » sans déglutition est ici décrite pour la première fois comme une manœuvre vagale dans le contexte de la réversion de la tachycardie supraventriculaire. Cette manœuvre présente un grand intérêt pour la recherche. La manœuvre de Valsalva modifiée devrait être comparée aux manœuvres vagales actuellement utilisées pour traiter la tachycardie supraventriculaire afin de déterminer si elle peut être une méthode alternative ou si, en raison de sa plus grande efficacité et de sa simplicité d'enseignement et d'exécution, elle devrait devenir la méthode de choix dans le traitement de première intention de la tachycardie supraventriculaire.

Commentaire : Reverse Valsalva Manoeuvre without swalling
Dans la manœuvre de Valsalva « inversée » sans déglutition, le patient, en position assise, tente d'inspirer contre la résistance pendant 10 s, en se pinçant le nez et en fermant fermement la bouche (au lieu expirer de l’air vers les trompes d’Eustache).
1- Expirez sans forcer en position assise
2- Pincez le nez et fermez la bouche (fermement)
3- Inspirez contre la résistance pendant dix secondes
4- Ça va mieux...

La manœuvre de Valsalva classique consiste à faire expirer de l’air au patient vers les trompes d’Eustache, en ayant la bouche fermée et le nez pincé (effort d’expiration forcée à glotte fermée pendant une quinzaine de secondes) : on demande au patient de souffler dans une seringue en étant en position allongée (sur le dos).
Pour la manoeuvre de Valsalva modifiée le patient réalise la manoeuvre classique, en position assise, puis le patient est mis en position allongée avec les jambes surélevées à 45 degrés tout de suite après les 15 secondes d'expiration forcée (https://doi.org/10.1016/S0140-6736(15)61485-4  ). Cette modification posturale permet d’améliorer significativement l’efficacité de la procédure de réversion de 17 % à 43 % dans le groupe avec modification posturale.

Double external defibrillation for shock-refractory ventricular fibrillation cardiac arrest: A step towards standardization.
Miraglia D, Ramzy M. | Am J Emerg Med. 2021 Mar;41:73-79
DOI: https://doi.org/10.1016/j.ajem.2020.12.031
Keywords: Double defibrillation; Double external defibrillation; Double sequential defibrillation; Double simultaneous defibrillation.

Reviews

Editorial : Double (or dual) external defibrillation (DED) has increasingly been used in the last few years by a number of emergency medical services (EMS) as a last resort to terminate ventricular fibrillation and pulseless ventricular tachycardia in adult patients who remain refractory to standard defibrillation. However, no randomized controlled trials comparing DED with standard defibrillation focusing on patient-oriented outcomes as the primary objective have been published to date. Selection criteria, procedure techniques, and protocol are not clearly defined and vary across observational studies. The terms and/or nomenclature used to describe DED are confusing and vary throughout the literature. Despite increased use of DED, many questions remain as to which patients will derive the most benefit from DED, when to implement DED, and the optimal form of delivering DED. The present paper provides a brief overview of the background, procedure techniques, pad placement, and factors affecting how DED is delivered. A further objective of this paper is to offer a proposal for a uniform nomenclature and a standardized protocol in the form of a flowchart for EMS agencies to guide further clinical trials and best practices. This paper should not only help give background on novel definitions and clarify nomenclature for this practice, but more importantly should help institutions lay the groundwork for performing EMS-based large trials to further investigate the effectiveness of DED.

Conclusion : EMS agencies performing this practice should adhere to a standardized operating protocol with stringent patient selection criteria, monitored through quality assurance and quality improvement efforts, in order to guide further clinical trials and best practices. This paper should not only help give background on novel definitions and clarify nomenclature for this practice but more importantly should help institutions lay the groundwork for performing EMS-based large trials to further investigate the effectiveness ofDED. In addition to the absence of available evidence, the literature that is available is highly inconsistent and is complicated by the lack of standardized protocols and practice. Much work is needed in this area, but the patient population of interest is so small and rarely encountered that a definitive trial powered for long term neurologically intact survival will be difficult, quite complex, and very expensive to do. Although challenging, however, it should be made a priority.

