Bibliographie de Médecine d'Urgence

Mois d'avril 2021

Academic Emergency Medicine

Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology.
Branch KRH, Strote J, Gunn M, Maynard C, Kudenchuk PJ, Brusen R, Petek BJ, Sayre MR, Edwards R, Carlbom D, Counts CR, Probstfield JL, Gatewood MO. | Acad Emerg Med.  2021 Apr;28(4):394-403
Keywords: CT angiography; abdominal CT; cardiac CT; cardiac arrest; cardiac computed tomography; observational cohort; out of hospital cardiac arrest; resuscitation complication; sudden death; sudden death diagnosis.


Introduction : Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients.

Méthode : From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause.

Résultats : SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis.

Conclusion : This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

Conclusion (proposition de traduction) : Cette étude de cohorte observationnelle suggère que la tomodensitométrie dans la mort subite est sûre, peut accélérer le diagnostic des causes potentielles et peut changer de manière significative la gestion clinique après un arrêt circulatoire idiopathique extra-hospitalier.

Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department.
Martel ML, Driver BE, Miner JR, Biros MH, Cole JB. | Acad Emerg Med.  2021 Apr;28(4):421-434
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original contribution

Introduction : The optimal agent to treat acute agitation in the emergency department (ED) has not been determined. The objective of this study was to compare the effectiveness and safety of intramuscular droperidol, ziprasidone, and lorazepam for acute agitation in the ED.

Méthode : This was a randomized, double-blind trial of ED patients with acute agitation requiring parenteral sedation. The study was conducted under exception from informed consent (21 CFR 50.24) from July 2004 to March 2005. Patients were randomized to receive 5 mg of droperidol, 10 mg of ziprasidone, 20 mg of ziprasidone, or 2 mg of lorazepam intramuscularly. We recorded Altered Mental Status Scale (AMSS) scores, nasal end-tidal carbon dioxide (ETCO2 ), and pulse oximetry (SpO2 ) at 0, 15, 30, 45, 60, 90, and 120 minutes as well as QTc durations and dysrhythmias. Respiratory depression was defined as a change in ETCO2 consistent with respiratory depression or SpO2 < 90%. The primary outcome was the proportion of patients adequately sedated (AMSS ≤ 0) at 15 minutes.

Résultats : We enrolled 115 patients. Baseline AMSS scores were similar between groups. For the primary outcome, adequate sedation at 15 minutes, droperidol administration was effective in 16 of 25 (64%) patients, compared to seven of 28 (25%) for 10 mg of ziprasidone, 11 of 31 (35%) for 20 mg of ziprasidone, and nine of 31 (29%) for lorazepam. Pairwise comparisons revealed that droperidol was more effective that the other medications, with 39% (95% confidence interval [CI] = 3% to 54%) more compared to 20 mg of ziprasidone and 33% (95% CI = 8% to 58%) more compared to lorazepam. There was no significant difference between groups in need of additional rescue sedation. Numerically, respiratory depression was lower with droperidol (3/25 [12%]) compared to 10 mg of ziprasidone (10/28 [36%]), 20 mg of ziprasidone (12/31 [39%]), or lorazepam (15/31 [48%]). One patient receiving 20 mg of ziprasidone required intubation to manage an acute subdural hematoma. No patients had ventricular dysrhythmias. QTc durations were similar in all groups.

Conclusion : Droperidol was more effective than lorazepam or either dose of ziprasidone for the treatment of acute agitation in the ED and caused fewer episodes of respiratory depression.

Conclusion (proposition de traduction) : Le dropéridol s'est avéré plus efficace que le lorazépam ou que l'une ou l'autre des doses de ziprasidone pour le traitement de l'agitation aiguë au service des urgences et a causé moins d'épisodes de dépression respiratoire.

Commentaire : 
• Posologie du dropéridol dans l'agitation : 5 mg IV ou 5 à 10 mg IM.
• La ziprasidone fait partie d'un groupe de nouveaux antipsychotiques dits atypiques (ou de deuxième génération), utilisés pour traiter la schizophrénie. Son principal avantage est sa faible propension à induire une prise de poids et les effets indésirables associés. Cependant, elle pourrait être un antipsychotique légèrement moins efficace que l'amisulpride, l'olanzapine et la rispéridone.

Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department.
Mori K, Abe T, Matsumoto J, Takahashi K, Takeuchi I. | Acad Emerg Med.  2021 Apr;28(4):435-443
Keywords: Aucun

Original contribution

Editorial : Older age is a risk factor for intracranial injury after head trauma, and computed tomography (CT) is generally recommended. We aimed to develop a clinical prediction rule for risk stratification to avoid CT head imaging in older adult patients with minor head injury, named Computed Tomography of the Head for the patients at Advanced age (CTHEAD). This was a single-center observational study in Japan that used retrospective chart review data to service a prediction rule that was prospectively validated. Patients aged ≥ 65 years who presented to our emergency department with a chief complaint of head trauma and a Glasgow Coma Scale (GCS) of ≥13 were eligible. Patients were excluded if they had GCS score < 13, anticoagulant therapy, focal neurologic symptoms, posttraumatic seizures, penetrating injury, evident depressed fracture, unknown mechanism, or CT not undertaken. The primary outcome was acute traumatic lesion on head CT. We screened 1,494 patients; 538 were included in the derivation cohort, and 580, in the validation cohort. Multivariable analysis of the derivation group found that high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, and anterograde amnesia were significantly associated with traumatic head findings on CT. A clinical prediction rule was developed from these four risk factors. The negative predictive value (NPV) of the absence of the four components was 95.1% (95% confidence interval [CI] = 92.9% to 96.7%), and the positive predictive value (PPV) of one or more risk factors was 20.6% (95% CI = 17.3% to 24.4%). The rule was validated prospectively with an NPV of zero risk factors of 94.5% (95% CI = 92.4% to 96.1%) and a PPV of one or more risk factors of 15.9% (95% CI = 13.0% to 19.3%). Fifty-three (9.1%) patients in the validation cohort experienced the primary outcome. The results suggest that older adult patients with minor head injury may forgo head CT if they do not have high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, or anterograde amnesia. External validation of this rule is needed.

Conclusion : A novel clinical decision rule for patients with minor head injury was developed and internally validated. Eligible older adult patients with minor head injury can forgo computed tomography head imaging with high negative predictive value if they have no high-risk mechanisms of injury, vomiting, witnessed loss of con- sciousness, or anterograde amnesia. Further external validation is needed.

Conclusion (proposition de traduction) : Une nouvelle règle de décision clinique pour les patients présentant un traumatisme crânien mineur a été développée et validée en interne. Les patients adultes âgés éligibles présentant un traumatisme crânien mineur peuvent éviter l'imagerie par tomodensitométrie cérébrale à haute valeur prédictive négative s'ils ne présentent aucun mécanisme à haut risque de blessure, de vomissement, de perte de conscience ou d'amnésie antérograde. Une validation externe supplémentaire est nécessaire.

