Bibliographie de Médecine d'Urgence

Mois de mars 2021


Academic Emergency Medicine

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).

Annals of Emergency Medicine

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. March 2021;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.

Annals of Intensive Care

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. An2021 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 de PCT plus élevés dans l'exacerbation aiguë sévère de BPCO causée par une infection bactérienne, la PCT avait une faible précision pour distinguer les infections bactériennes et non bactériennes. La procalcitonine peut ne pas être suffisante comme marqueur autonome pour initier un traitement antibiotique dans ce contexte.

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.

Chest

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.

Clinical Infectious Diseases

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.

Critical Care

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.

Critical Care Medicine

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.

Emergency Care Journal

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.

Emergency Medicine Journal

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.

Intensive Care Medicine

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

Internal and Emergency Medicine

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.

Journal of the American Medical Association

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.

Lancet Infectious Diseases

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.

Pediatric Emergency Care

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.

Prehospital Emergency Care

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.

Sages-Femmes

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 : 

The Journal of Emergency Medicine

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.

The Ultrasound Journal

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.


Mois de mars 2021