Conclusion (proposition de traduction) : Les agences de services médicaux d'urgence qui pratiquent cette pratique doivent adhérer à un protocole opératoire normalisé avec des critères de sélection des patients stricts, surveillés par des efforts d'assurance qualité et d'amélioration de la qualité, afin de guider d'autres essais cliniques et les meilleures pratiques. Ce document devrait non seulement aider à donner des informations sur les nouvelles définitions et clarifier la nomenclature de cette pratique, mais surtout devrait aider les institutions à jeter les bases de la réalisation d'essais de grande envergure basés sur les services médicaux d'urgence afin d'étudier plus en profondeur l'efficacité de la double (ou double) défibrillatio externe. En plus de l'absence de preuves disponibles, la littérature disponible est très incohérente et est compliquée par le manque de protocoles et de pratiques normalisés. Il reste beaucoup à faire dans ce domaine, mais la population de patients concernée est si petite et si rare qu’un essai définitif visant à assurer une survie neurologique intacte à long terme s’avérera difficile, assez complexe et très coûteux à réaliser. Bien qu’elle soit difficile, elle devrait être considérée comme une priorité.

Commentaire :  Deux positions habituelles de placement des électrodes pour la double défibrillation externe :
• placement antéro-apicale/antéro-antérieure avec le deuxième jeu de palettes placé à côté du premier jeu à droite du sternum et à l'apex (deux dessins de droite) ;
• placement antéro-postérieur et antéro-apical (antérieur-antérieur) pour les électrodes de la double défibrillation (deux dessins de gauche).
Cette approche réduira la probabilité que les palettes de défibrillation soient en contact les unes avec les autres.

Protocole pour la double défibrillation externe.

ATTENTION :
Les recommandations de l'ERC 2021   pour la FV réfractaire, ne recommande pas l'utilisation de la double défibrillation séquentielle, en dehors d'un environnement de recherche.
Il est proposé d'envisagez plutôt d'utiliser un autre positionnent des palettes de défibrillation (par exemple, antéro-postérieur).

The diamond of death: Hypocalcemia in trauma and resuscitation.
Wray JP, Bridwell RE, Schauer SG, Shackelford SA, Bebarta VS, Wright FL, Bynum J, Long B. | Am J Emerg Med. 2021 Mar;41:104-109
DOI: https://doi.org/10.1016/j.ajem.2020.12.065
Keywords: Calcium; Coagulopathy; Critical; Hypocalcemia; Resuscitation; Trauma.

Review

Introduction : Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in trauma.

Méthode : This narrative review of available literature describes the physiology and role of calcium in trauma resuscitation. Authors did not perform a systematic review or meta-analysis.

Discussion : Calcium is a divalent cation found in various physiologic forms, specifically the bound, inactive state and the unbound, physiologically active state. While calcium plays several important physiologic roles in multiple organ systems, the negative hemodynamic effects of hypocalcemia are crucial to address in trauma patients. The negative ramifications of hypocalcemia are intrinsically linked to components of the lethal triad of acidosis, coagulopathy, and hypothermia. Hypocalcemia has direct and indirect effects on each portion of the lethal triad, supporting calcium's potential position as a fourth component in this proposed lethal diamond. Trauma patients often present hypocalcemic in the setting of severe hemorrhage secondary to trauma, which can be worsened by necessary transfusion and resuscitation. The critical consequences of hypocalcemia in the trauma patient have been repeatedly demonstrated with the associated morbidity and mortality. It remains poorly defined when to administer calcium, though current data suggest that earlier administration may be advantageous.

Conclusion : Calcium is a key component of trauma resuscitation and the coagulation cascade. Recent data portray the intricate physiologic reverberations of hypocalcemia in the traumatically injured patient; however, future research is needed to further guide the management of these patients.

Conclusion (proposition de traduction) : Le calcium est un élément clé de la réanimation traumatologique et de la cascade de coagulation. Des données récentes décrivent les répercussions physiologiques complexes de l'hypocalcémie chez le patient traumatisé ; cependant, des recherches futures sont nécessaires pour guider davantage la prise en charge de ces patients.

Electrocardiographic manifestations of COVID-19.
Long B, Brady WJ, Bridwell RE, Ramzy M, Montrief T, Singh M, Gottlieb M. | Am J Emerg Med. 2021 Mar;41:96-103
DOI: https://doi.org/10.1016/j.ajem.2020.12.060  | Télécharger l'article au format  
Keywords: Arrhythmia; COVID-19; Cardiac; Coronavirus; Dysrhythmia; ECG; EKG; Electrocardiogram; Emergency medicine; SARS-CoV-2.

Review

Introduction : Coronavirus disease of 2019 (COVID-19) is a lower respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This disease can impact the cardiovascular system and lead to abnormal electrocardiographic (ECG) findings. Emergency clinicians must be aware of the ECG manifestations of COVID-19.