Low‐dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta‐analysis.
Balzer N, McLeod SL, Walsh C, Grewal K. | Acad Emerg Med.  2021 Apr;28(4):444-454
Keywords: Aucun


Introduction : There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED.

Méthode : Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence.

Résultats : Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence.

Conclusion : Low-dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.

Conclusion (proposition de traduction) : La kétamine à faible dose et la morphine avaient une efficacité analgésique similaire dans les 60 minutes suivant l'administration avec des profils de sécurité comparables, ce qui suggère que la kétamine à faible dose est un analgésique alternatif efficace pour le contrôle de la douleur aiguë au service des urgences.

Commentaire : Les doses de kétamine « sous-dissociatives » avec des propriétés analgésiques dans la douleur aiguë et chronique utilisées ici sont < 0,5 mg/kg IV.

AEM Education and Training

Mastering Electrocardiogram Interpretation Skills Through a Perceptual and Adaptive Learning Module.
Krasne S, Stevens CD, Kellman PJ, Niemann JT. | AEM Educ Train.  2021 April;5(2):1–11
Keywords: Aucun

Original Contribution

Editorial : Although accurate interpretation of the standard 12‐lead electrocardiogram (ECG) is fundamental to diagnosing heart disease, several prior studies report low accuracy rates among medical students, residents, and practicing physicians. The objective of this study was to determine if an online ECG Perceptual and Adaptive Learning Module (ECG PALM) is an efficient instrument to teach ECG interpretation. The ECG PALM consists of 415 unique ECG tracings with associated pretest, posttest, and delayed tests, each using 30 additional ECGs to gauge the effectiveness and durability of training. Between 2013 and 2015, a total of 113 third‐year and 156 fourth‐year medical students and 34 first‐year, 41 second‐year, and 37 third‐year emergency medicine residents completed the PALM and associated tests. We measured two mastery criteria: accuracy, the percentage of correct interpretations, and fluency, the percentage of images interpreted accurately within 15 seconds. The ECG PALM produced statistically significant improvements (0.0001 < p < 0.0045) in student and resident performance for both accuracy (effect size = 0.9 to 3.2) and fluency (effect size = 2.5 to 3.1) following training ranging from 46 ± 24 minutes (R3s) to 88 ± 32 minutes (third‐year medical students). Medical students and residents performed significantly better on a test the year following training (delayed test) than those without prior ECG PALM training (pretest). The fluency of R3 residents in classifying the 15 diagnostic categories was less than 60% for nine of the 15 diagnoses and greater than 80% for only one. Following PALM training, fluency was higher than 80% for seven of the 15 categories and less than 60% for only two categories. Accuracy in recognizing ST‐elevation myocardial infarctions (STEMIs) was high both before and after PALM training for R3s, but fluency was only 64% for anterior STEMIs on the pretest, increasing to 93% following PALM training. These observations suggest that the ECG PALM is an effective and durable supplemental tool for developing mastery in interpreting common ECG abnormalities.

Conclusion : Training electrocardiogram interpretation using percep- tual learning approaches and a response time–based adaptive learning algorithm can produce large and dur- able increases in skills for both undergraduate medical students and postgraduate residents. These approaches might also be useful for maintaining electrocardiogram interpretation skills among practicing clinicians.

Conclusion (proposition de traduction) : La formation à l'interprétation d'électrocardiogramme à l'aide d'approches d'apprentissage perceptif et d'un algorithme d'apprentissage adaptatif basé sur le temps de réponse peut produire des augmentations importantes et durables des compétences tant pour les étudiants en médecine de premier cycle que pour les résidents de troisième cycle. Ces approches pourraient également être utiles pour maintenir les compétences d'interprétation des électrocardiogrammes chez les cliniciens praticiens.

Anaesthesia, Critical Care & Pain Medicine

Ultrasonography for airway management.
Zetlaoui PJ | Anaesth Crit Care Pain Med.  2021 Apr;40(2):100821
Keywords: Difficult airway evaluation; Endotracheal tube position; Gastric volume; Obstructive sleep apnoea syndrome; Pleural sliding; Tracheal intubation; Ultrasonography.


Editorial : Ultrasonography (USG) allows a new approach to the airway in anaesthesia and intensive care. USG visualises the airway from the mouth to the lungs. By exploring the entire airway, USG proposes new criteria (1) to assess the risk of difficult laryngoscopy, (2) to anticipate the management of a difficult airway, (3) to confirm the position of the endotracheal tube (ETT), and (4) to confirm that the lungs are effectively ventilated. Intraoperatively, USG may also help to resolve acute ventilatory problems such as pneumothorax, delayed selective bronchial intubation after patient positioning (Trendelenburg, prone or lateral position) or acute pulmonary oedema.

Anesthesia & Analgesia

Aspirin Use Is Associated With Decreased Mechanical Ventilation, Intensive Care Unit Admission, and In-Hospital Mortality in Hospitalized Patients With Coronavirus Disease 2019.
Chow JH, Khanna AK, Kethireddy S, Yamane D, Levine A, Jackson AM, McCurdy MT, Tabatabai A, Kumar G, Park P, Benjenk I, Menaker J, Ahmed N, Glidewell E, Presutto E, Cain S, Haridasa N, Field W, Fowler JG, Trinh D, Johnson KN, Kaur A, Lee A, Sebastian K, Ulrich A, Peña S, Carpenter R, Sudhakar S, Uppal P, Fedeles BT, Sachs A, Dahbour L, Teeter W, Tanaka K, Galvagno SM, Herr DL, Scalea TM, Mazzeffi MA. | Anesth Analg.  2021 Apr 1;132(4):930-941
Keywords: Aucun

Original Clinical Research Report

Introduction : Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality.

Méthode : A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions.

Résultats : Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users.

Conclusion : Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients.

Conclusion (proposition de traduction) : L'utilisation d'aspirine peut être associée à de meilleurs résultats chez les patients hospitalisés atteints de COVID-19. Cependant, un essai contrôlé randomisé suffisamment puissant est nécessaire pour évaluer s'il existe une relation de cause à effet entre l'utilisation d'aspirine et la réduction des lésions pulmonaires et de la mortalité chez les patients COVID-19.

Safety and Efficacy of the Combination of Propofol and Ketamine for Procedural Sedation/Anesthesia in the Pediatric Population: A Systematic Review and Meta-analysis.
Hayes JA, Aljuhani T, De Oliveira K, Johnston BC. | Anesth Analg.  2021 Apr 1;132(4):979-992
Keywords: Aucun

Review Article

Introduction : Drugs such as propofol and ketamine are used alone or in combination to provide sedation for medical procedures in children. The purpose of this systematic review was to compare the safety and effectiveness of propofol and ketamine to other drug regimens.