Méthode : This narrative review outlines the pathophysiology and electrocardiographic findings associated with COVID-19.

Discussion : COVID-19 is a potentially critical illness associated with a variety of ECG abnormalities, with up to 90% of critically ill patients demonstrating at least one abnormality. The ECG abnormalities in COVID-19 may be due to cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury. While sinus tachycardia is the most common abnormality, others include supraventricular tachycardias such as atrial fibrillation or flutter, ventricular arrhythmias such as ventricular tachycardia or fibrillation, various bradycardias, interval and axis changes, and ST segment and T wave changes. Several ECG presentations are associated with poor outcome, including atrial fibrillation, QT interval prolongation, ST segment and T wave changes, and ventricular tachycardia/fibrillation.

Conclusion : This review summarizes the relevant ECG findings associated with COVID-19. Knowledge of these findings in COVID-19-related electrocardiographic presentations may assist emergency clinicians in the evaluation and management of potentially infected and infected patients.

Conclusion (proposition de traduction) : Cette revue résume les constatations pertinentes relatives aux ECG associées à la COVID-19. La connaissance de ces constatations dans les présentations électrocardiographiques liées à la COVID-19 peut aider les urgentistes à évaluer et à gérer les patients potentiellement infectés et ceux infectés.

Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department.
Driver BE, Prekker ME, Reardon RF, Sandefur BJ, April MD, Walls RM, Brown CA 3rd. | J Emerg Med. 2021 Mar;60(3):265-272
DOI: https://doi.org/10.1016/j.jemermed.2020.10.042  | Télécharger l'article au format  
Keywords: difficult airway; emergency intubation; ketamine; rapid sequence intubation; topical anesthesia.

Original Contribution

Introduction : Rapid sequence intubation (RSI), defined as near-simultaneous administration of a sedative and neuromuscular blocking agent, is the most common and successful method of tracheal intubation in the emergency department. However, RSI is sometimes avoided when the physician believes there is a risk of a can't intubate/can't oxygenate scenario or critical hypoxemia because of distorted anatomy or apnea intolerance. Traditionally, topical anesthesia alone or in combination with low-dose sedation are used when physicians deem RSI too risky. Recently, a ketamine-only strategy has been suggested as an alternative approach.
Objective: We compared first attempt success and complications between ketamine-only, topical anesthesia alone or with low-dose sedation, and RSI approaches.

Méthode : We analyzed registry data from the National Emergency Airway Registry, comprising emergency department intubation data from 25 centers from January 2016 to December 2018. We excluded pediatric patients (<14 years of age), those in cardiac and respiratory arrest, or those with an alternate pharmacologic approach (i.e., neuromuscular blocking agent only or nonketamine sedative alone). We analyzed first attempt intubation success and adverse events across the 3 intubation approaches. We calculated differences in outcomes between the ketamine-only and topical anesthesia groups.

Résultats : During the study period, 12,511 of 19,071 intubation encounters met inclusion criteria, including 102 (0.8%) intubated with ketamine alone, 80 (0.6%) who had intubation facilitated by topical anesthesia, and 12,329 (98.5%) who underwent RSI. Unadjusted first attempt success was 61%, 85%, and 90% for the 3 groups, respectively. Hypoxemia (defined as oxygen saturation <90%) occurred in 16%, 13%, and 8% of patients during the first attempt, respectively. At least 1 adverse event occurred in 32%, 19%, and 14% of the courses of intubation for the 3 groups, respectively. In comparing the ketamine-only and topical anesthesia groups, the difference in first pass success was -24% (95% confidence interval -37% to -12%), and the difference in number of cases with ≥1 adverse event was 13% (95% confidence interval 0-25%), both favoring the topical anesthesia group.

Conclusion : Although sometimes advocated, the ketamine-only intubation approach is uncommon and is associated with lower success and higher complications compared with topical anesthesia and RSI approaches.

Conclusion (proposition de traduction) : Bien que parfois préconisée, l'approche de l'intubation avec seulement de la kétamine est rare et est associée à un succès moindre et à des complications plus élevées par rapport à l'anesthésie topique et aux approches d'intubation à séquence rapide.

Traumatic Brain Injury in Patients Receiving Direct Oral Anticoagulants.
Santing JAL, Van den Brand CL, Jellema K. | J Emerg Med. 2021 Mar;60(3):285-291
DOI: https://doi.org/10.1016/j.jemermed.2020.09.012  | Télécharger l'article au format  
Keywords: DOACs; head trauma; intracranial hematoma; reversal agents; traumatic brain injury.

Original contribution

Introduction : Emergency departments (EDs) are faced with a growing number of patients with traumatic brain injury (TBI) using direct oral anticoagulants (DOACs). However, there remains uncertainty about the bleeding risk, rate of hematoma expansion, and the efficacy of reversal strategies in these patients.
Objective: This study aims to identify the risk of traumatic hemorrhagic complications in patients with TBI using DOACs.

Méthode : In this retrospective study we included patients with TBI. All TBI patients were using DOACs, attended one of the three EDs of our hospital between January 2016 and October 2019, and received a computed tomography (CT) scan of the brain. The primary outcome was any traumatic intracranial hemorrhage on CT. Secondary outcomes were the use of reversal agents, secondary neurological deterioration, a neurosurgical intervention within 30 days after the injury, length of stay (LOS), Glasgow Outcome Scale (GOS) at discharge, and mortality.

Résultats : Of the included patients (N = 316), 24 patients (7.6%, 95% confidence interval [CI] 4.2-9.8) presented with a traumatic intracranial hematoma (ICH). Seven patients (2.2%, 95% CI 0.6-3.8) received a reversal agent and 1 patient (0.3%, 95% CI -0.3-0.9) underwent a neurosurgical intervention. Of the 24 patients with a traumatic ICH, progression of the lesion was seen in 6 patients (1.9%, 95% CI 0.4-3.4). The mean LOS was 6.5 days (95% CI 3.0-10.1) and the mean GOS at discharge was 4 (95% CI 3.6-4.6). Death occurred in 1 patient (0.3%, 95% CI -0.3-0.9) suffering from an ICH.

Conclusion : Based on the present findings it can be postulated that TBI patients using DOACs have a low risk for ICH. Hematoma progression occurred, however, in a substantial number of patients. Considering the retrospective nature of the present study, future prospective trials are needed to confirm this finding.

Conclusion (proposition de traduction) : Sur la base des présents résultats, on peut postuler que les patients atteints de lésions cérébrales traumatiques utilisant des anticoagulants oraux directs ont un faible risque d'hématome intracrânien. Cependant, une progression de l'hématome est survenue chez un nombre important de patients. Compte tenu de la nature rétrospective de la présente étude, de futurs essais prospectifs sont nécessaires pour confirmer cette découverte.

The Effect of Different Personal Protective Equipment Masks on Health Care Workers' Cardiopulmonary Resuscitation Performance During the Covid-19 Pandemic.
Serin S, Caglar B. | J Emerg Med. 2021 Mar;60(3):292-298
DOI: https://doi.org/10.1016/j.jemermed.2020.11.005  | Télécharger l'article au format  
Keywords: masks; respiratory protective devices; resuscitation.

Original contribution

Introduction : Personal protective equipment (PPE) is equipment that protects health care workers from harmful agents and organisms. The importance of this equipment was noticed again with the Coronavirus Disease 2019 (COVID-19) pandemic.
Objectives: In this study, we investigated the effect of different masks used as PPE on resuscitation quality and rescuer fatigue.

Méthode : Participants applied chest compression without a mask, with a surgical mask, a filtering face-piece respirator (FFR) mask, and a half-face mask with active P3 filter. A smart watch was worn on the left wrists of the participants during chest compression in each condition. They were requested to rate their fatigue on a visual analogue scale.

Résultats : Statistically higher average pulse rates were found in the FFR mask and half-face mask conditions. FFR mask and half-face mask resulted in statistically worse results than surgical mask and no-mask conditions in the number of compressions per minute, compression depth, and compression effectiveness. Further, half-face mask and FFR mask caused more fatigue in participants.

Conclusion : Protective masks other than surgical masks used as PPE increase rescuer fatigue in CPR and negatively affect the quality of chest compressions.

Conclusion (proposition de traduction) : Les masques de protection autres que les masques chirurgicaux utilisés comme équipement de protection individuelle augmentent la fatigue du secouriste lors de la RCP et affectent négativement la qualité des compressions thoraciques.

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians.
Menegas S, Moayedi S, Torres M. | J Emerg Med. 2021 Mar;60(3):310-320
DOI: https://doi.org/10.1016/j.jemermed.2020.10.043  | Télécharger l'article au format  
Keywords: Bartholin abscess; abscess; antibiotics; breast abscess; dental abscess; hidradenitis suppurativa; incision and drainage; loop drainage; needle aspiration; packing; peritonsillar abscess; pilonidal abscess; ultrasound.