Méthode : We searched Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Web of Science, and the grey literature (meta-Register of Controlled Trials,, and Google Scholar) for randomized controlled studies comparing intravenous propofol and ketamine to any other single or combination drug regimen administered to children undergoing diagnostic or therapeutic procedures. Meta-analyses were performed for primary (hemodynamic and respiratory adverse events) and secondary outcomes using RevMan 5.3. We assessed the risk of bias and the certainty (quality) evidence for all outcomes using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Résultats : Twenty-nine studies were included for analysis. Based on low-to-moderate quality evidence, we concluded that the use of propofol and ketamine may result in a slight-to-small reduction in the risk of hypotension, bradycardia, and apnea, and a slight increase in the risk of tachycardia, hypertension, and other respiratory adverse events, such as cough or laryngospasm. The ratio of propofol to ketamine and comparator drug regimen subgroups effects were important for desaturation and some secondary outcomes.

Conclusion : The use of propofol and ketamine had a minimal effect on the incidence of adverse events and other secondary outcomes. Large-scale studies are required to more accurately estimate adverse event rates and the effects of propofol and ketamine on patient-important outcomes.

Conclusion (proposition de traduction) : L’utilisation du propofol et de la kétamine a eu un effet minime sur l’incidence des effets indésirables et d’autres effets secondaires. Des études à grande échelle sont nécessaires pour estimer avec plus de précision les taux d’effets indésirables et les effets du propofol et de la kétamine sur les résultats importants pour le patient.

Annals of Emergency Medicine

Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults.
McAlister FA, Youngson E, Rowe BH. | Ann Emerg Med.  2021 Apr;77(4):425-432
Keywords: Aucun


Introduction : We determine the frequency of elevated blood pressure (BP) readings in the emergency department (ED), the proportion of patients with prior or subsequent diagnosis of hypertension assigned in other settings, and the association between ED BP levels and cardiovascular outcomes after ED discharge.

Méthode : This was a retrospective cohort study using electronic medical records for all adults treated and released from a large-volume ED in 2016 that were linked to administrative records for all health care encounters in the province for 2 years before and after the index ED visit. The primary outcome measure was a composite of stroke or transient ischemic attack, acute coronary syndrome, new heart failure, or death.

Résultats : Of 30,278 adults treated and released from the ED, 14,717 (48.6%) had elevated BP readings; 10,732 (72.9%) had no prior diagnosis of hypertension. Of the 3,480 patients with no prior diagnosis of hypertension but an ED BP greater than or equal to 160/100 mm Hg, 907 (26.1%) subsequently received a diagnosis of chronic hypertension or were prescribed antihypertensive therapy in other settings within 2 years. Among patients without a history of hypertension, those with an ED BP greater than or equal to 160/100 mm Hg were more likely to meet the composite outcome (stroke, transient ischemic attack, acute coronary syndrome, heart failure, or death) in the subsequent year (3.3% versus 2.5%) or 2 years (5.9% versus 3.8%) than those with ED BPs 120 to 139/80 to 89 mm Hg; however, after adjusting for age, sex, diabetes, atrial fibrillation, and prior cardiovascular disease, their risk was not elevated (adjusted hazard ratio 0.84; 95% confidence interval 0.71 to 1.004 during 2 years).

Conclusion : Elevated BP readings in the ED are common and are often the first time hypertension is detected; however, they were not associated with adverse cardiovascular outcomes within 2 years of the visit.

Conclusion (proposition de traduction) : La constatation d'une pression artérielle élevée aux urgences est courantes et c'est souvent la première fois qu'une hypertension est détectée ; cependant, elles n'étaient pas associés à des conséquences cardiovasculaires défavorables dans les 2 ans suivant la consultation.

Lung Ultrasonography for the Diagnosis of SARS-CoV-2 Pneumonia in the Emergency Department.
Pivetta E, Goffi A, Tizzani M, Locatelli SM, Porrino G, Losano I, Leone D, Calzolari G, Vesan M, Steri F, Ardito A, Capuano M, Gelardi M, Silvestri G, Dutto S, Avolio M, Cavallo R, Bartalucci A, Paglieri C, Morello F, Richiardi L, Maule MM, Lupia E; Molinette MedUrg Group on Lung Ultrasound. | Ann Emerg Med.  2021 Apr;77(4):385-394
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : Accurate diagnostic testing to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is critical. Although highly specific, SARS-CoV-2 reverse transcriptase-polymerase chain reaction (RT-PCR) has been shown in clinical practice to be affected by a noninsignificant proportion of false-negative results. This study seeks to explore whether the integration of lung ultrasonography with clinical evaluation is associated with increased sensitivity for the diagnosis of coronavirus disease 2019 pneumonia, and therefore may facilitate the identification of false-negative SARS-CoV-2 RT-PCR results.

Méthode : This prospective cohort study enrolled consecutive adult patients with symptoms potentially related to SARS-CoV-2 infection who were admitted to the emergency department (ED) of an Italian academic hospital. Immediately after the initial assessment, a lung ultrasonographic evaluation was performed and the likelihood of SARS-CoV-2 infection, based on both clinical and lung ultrasonographic findings ("integrated" assessment), was recorded. RT-PCR SARS-CoV-2 detection was subsequently performed.

Résultats : We enrolled 228 patients; 107 (46.9%) had SARS-CoV-2 infection. Sensitivity and negative predictive value of the clinical-lung ultrasonographic integrated assessment were higher than first RT-PCR result (94.4% [95% confidence interval {CI} 88.2% to 97.9%] versus 80.4% [95% CI 71.6% to 87.4%] and 95% [95% CI 89.5% to 98.2%] versus 85.2% [95% CI 78.3% to 90.6%], respectively). Among the 142 patients who initially had negative RT-PCR results, 21 tested positive at a subsequent molecular test performed within 72 hours. All these false-negative cases were correctly identified by the integrated assessment.

Conclusion : This study suggests that, in patients presenting to the ED with symptoms commonly associated with SARS-CoV-2 infection, the integration of lung ultrasonography with clinical evaluation has high sensitivity and specificity for coronavirus disease 2019 pneumonia and it may help to identify false-negative results occurring with RT-PCR.

Conclusion (proposition de traduction) : Cette étude suggère que, chez les patients se présentant aux urgences avec des symptômes couramment associés à une infection par le SRAS-CoV-2, l'intégration de l'échographie pulmonaire à l'évaluation clinique présente une sensibilité et une spécificité élevées pour la pneumonie à coronavirus 2019 et peut aider à identifier les faux négatifs résultats obtenus avec la RT-PCR.

Predicting Progression to Septic Shock in the Emergency Department Using an Externally Generalizable Machine-Learning Algorithm.
Wardi G, Carlile M, Holder A, Shashikumar S, Hayden SR, Nemati S. | Ann Emerg Med.  2021 Apr;77(4):395-406
Keywords: Aucun

Infectious Disease

Introduction : Machine-learning algorithms allow improved prediction of sepsis syndromes in the emergency department (ED), using data from electronic medical records. Transfer learning, a new subfield of machine learning, allows generalizability of an algorithm across clinical sites. We aim to validate the Artificial Intelligence Sepsis Expert for the prediction of delayed septic shock in a cohort of patients treated in the ED and demonstrate the feasibility of transfer learning to improve external validity at a second site.

Méthode : This was an observational cohort study using data from greater than 180,000 patients from 2 academic medical centers between 2014 and 2019, using multiple definitions of sepsis. The Artificial Intelligence Sepsis Expert algorithm was trained with 40 input variables at the development site to predict delayed septic shock (occurring greater than 4 hours after ED triage) at various prediction windows. We then validated the algorithm at a second site, using transfer learning to demonstrate generalizability of the algorithm.

Résultats : We identified 9,354 patients with severe sepsis, of whom 723 developed septic shock at least 4 hours after triage. The Artificial Intelligence Sepsis Expert algorithm demonstrated excellent area under the receiver operating characteristic curve (>0.8) at 8 and 12 hours for the prediction of delayed septic shock. Transfer learning significantly improved the test characteristics of the Artificial Intelligence Sepsis Expert algorithm and yielded comparable performance at the validation site.

Conclusion : The Artificial Intelligence Sepsis Expert algorithm accurately predicted the development of delayed septic shock. The use of transfer learning allowed significantly improved external validity and generalizability at a second site. Future prospective studies are indicated to evaluate the clinical utility of this model.

Conclusion (proposition de traduction) : L'algorithme « Artificial Intelligence Sepsis Expert » a prédit avec précision le développement d'un choc septique retardé. L'utilisation de l'apprentissage par transfert a permis d'améliorer considérablement la validité externe et la généralisabilité sur un deuxième site. Des études prospectives futures sont indiquées pour évaluer l'utilité clinique de ce modèle.

Commentaire : Le « Machine Learning » est une technologie d’intelligence artificielle permettant aux ordinateurs d’apprendre sans avoir été programmés explicitement à cet effet. Elle est une branche de l’intelligence artificielle englobant de nombreuses méthodes permettant de créer automatiquement des modèles à partir des données. Ces méthodes sont en fait des algorithmes.
Un programme informatique traditionnel effectue une tâche en suivant des instructions précises, et donc systématiquement de la même façon. Au contraire, un système Machine Learning ne suit pas d’instructions, mais apprend à partir de l’expérience. Par conséquent, ses performances s’améliorent au fil de son « entraînement » à mesure que l’algorithme est exposé à davantage de données.

Do Systemic Corticosteroids Reduce Mortality in Critically Ill Adult Patients With COVID-19?.
Yoo MJ, Long B, Gottlieb M. | Ann Emerg Med.  2021 Apr;77(4):407-409
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Infectious Disease

Introduction : Meta-analysis authors performed a search of, the Chinese Clinical Trial Registry, and the European Union Clinical Trials Register for registered studies from December 31, 2019, to April 6, 2020. The authors included studies that evaluated systemic corticosteroids for the treatment of suspected or confirmed COVID- 19 in hospitalized, critically ill adult patients.

Méthode : The authors screened all randomized controlled trials that compared systemic corticosteroids with placebo or usual care in critically ill adult patients with COVID-19 with a primary outcome of mortality. All patients across the selected studies received respiratory support with either oxygen supplementation or mechanical ventilation. Authors of the identified trials were directly recruited to assist in the meta- analysis and provided all data directly.

Résultats : The primary outcome was 28-day all-cause mortality. The secondary outcome was investigator-defined serious adverse events. The data were analyzed with an odds ratio derived with inverse variance–weighted fixed effects and random effects with 95% confidence intervals. Furthermore, the authors assessed heterogeneity with the I2 statistic and the Cochrane Q statistic. Risk of bias was determined by the Cochrane Risk of Bias Assessment Tool.

Conclusion : Corticosteroids are associated with reduced rates of all-cause mortality in critically ill adult patients receiving respiratory support who have suspected or confirmed coronavirus disease 2019 (COVID-19).

Conclusion (proposition de traduction) : Les corticostéroïdes sont associés à une réduction des taux de mortalité toutes causes confondues chez les patients adultes gravement malades bénéficiant d'une assistance respiratoire qui sont soupçonné ou confirmé d'être atteint d'une maladie à coronavirus 2019 (COVID-19).

Annals of Intensive Care

ABO blood types and sepsis mortality.
Itenov TS, Sessler DI, Khanna AK, Ostrowski SR, Johansson PI, Erikstrup C, Pedersen OB, Rygård SL, Holst LB, Bestle MH, Hein L, Lindhardt A, Tousi H, Andersen MH, Mohr T, Lundgren JD, Jensen JU. | Ann Intensive Care.  2021 Apr 20;11(1):61
DOI:  | Télécharger l'article au format  
Keywords: Anaesthesia; Blood type; Intensive care; Mortality; Sepsis; Septic shock.


Introduction : We aimed to determine if the ABO blood types carry different risks of 30-day mortality, acute kidney injury (AKI), and endothelial damage in critically ill patients with sepsis. This was a retrospective cohort study of three independent cohorts of critically ill patients from the United States and Scandinavia consisting of adults with septic shock. We compared the 30-day mortality across the blood types within each cohort and pooled the results in a meta-analysis. We also estimated the incidence of AKI and degree of endothelial damage, as measured by blood concentrations of soluble thrombomodulin and syndecan-1.

Résultats : We included 12,342 patients with severe sepsis. In a pooled analysis blood type B carried a slightly lower risk of 30-day all-cause mortality compared to non-blood type B (adjusted HR 0.88; 95%-CI 0.79-0.98; p = 0.02). There was no difference in the risk of AKI. Soluble thrombomodulin and syndecan-1 concentrations were lower in patients with blood type B and O compared to blood type A, suggesting less endothelial damage.

Conclusion : Septic patients with blood type B had less endothelial damage, and a small reduction in mortality. The exposure is, however, unmodifiable.

Conclusion (proposition de traduction) : Les patients septiques de groupe sanguin B avaient moins de lésions endothéliales et une légère réduction de la mortalité. L'exposition est cependant non modifiable.