Clinical Review

Introduction : Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.

Méthode : This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.

Discussion : Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.

Conclusion : This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.

Conclusion (proposition de traduction) : Cette revue évalue la littérature récente sur la prise en charge des abcès pour les cliniciens en médecine d'urgence.

The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review.
Hickey S, Hickman ZL, Conway J, Giwa A. | J Emerg Med. 2021 Mar;60(3):321-330
DOI: https://doi.org/10.1016/j.jemermed.2020.10.037  | Télécharger l'article au format  
Keywords: DOAC; NOAC; TBI; delayed intracranial hemorrhage; direct oral anticoagulant; mTBI; mild traumatic brain injury; novel oral anticoagulant; traumatic brain injury; traumatic intracranial hemorrhage.

Original contribution

Introduction : The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications.
Objective: Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI.

Méthode : We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs.

Résultats : There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH.

Conclusion : This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.

Conclusion (proposition de traduction) : Cette revue systématique confirme que l'hémorragie intracrânienne traumatique retardée après une lésion cérébrale traumatique légère chez les patients sous anticoagulants oraux directs est rare. Cependant, de grandes études prospectives multicentriques sont nécessaires pour confirmer la véritable incidence d'hémorragie intracrânienne traumatique retardée cliniquement significative après l'utilisation d'anticoagulants oraux directs. En raison des données limitées, nous recommandons d'utiliser la prise de décision partagée pour les patients candidats à la sortie.

Resuscitating Resuscitation: Advanced Therapies for Resistant Ventricular Dysrhythmias.
Roach C, Tainter CR, Sell RE, Wardi G. | J Emerg Med. 2021 Mar;60(3):331-341
DOI: https://doi.org/10.1016/j.jemermed.2020.10.051  | Télécharger l'article au format  
Keywords: cardiac arrest; dual-sequence defibrillation; esmolol; extracorporeal cardiopulmonary resuscitation; stellate ganglion block.

Original contribution

Introduction : More than 640,000 combined in-hospital and out-of-hospital cardiac arrests occur annually in the United States. However, survival rates and meaningful neurologic recovery remain poor. Although "shockable" rhythms (i.e., ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have the best outcomes, many of these ventricular dysrhythmias fail to return to a perfusing rhythm (resistant VF/VT), or recur shortly after they are resolved (recurrent VF/VT).

Méthode : This review discusses 4 emerging therapies in the emergency department for treating these resistant or recurrent ventricular dysrhythmias: beta-blocker therapy, dual simultaneous external defibrillation, stellate ganglion blockade, and extracorporeal cardiopulmonary resuscitation. We discuss the underlying physiology of each therapy, review relevant literature, describe when these approaches should be considered, and provide evidence-based recommendations for these techniques.

Discussion : Esmolol may mitigate some of epinephrine's negative effects when used during resuscitation, improving both postresuscitation cardiac function and long-term survival. Dual simultaneous external defibrillation targets the region of the heart where ventricular fibrillation typically resumes and may apply a more efficient defibrillation across the heart, leading to higher rates of successful defibrillation. Stellate ganglion blocks, recently described in the emergency medicine literature, have been used to treat patients with recurrent VF/VT, resulting in significant dysrhythmia suppression. Finally, extracorporeal cardiopulmonary resuscitation is used to provide cardiopulmonary support while clinicians correct reversible causes of arrest, potentially resulting in improved survival and good neurologic functional outcomes.

Conclusion : These emerging therapies do not represent standard practice; however, they may be considered in the appropriate clinical scenario when standard therapies are exhausted without success.

Conclusion (proposition de traduction) : Ces thérapies émergentes ne représentent pas une pratique standard ; cependant, ils peuvent être pris en compte dans le scénario clinique approprié lorsque les thérapies standard sont épuisées sans succès.

Emergency Ultrasound in Trauma Patients: Beware of Pitfalls and Artifacts!.
Barbera P, Campo I, Derchi LE, Bertolotto M. | J Emerg Med. 2021 Mar;60(3):368-376
DOI: https://doi.org/10.1016/j.jemermed.2020.10.007  | Télécharger l'article au format  
Keywords: abdominal trauma; artifacts; diagnostic pitfalls; ultrasonography.