Archives of Academic Emergency Medicine

Factors Related to Mortality in Patients with Fournier's Gangrene or Necrotising Fasciitis; a 10-year Cross-Sectional Study.
Ansari Djafari A, Rahavian A, Javanmard B, Montazeri S, Shahabi V, Hojjati SA, Ghiasy S, Hamidi R, Khoshnevis J. | Arch Acad Emerg Med.  2021 Apr 17;9(1):e33
DOI:  | Télécharger l'article au format  
Keywords: Fournier’s Gangrene; Fournier’s Gangrene Severity Index; Mortality; Thrombocytopenia.

Original/Research Article

Introduction : Fournier's gangrene (FG) is a life-threatening disease, even with early diagnosis and administration of vigorous treatment, its mortality rate is high. This study aimed to evaluate the factors relate to mortality in patients with FG or necrotising fasciitis managed in a referral center.

Méthode : This retrospective cross-sectional study was conducted on patients managed in a tertiary referral center, Tehran, Iran, from March 2009 to March 2019, with diagnosis of FG or necrotising fasciitis. The correlation between different demographic and clinical parameters with mortality was analysed and reported.

Résultats : 73 cases with the mean age of 59.1 ± 15.8 (range: 25 - 88) years were studied (87.7% male). 21 (28.8%) patients died. Escherichia coli (26 cases, 35.6%) was the most frequent microorganism in cultures. Non-survived cases had higher mean age (p = 0.01), higher frequency of hyperlipidaemia (p = 0.02), immunosuppression (p < 0.001), longer hospital stay (p=0.02), lower blood pressure (p=0.01), and lower platelet count (p=<0.001). Based on multivariate analysis, age (p = 0.015; Odds: 0.88 (0.79-0.97)), haematocrit level (p = 0.01; Odds: 1.27 (1.04-1.55)), platelet count (p = 0.03; Odds: 10.11 (1.14-89.35)), and immunosuppression (p = 0.01; Odds: 0.01 (0.0-0.54)) were independent related factors of mortality.

Conclusion : The rate of mortality due to FG and necrotizing fasciitis was 28.8%. Based on multivariate analysis, the independent related factors of mortality were older age, lower haematocrit level and platelet count, and presence of immunosuppression.

Conclusion (proposition de traduction) : Le taux de mortalité dû à la gangrène de Fournier et à la fasciite nécrosante était de 28,8 %. Sur la base d'une analyse multivariée, les facteurs indépendants de mortalité liés étaient l'âge avancé, un taux d'hématocrite et une numération plaquettaire inférieurs et la présence d'une immunosuppression.

British Medical Journal

Screening and management of atrial fibrillation in primary care.
Ponamgi SP, Siontis KC, Rushlow DR, Graff-Radford J, Montori V, Noseworthy PA. | BMJ.  2021 Apr 12;373:n379
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Editorial : Atrial fibrillation is a common chronic disease seen in primary care offices, emergency departments, inpatient hospital services, and many subspecialty practices. Atrial fibrillation care is complicated and multifaceted, and, at various points, clinicians may see it as a consequence and cause of multi-morbidity, as a silent driver of stroke risk, as a bellwether of an acute medical illness, or as a primary rhythm disturbance that requires targeted treatment. Primary care physicians in particular must navigate these priorities, perspectives, and resources to meet the needs of individual patients. This includes judicious use of diagnostic testing, thoughtful use of novel therapeutic agents and procedures, and providing access to subspecialty expertise. This review explores the epidemiology, screening, and risk assessment of atrial fibrillation, as well as management of its symptoms (rate and various rhythm control options) and stroke risk (anticoagulation and other treatments), and offers a model for the integration of the components of atrial fibrillation care.

Conclusion : The global burden of atrial fibrillation is rapidly increasing with our aging population and improved success of the procedure with early intervention. With improved catheter designs and safety of existing atrial fibrillation ablation techniques, future studies may need to look at outcomes of early electrophysiological intervention in patients with asymptomatic screen detected atrial fibrillation as opposed to observation and rate control.

Conclusion (proposition de traduction) : Le coût mondial de la fibrillation atriale augmente rapidement avec le vieillissement de notre population et l'amélioration du succès de la procédure avec une intervention précoce. Avec l'amélioration de la conceptions des cathéters et de la sécurité des techniques existantes d'ablation de la fibrillation atriale, les futures études pourraient devoir examiner les résultats d'une intervention électrophysiologique précoce chez les patients présentant une fibrillation atriale détectée lors d'un dépistage asymptomatique, par opposition à l'observation et au contrôle de la fréquence.


The Relationship Between Asthma and Cardiovascular Disease: An Examination of the Framingham Offspring Study.
Pollevick ME, Xu KY, Mhango G, Federmann EG, Vedanthan R, Busse P, Holguin F, Federman AD, Wisnivesky JP. | Chest.  2020 Dec 11:S0012-3692(20)35355-1
Keywords: Framingham Offspring Cohort; asthma; cardiovascular disease.

Original Research

Introduction : Although asthma has been suggested as a risk factor for cardiovascular disease (CVD), robust longitudinal evidence of this relationship is limited.
Research question: Using Framingham Offspring Cohort data, the goal of this study was to longitudinally examine the association between asthma and lifetime risk of CVD while controlling for cardiovascular risk factors included in the Framingham Risk Score.

Méthode : Data were analyzed from a prospective population-based cohort of 3,612 individuals, ages 17 to 77 years, who participated in Framingham Offspring Study examinations from 1979 to 2014. Asthma was defined based on physician diagnosis during study interviews. Incident CVD included myocardial infarction, angina, coronary insufficiency, stroke, transient ischemic attack, and heart failure. Time-dependent Cox regression models were used to evaluate the relationship between asthma and CVD incidence.

Résultats : Overall, 533 (15%) participants had a diagnosis of asthma and 897 (25%) developed CVD during the course of the study. Unadjusted analyses revealed that asthma was associated with increased CVD incidence (hazard ratio, 1.40; 95% CI, 1.17-1.68). Cox regression also showed an adjusted association between asthma and CVD incidence (hazard ratio, 1.28; 95% CI, 1.07-1.54) after controlling for established cardiovascular risk factors.

Conclusion : This prospective analysis with > 35 years of follow-up shows that asthma is a risk factor for CVD after adjusting for potential confounders. When assessing risk of cardiovascular disease, asthma should be evaluated and managed as a risk factor contributing to morbidity and mortality.

Conclusion (proposition de traduction) : Cette analyse prospective avec > 35 ans de suivi montre que l'asthme est un facteur de risque de maladie cardiovasculaire après ajustement pour les facteurs de confusion potentiels. Lors de l'évaluation du risque de maladie cardiovasculaire, l'asthme doit être évalué et pris en charge comme un facteur de risque contribuant à la morbidité et à la mortalité.

Comparative Effectiveness of Heart Rate Control Medications for the Treatment of Sepsis-Associated Atrial Fibrillation.
Bosch NA, Rucci JM, Massaro JM, Winter MR, Quinn EK, Chon KH, McManus DD, Walkey AJ. | Chest.  2020 Oct 24;159(4):1452–9
Keywords: atrial fibrillation; comparative effectiveness; rate control; sepsis.

Research article

Introduction : Atrial fibrillation (AF) with rapid ventricular response frequently complicates the management of critically ill patients with sepsis and may necessitate the initiation of medication to avoid hemodynamic compromise. However, the optimal medication to achieve rate control for AF with rapid ventricular response in sepsis is unclear.
Research question: What is the comparative effectiveness of frequently used AF medications (β-blockers, calcium channel blockers, amiodarone, and digoxin) on heart rate (HR) reduction among critically ill patients with sepsis and AF with rapid ventricular response?

Méthode : We conducted a multicenter retrospective cohort study among patients with sepsis and AF with rapid ventricular response (HR > 110 beats/min). We compared the rate control effectiveness of β-blockers to calcium channel blockers, amiodarone, and digoxin using multivariate-adjusted, time-varying exposures in competing risk models (for death and addition of another AF medication), adjusting for fixed and time-varying confounders.

Résultats : Among 666 included patients, 50.6% initially received amiodarone, 10.1% received a β-blocker, 33.8% received a calcium channel blocker, and 5.6% received digoxin. The adjusted hazard ratio for HR of < 110 beats/min by 1 h was 0.50 (95% CI, 0.34-0.74) for amiodarone vs β-blocker, 0.37 (95% CI, 0.18-0.77) for digoxin vs β-blocker, and 0.75 (95% CI, 0.51-1.11) for calcium channel blocker vs β-blocker. By 6 h, the adjusted hazard ratio for HR < 110 beats/min was 0.67 (95% CI, 0.47-0.97) for amiodarone vs β-blocker, 0.60 (95% CI, 0.36-1.004) for digoxin vs β-blocker, and 1.03 (95% CI, 0.71-1.49) for calcium channel blocker vs β-blocker.

Conclusion : In a large cohort of patients with sepsis and AF with rapid ventricular response, a β-blocker treatment strategy was associated with improved HR control at 1 h, but generally similar HR control at 6 h compared with amiodarone, calcium channel blocker, or digoxin.

Conclusion (proposition de traduction) : Dans une grande cohorte de patients présentant une septicémie et une fibrillation atriale avec réponse ventriculaire rapide, une stratégie de traitement par β-bloquant a été associée à un meilleur contrôle de la fréquence cardiaque à 1 h, mais généralement un contrôle de la fréquence cardiaque similaire à 6 h par rapport à l'amiodarone, un inhibiteur calcique, ou la digoxine.

Commentaire : Pour mémoire :
Taboulet P and al. Prise en charge de la fibrillation atriale en médecine d’urgence. Recommandations formalisées d’experts de la Société française de médecine d’urgence en partenariat avec la Société française de cardiologie   - 2015 IV : intraveineux ; bpm : battements par minute
1. Fraction d’éjection ventriculaire gauche (FEVG) altérée ou inconnue
2. Bétabloquant IV (aténolol, esmolol) ou inhibiteur calcique IV (vérapamil, diltiazem) ; traitement bêtabloquant ou inhibiteur calcique possible par voie orale
3. Bêtabloquant ß1-sélectif (nébivolol, carvédilol, bisoprolol, métoprolol) : débuter par la dose la plus faible
4. Digoxine IV en premier choix. Amiodarone IV en premier choix, si l’hémodynamique est instable et la fraction d’éjection du VG basse. La digoxine et l’amiodarone peuvent être associées
5. La digoxine doit être ajoutée quand la monothérapie ci-dessus est insuffisante
6. L’amiodarone peut être envisagée par voie orale quand les autres molécules sont inefficaces ou contre-indiquées
7. Choc électrique recommandé si les mesures pharmacologiques ne permettent pas une amélioration rapide des patients avec une ischémie myocardique persistante, une hypotension symptomatique, une angine de poitrine ou une défaillance cardiaque.

L'aténolol (Ténormine 5 mg/10 ml) se caractérise par 3 propriétés pharmacologiques :
• activité bêtabloquante bêta 1 cardiosélective ;
• effet anti-arythmique ;
• absence de pouvoir agoniste partiel (ou d'activité sympathomimétique intrinsèque).
L'effet d'une injection intraveineuse d'aténolol est quasi immédiat.
La demi-vie d'élimination est de 9 heures mais l'activité bêta-bloquante couvre le nycthémère.
Posologie : 5 à 10 mg par injection IV lente (2 ml/min) pour amener le rythme cardiaque à 60 bpm ou moins.

L'esmolol (Brévibloc 100 mg/10 ml) se caractérise par 3 propriétés pharmacologiques :
• bêta-bloquant cardiosélectif ;
• effet anti-arythmique ;
• aucune activité sympathomimétique intrinsèque (ASI) significative ni de propriétés stabilisantes des membranes.
L'effet d'une injection intraveineuse d'aténolol est obtenu en deux minutes.
La demi-vie d'élimination est de 9 minutes.
Administration séquentielle : dose de charge de 500 µg/kg en 1 minute, puis 50 µg/kg en 4 minutes.

Management for the Drowning Patient.
Szpilman D, Morgan PJ. | Chest.  2020 Oct 14:S0012-3692(20)34896-0
Keywords: acute lung injury; aspirations; critical care; drowningl; immersion; resuscitation; submersion.

Review article

Editorial : Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid." According to the World Health Organization, drowning claims the lives of > 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that > 90% of drownings are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of oxygen in different proportions. The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a noncardiogenic pulmonary edema. Salt and fresh water aspirations cause similar pathology. If the person is not rescued, aspiration continues, and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt ≤ 20% or Pao2:Fio2 ≥ 250. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essential steps from the first call to action until the best practice at the prehospital, ED, and hospitalization.

Conclusion : As one of the most common causes of unintentional injury-related morbidity and mortality worldwide, drowning remains a significant public health issue and an extremely complex process in which there is no simple, or single solution. However, the true impact of drowning on public health is unknown due to a lack of high-quality epidemiological data in the field. The most effective intervention to reduce drowning deaths is prevention. When prevention fails further reduction in morbidity and mortality is only achieved by effective rescue, and early clinical interventions when indicated. In many areas of medicine, it is obvious that prevention is better than cure, but how do you motivate and educate those populations that are at the highest risk? Does it require the emotive scenario of a child death or severe neurological insult as a result of a drowning event for people to act? The drowning process may involve a complex interplay between acute injury or disease and an inability to maintain the airway clear of the waters surface. The simple life skills of water awareness and the ability to float face up will prevent many of the complications of this potentially fatal process. There is a deficit of high-quality scientific evidence at all stages of the patient’s journey following a drowning event, particularly in the hospital setting. These events result in a multisystem disorder to a greater or lesser extent depending upon the duration of the hypoxic insult. Following a successful rescue, the key therapy is oxygen, and facilitation of its’ delivery to the tissues of the body.