Ultrasound in Emergency Medicine

Introduction : Ultrasonography (US) is highly dependent on operators' skills. It is not only a matter of correct scan techniques; there are anatomical structures and variants, as well as artifacts, which can produce images difficult to interpret and which, if not properly understood, can be causes of errors.

Méthode : This paper will review relatively common US pitfalls and artifacts that can be encountered in trauma patients and will offer tips to recognize and avoid them.

Discussion : Normal anatomical structures and anatomical variants can mimic fluid collections or perisplenic lesions. Examination along multiple scan planes, real-time observation of movements or repetition of the study after the patient has drunk some fluid or after placing a finger on her/his body wall can help proper identification. The term artifact in US imaging refers to display phenomena not properly representing the imaged structures. This can result in images suggesting fracture lines within organs or at their borders, lung consolidations, or pleural effusions, and abdominal fluid collections. Their knowledge is the first step to recognize them; then, use of multiple scan planes or repetition of the study after voiding or changes of equipment setting can make them disappear or clarify their nature.

Conclusion : We present possible anatomic pitfalls and artifacts that may affect correct interpretation of US images in patients with abdominal trauma and suggest how to avoid or to clarify them during the examination. Knowing their existence, their appearances, and the reasons why they are produced is important for proper use of this diagnostic technique.

Conclusion (proposition de traduction) : Nous présentons les éventuels pièges anatomiques et artefacts qui peuvent affecter l'interprétation correcte des images échographiques chez les patients présentant un traumatisme abdominal et suggérons comment les éviter ou les clarifier lors de l'examen. Connaître leur existence, leurs apparences et les raisons pour lesquelles ils sont produits est important pour une bonne utilisation de cette technique de diagnostic.

Discontinuing β-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial.
Dinh A, Ropers J, Duran C, Davido B, Deconinck L, Matt M, Senard O, Lagrange A, Makhloufi S, Mellon G, de Lastours V, Bouchand F, Mathieu E, Kahn JE, Rouveix E, Grenet J, Dumoulin J, Chinet T, Pépin M, Delcey V, Diamantis S, Benhamou D, Vitrat V, Dombret MC, Renaud B, Perronne C, Claessens YE, Labarère J, Bedos JP, Aegerter P, Crémieux AC; Pneumonia Short Treatment (PTC) Study Group. | Lancet. 2021 Mar 27;397(10280):1195-1203
DOI: https://doi.org/10.1016/s0140-6736(21)00313-5  | Télécharger l'article au format  
Keywords: Aucun

Articles

Introduction : Shortening the duration of antibiotic therapy for patients admitted to hospital with community-acquired pneumonia should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs. We aimed to assess the need for an additional 5-day course of β-lactam therapy among patients with community-acquired pneumonia who were stable after 3 days of treatment.

Méthode : We did this double-blind, randomised, placebo-controlled, non-inferiority trial (the Pneumonia Short Treatment [PTC]) in 16 centres in France. Adult patients (aged ≥18 years) admitted to hospital with moderately severe community-acquired pneumonia (defined as patients admitted to a non-critical care unit) and who met prespecified clinical stability criteria after 3 days of treatment with β-lactam therapy were randomly assigned (1:1) to receive β-lactam therapy (oral amoxicillin 1 g plus clavulanate 125 mg three times a day) or matched placebo for 5 extra days. Randomisation was done using a web-based system with permuted blocks with random sizes and stratified by randomisation site and Pneumonia Severity Index score. Participants, clinicians, and study staff were masked to treatment allocation. The primary outcome was cure 15 days after first antibiotic intake, defined by apyrexia (temperature ≤37·8°C), resolution or improvement of respiratory symptoms, and no additional antibiotic treatment for any cause. A non-inferiority margin of 10 percentage points was chosen. The primary outcome was assessed in all patients who were randomly assigned and received any treatment (intention-to-treat [ITT] population) and in all patients who received their assigned treatment (per-protocol population). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT01963442, and is now complete.

Résultats : Between Dec 19, 2013, and Feb 1, 2018, 706 patients were assessed for eligibility, and after 3 days of β-lactam treatment, 310 eligible patients were randomly assigned to receive either placebo (n=157) or β-lactam treatment (n=153). Seven patients withdrew consent before taking any study drug, five in the placebo group and two in the β-lactam group. In the ITT population, median age was 73·0 years (IQR 57·0-84·0) and 123 (41%) of 303 participants were female. In the ITT analysis, cure at day 15 occurred in 117 (77%) of 152 participants in the placebo group and 102 (68%) of 151 participants in the β-lactam group (between-group difference of 9·42%, 95% CI -0·38 to 20·04), indicating non-inferiority. In the per-protocol analysis, 113 (78%) of 145 participants in the placebo treatment group and 100 (68%) of 146 participants in the β-lactam treatment group were cured at day 15 (difference of 9·44% [95% CI -0·15 to 20·34]), indicating non-inferiority. Incidence of adverse events was similar between the treatment groups (22 [14%] of 152 in the placebo group and 29 [19%] of 151 in the β-lactam group). The most common adverse events were digestive disorders, reported in 17 (11%) of 152 patients in the placebo group and 28 (19%) of 151 patients in the β-lactam group. By day 30, three (2%) patients had died in the placebo group (one due to bacteraemia due to Staphylococcus aureus, one due to cardiogenic shock after acute pulmonary oedema, and one due to heart failure associated with acute renal failure) and two (1%) in the β-lactam group (due to pneumonia recurrence and possible acute pulmonary oedema).

Conclusion : Among patients admitted to hospital with community-acquired pneumonia who met clinical stability criteria, discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment. These findings could allow substantial reduction of antibiotic consumption.

Conclusion (proposition de traduction) : Parmi les patients hospitalisés pour une pneumonie communautaire répondant aux critères de stabilité clinique, l'arrêt du traitement par β-lactamine après 3 jours était non inférieur à 8 jours de traitement. Ces résultats pourraient permettre une réduction substantielle de la consommation d'antibiotiques.

Commentaire : Voir l'analyse de l'article sur le site Info-ATBVAC : 3 jours de traitement pour les PAC hospitalisées en dehors de la réanimation et dont l’évolution précoce est favorable ?  . Rédigé par le Dr Jean-Pierre Bru, le 15 avril 2021.

Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome.
Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. . | N Engl J Med. 2020 Mar 12;382(11):999-1008
DOI: https://doi.org/10.1056/nejmoa1916431  | Télécharger l'article au format  
Keywords: Aucun

Original article

Introduction : In patients with acute respiratory distress syndrome (ARDS), the National Heart, Lung, and Blood Institute ARDS Clinical Trials Network recommends a target partial pressure of arterial oxygen (Pao2) between 55 and 80 mm Hg. Prospective validation of this range in patients with ARDS is lacking. We hypothesized that targeting the lower limit of this range would improve outcomes in patients with ARDS.

Méthode : In this multicenter, randomized trial, we assigned patients with ARDS to receive either conservative oxygen therapy (target Pao2, 55 to 70 mm Hg; oxygen saturation as measured by pulse oximetry [Spo2], 88 to 92%) or liberal oxygen therapy (target Pao2, 90 to 105 mm Hg; Spo2, ≥96%) for 7 days. The same mechanical-ventilation strategies were used in both groups. The primary outcome was death from any cause at 28 days.

Résultats : After the enrollment of 205 patients, the trial was prematurely stopped by the data and safety monitoring board because of safety concerns and a low likelihood of a significant difference between the two groups in the primary outcome. Four patients who did not meet the eligibility criteria were excluded. At day 28, a total of 34 of 99 patients (34.3%) in the conservative-oxygen group and 27 of 102 patients (26.5%) in the liberal-oxygen group had died (difference, 7.8 percentage points; 95% confidence interval [CI], -4.8 to 20.6). At day 90, 44.4% of the patients in the conservative-oxygen group and 30.4% of the patients in the liberal-oxygen group had died (difference, 14.0 percentage points; 95% CI, 0.7 to 27.2). Five mesenteric ischemic events occurred in the conservative-oxygen group.

Conclusion : Among patients with ARDS, early exposure to a conservative-oxygenation strategy with a Pao2 between 55 and 70 mm Hg did not increase survival at 28 days.

Conclusion (proposition de traduction) : Chez les patients en SDRA, l’exposition précoce à une stratégie d’oxygénation conservatrice avec un PaO₂ entre 55 et 70 mm Hg n’a pas augmenté la survie à 28 jours.

Hereditary Angioedema.
Busse PJ, Christiansen SC. | N Engl J Med. 2020 Mar 19;382(12):1136-1148
DOI: https://doi.org/10.1056/nejmra1808012
Keywords: Aucun

Review Article

Editorial : This article reviews the progress made during the past decade in elucidating the pathophysiological mechanisms of hereditary angioedema and the subsequent development of targeted treatments for the disorder, with anticipated reductions in morbidity and mortality and an improved quality of life. The clinical vignette below illustrates the profound effect of these treatments.

Conclusion : In the past, patients with hereditary angioedema often had anxiety, depression, and disruption of work, school, and daily life. An improved undertanding of the pathophysiology of hereditary angioedema and classification of phenotypes has driven the investigation of new and targeted therapies. On demand treatments have incrementally enhanced patients’ safety and quality of life. Effective and safe prophylactic treatments now provide a pathway toward a normal life. A shift in the treatment paradigm toward the expanded use of prophylaxis is anticipated, which should ameliorate the ever-present fear of disfiguring, painful, or fatal attacks. With appropriate care, the next generation of patients with hereditary angioedema may no longer have to experience the burden of what has been labeled a catastrophic disease.

Conclusion (proposition de traduction) : Dans le passé, les patients présentant un angio-œdème héréditaire souffraient souvent d'anxiété, de dépression et de perturbations du travail, de l'école et de la vie quotidienne. Une meilleure compréhension de la physiopathologie de l'angio-œdème héréditaire et de la classification des phénotypes a conduit à la recherche de thérapies nouvelles et ciblées. Les traitements à la demande ont progressivement amélioré la sécurité et la qualité de vie des patients. Les traitements prophylactiques efficaces et sûrs offrent désormais une voie vers une vie normale. Un changement de paradigme de traitement vers une utilisation élargie de la prophylaxie est anticipé, ce qui devrait atténuer la peur toujours présente d'attaques défigurantes, douloureuses ou mortelles. Avec des soins appropriés, la prochaine génération de patients atteints d'angio-œdème héréditaire pourrait ne plus avoir à subir le poids imputable à ce qui a été qualifié de maladie catastrophique.

Diagnostic accuracy of lung ultrasound for SARS-CoV-2: a retrospective cohort study.
Brenner DS, Liu GY, Omron R, Tang O, Garibaldi BT, Fong TC. | Ultrasound J. 2021 Mar 1;13(1):12
DOI: https://doi.org/10.1186/s13089-021-00217-7  | Télécharger l'article au format  
Keywords: COVID-19; Diagnosis; POCUS; RT-PCR; SARS-CoV-2; Triage; Ultrasound.

ORIGINAL ARTICLE

Introduction : As medical infrastructures are strained by SARS-CoV-2, rapid and accurate screening tools are essential. In portions of the world, reverse transcription polymerase chain reaction (RT-PCR) testing remains slow and in limited supply, and computed tomography is expensive, inefficient, and involves exposure to ionizing radiation. Multiple studies evaluating the efficiency of lung point-of-care ultrasound (POCUS) have been published recently, but include relatively small cohorts and often focus on characteristics associated with severe illness rather than screening efficacy. This study utilizes a retrospective cohort to evaluate the test characteristics (sensitivity, specificity, likelihood ratios, predictive values) of lung POCUS in the diagnosis of SARS-CoV-2, and to determine lung score cutoffs that maximize performance for use as a screening tool.

Résultats : Lung POCUS examinations had sensitivity 86%, specificity 71.6%, NPV 81.7%, and PPV 77.7%. The Lung Ultrasound Score had an area under the curve of 0.84 (95% CI 0.78, 0.90). When including only complete examinations visualizing 12 lung fields, lung POCUS had sensitivity 90.9% and specificity 75.6%, with NPV 87.2% and PPV 82.0% and an area under the curve of 0.89 (95% CI 0.83, 0.96). Lung POCUS was less accurate in patients with a history of interstitial lung disease, severe emphysema, and heart failure.

Conclusion : When applied in the appropriate patient population, lung POCUS is an inexpensive and reliable tool for rapid screening and diagnosis of SARS-CoV-2 in symptomatic patients with influenza-like illness. Adoption of lung POCUS screening for SARS-CoV-2 may identify patients who do not require additional testing and reduce the need for RT-PCR testing in resource-limited environments and during surge periods.

Conclusion (proposition de traduction) : Lorsqu'elle est appliquée à la population de patients appropriée, l'échographie pulmonaire au point d'intervention est un outil peu coûteux et fiable pour le dépistage et le diagnostic rapides du SRAS-CoV-2 chez les patients symptomatiques atteints d'un syndrome grippal. L'adoption du dépistage par échographie pulmonaire au point d'intervention pour le SRAS-CoV-2 peut identifier les patients qui ne nécessitent pas de tests supplémentaires et réduire le besoin de tests RT-PCR dans des environnements à ressources limitées et pendant les périodes de pointe.