Conclusion (proposition de traduction) : En tant que l'une des causes les plus courantes de morbidité et de mortalité liées aux blessures non intentionnelles dans le monde, la noyade reste un problème de santé publique important et un processus extrêmement complexe dans lequel il n'y a pas de solution simple ou unique. Cependant, le véritable impact de la noyade sur la santé publique est inconnu en raison d'un manque de données épidémiologiques de haute qualité sur le terrain. L'intervention la plus efficace pour réduire les décès par noyade est la prévention. Lorsque la prévention échoue, une réduction supplémentaire de la morbidité et de la mortalité n'est obtenue que par un sauvetage efficace et des interventions cliniques précoces lorsque cela est indiqué. Dans de nombreux domaines de la médecine, il est évident qu'il vaut mieux prévenir que guérir, mais comment motiver et éduquer les populations les plus exposées ? Faut-il le scénario émotionnel d’un décès d’enfant ou d’une atteinte neurologique grave à la suite d’une noyade pour que les gens agissent ? Le processus de noyade peut impliquer une interaction complexe entre une blessure ou une maladie aiguës et une incapacité à maintenir les voies respiratoires dégagées hors de l'eau. La simple connaissance de l’eau et la capacité à flotter face visible permettront d’éviter bon nombre des complications de ce processus potentiellement mortel. Il existe un déficit de preuves scientifiques de haute qualité à toutes les étapes du parcours du patient après une noyade, en particulier en milieu hospitalier. Ces événements entraînent une défaillance multiviscérale à un degré plus ou moins important selon la durée de l'agression hypoxique. Après un sauvetage réussi, la thérapeutique clé est l’oxygène et la facilitation de son acheminement vers les tissus du corps.

Dosing Fluids in Early Septic Shock.
Chaudhuri D, Herritt B, Lewis K, Diaz-Gomez JL, Fox-Robichaud A, Ball I, Granton J, Rochwerg B. | Chest.  2020 Oct 13:S0012-3692(20)34890-X
Keywords: critical care echocardiography; fluid management; sepsis; volume responsive.

Review article

Editorial : Early IV fluid administration remains one of the modern pillars of sepsis treatment; however, questions regarding amount, type, rate, mechanism of action, and even the benefits of fluid remain unanswered. Administering the optimal fluid volume is important, because overzealous fluid resuscitation can precipitate multiorgan failure, prolong mechanical ventilation, and worsen patient outcomes. After the initial resuscitation, further fluid administration should be determined by individual patient factors and measures of fluid responsiveness. This review describes various static and dynamic measures that are used to assess fluid responsiveness and summarizes the evidence addressing these metrics. Subsequently, we outline a practical approach to the evaluation of fluid responsiveness in early septic shock and explore further areas crucial to ongoing research examining this topic.

Conclusion : An international prospective observational study of 2213 critically ill patients showed that the number one indication for fluid challenge was hypotension (59%) and that in 43% of the cases in which fluid was given, no hemodynamic measures of fluid responsiveness were used. Even in the cases where a measure of fluid responsiveness was employed, the results of the test were not used to inform further fluid administration. This study nicely illustrates the degree of uncertainty that currently exists around dosing fluids and measures of fluid responsiveness in critically ill patients.
As summarized here, the various methods used to asses fluid responsiveness in patients with septic shock have advantages and disadvantages across diverse patient populations. At present, dynamic measures are more reliable for guiding fluid resuscitation than static measures however, higher quality data and expertise, especially in critical care echocardiography, is required.
While awaiting more definitive evidence, the following approach should be considered: If the mean arterial pressure remains below 65 mm Hg after the initial 30 cc/kg of crystalloid resuscitation, we assess for fluid responsiveness. Other than intravenous medications, we advocate against further fluid administration for patients who are found to be fluid unresponsive. If a patient is fluid responsive or has uncertain or conflicting assessments, then we would give a fluid bolus and reassess for clinical improvement. If there are signs of clinical improvement with fluid administration and the patient remains fluid responsive based on assessment, then repeated bolusing is warranted. Frequent reassessment is require to determine when further fluid administration is no longer beneficial. In this situation, if hypotension persists, vasopressors should be employed to achieve blood pressure goals.

Conclusion (proposition de traduction) : Une étude observationnelle prospective internationale portant sur 2 113 patients de réanimation a montré que l’indication numéro un de l'indication du remplissage vasculaire était l’hypotension (59 %) et que dans 43 % des cas où un remplissage vasculaire été administré, aucune mesure hémodynamique à la réponse au remplissage n’a été utilisée. Même dans les cas où une mesure du remplissage vasculaire a été utilisée, les résultats du test n’ont pas été utilisés pour guider l’administration ultérieure du remplissage vasculaire. Cette étude illustre bien le degré d’incertitude qui existe actuellement autour du remplissage vasculaire et des mesures de la la réponse au remplissage chez les patients de réanimation.
Tel que résumé ici, les différentes méthodes utilisées pour évaluer la réponse au remplissage vasculaire chez les patients présentant un choc septique présentent des avantages et des inconvénients pour différentes populations de patients. À l’heure actuelle, les mesures dynamiques sont plus fiables pour orienter la réanimation liquidienne que les mesures statiques, mais il faut disposer de données et d’expertise de meilleure qualité, particulièrement en échocardiographie de soins intensifs.
Dans l’attente de preuves plus définitives, l’approche suivante devrait être envisagée : Si la pression artérielle moyenne reste inférieure à 65 mmHg après les 30 cc/kg initiaux de remplissage vasculaire avec un cristallloïde, nous évaluons la réponse au remplissage. Outre les médicaments par voie intraveineuse, nous préconisons l’administration de liquides supplémentaires pour les patients qui ne répondent pas aux besoins du remplissage. Si un patient répond aux remplissage ou a des évaluations incertaines ou contradictoires, nous lui donnons alors un bolus de liquide et réévaluons en vue d’une amélioration clinique. S’il y a des signes d’amélioration clinique après l’administration du remplissage et que le patient reste réhydraté d’après l’évaluation, une administration répétée de bolus est justifiée. Une réévaluation fréquente est nécessaire pour déterminer quand une autre administration de liquide n’est plus bénéfique. Dans ce cas, si l’hypotension persiste, il faut utiliser des vasopresseurs pour atteindre les objectifs de tension artérielle.


Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results From the CABANA Trial.
Packer DL, , Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, Poole JE, Bahnson TD, Lee KL, Mark DB; CABANA Investigators. | Circulation.  2021 Apr 6;143(14):1377-1390.
Keywords: antiarrhythmic drug; atrial fibrillation; catheter ablation; heart failure; paroxysmal atrial fibrillation; persistent atrial fibrillation; pulmonary vein.

Original Research Article

Introduction : In patients with heart failure and atrial fibrillation (AF), several clinical trials have reported improved outcomes, including freedom from AF recurrence, quality of life, and survival, with catheter ablation. This article describes the treatment-related outcomes of the AF patients with heart failure enrolled in the CABANA trial (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation).

Méthode : The CABANA trial randomized 2204 patients with AF who were ≥65 years old or <65 years old with ≥1 risk factor for stroke at 126 sites to ablation with pulmonary vein isolation or drug therapy including rate or rhythm control drugs. Of these, 778 (35%) had New York Heart Association class >II at baseline and form the subject of this article. The CABANA trial's primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest.

Résultats : Of the 778 patients with heart failure enrolled in CABANA, 378 were assigned to ablation and 400 to drug therapy. Ejection fraction at baseline was available for 571 patients (73.0%), and 9.3% of these had an ejection fraction <40%, whereas 11.7% had ejection fractions between 40% and 50%. In the intention-to-treat analysis, the ablation arm had a 36% relative reduction in the primary composite end point (hazard ratio, 0.64 [95% CI, 0.41-0.99]) and a 43% relative reduction in all-cause mortality (hazard ratio, 0.57 [95% CI, 0.33-0.96]) compared with drug therapy alone over a median follow-up of 48.5 months. AF recurrence was decreased with ablation (hazard ratio, 0.56 [95% CI, 0.42-0.74]). The adjusted mean difference for the AFEQT (Atrial Fibrillation Effect on Quality of Life) summary score averaged over the entire 60-month follow-up was 5.0 points, favoring the ablation arm (95% CI, 2.5-7.4 points), and the MAFSI (Mayo Atrial Fibrillation-Specific Symptom Inventory) frequency score difference was -2.0 points, favoring ablation (95% CI, -2.9 to -1.2).

Conclusion : In patients with AF enrolled in the CABANA trial who had clinically diagnosed stable heart failure at trial entry, catheter ablation produced clinically important improvements in survival, freedom from AF recurrence, and quality of life relative to drug therapy. These results, obtained in a cohort most of whom had preserved left ventricular function, require independent trial verification.

Conclusion (proposition de traduction) : Chez les patients présentant une FA inclus dans l'essai CABANA qui étaient diagnostiqué cliniquement avec une insuffisance cardiaque stable à l'entrée de l'essai, l'ablation par cathéter a produit des améliorations cliniquement importantes de la survie, de l'absence de récidive de FA et de la qualité de vie par rapport au traitement médicamenteux. Ces résultats, obtenus dans une cohorte dont la plupart avaient conservé la fonction ventriculaire gauche, nécessitent une vérification d'essai indépendante.

Cochrane Database of Systematic Reviews

Thrombolytic therapy for pulmonary embolism.
Zuo Z, Yue J, Dong BR, Wu T, Liu GJ, Hao Q. | Cochrane Database Syst Rev.  2021 Apr 15;4(4):CD004437
Keywords: Aucun


Introduction : Thrombolytic therapy is usually reserved for people with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and may reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhage. This is the fourth update of the Cochrane review first published in 2006.
Objectives: To assess the effects of thrombolytic therapy for acute pulmonary embolism.

Méthode : The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and trials registers to 17 August 2020. We undertook reference checking to identify additional studies.
Selection criteria: We included randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo, or surgical intervention for people with acute PE (massive/submassive). We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug.
Data collection and analysis: Two review authors (ZZ, QH) assessed the eligibility and risk of bias of trials and extracted data. We calculated effect estimates using the odds ratio (OR) with a 95% confidence interval (CI) or the mean difference (MD) with a 95% CI. The primary outcomes of interest were death, recurrence of PE and haemorrhagic events. We assessed the certainty of the evidence using GRADE criteria.

Résultats : We identified three new studies for inclusion in this update. We included 21 trials in the review, with a total of 2401 participants. No studies compared thrombolytics versus surgical intervention. We were not able to include one study in the meta-analysis because it provided no extractable data. Most studies carried a high or unclear risk of bias related to randomisation and blinding. Meta-analysis showed that, compared to control (heparin alone or heparin plus placebo), thrombolytics plus heparin probably reduce both the odds of death (OR 0.58, 95% CI 0.38 to 0.88; 19 studies, 2319 participants; low-certainty evidence), and recurrence of PE (OR 0.54, 95% CI 0.32 to 0.91; 12 studies, 2050 participants; low-certainty evidence). Effects on mortality weakened when six studies at high risk of bias were excluded from analysis (OR 0.71, 95% CI 0.45 to 1.13; 13 studies, 2046 participants) and in the analysis of submassive PE participants (OR 0.61, 95% CI 0.37 to 1.02; 1993 participants). Effects on recurrence of PE also weakened after removing one study at high risk of bias for sensitivity analysis (OR 0.60, 95% CI 0.35 to 1.04; 11 studies, 1949 participants). We downgraded the certainty of evidence to low because of 'Risk of bias' concerns. Major haemorrhagic events were probably more common in the thrombolytics group than in the control group (OR 2.84, 95% CI 1.92 to 4.20; 15 studies, 2101 participants; moderate-certainty evidence), as were minor haemorrhagic events (OR 2.97, 95% CI 1.66 to 5.30; 13 studies,1757 participants; low-certainty evidence). We downgraded the certainty of the evidence to moderate or low because of 'Risk of bias' concerns and inconsistency. Haemorrhagic stroke may occur more often in the thrombolytics group than in the control group (OR 7.59, 95% CI 1.38 to 41.72; 2 studies, 1091 participants). Limited data indicated that thrombolytics may benefit haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, composite clinical outcomes, need for escalation and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and the small number of participants involved warrant caution when interpreting results. The length of hospital stay was shorter in the thrombolytics group than in the control group (mean difference (MD) -1.40 days, 95% CI -2.69 to -0.11; 5 studies, 368 participants)…

Conclusion : Low-certainty evidence suggests that thrombolytics may reduce death following acute pulmonary embolism compared with heparin (the effectiveness was mainly driven by one trial with massive PE). Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events, including haemorrhagic stroke. More studies of high methodological quality are needed to assess safety and cost effectiveness of thrombolytic therapy for people with pulmonary embolism.

Conclusion (proposition de traduction) : Des preuves de faible certitude suggèrent que les thrombolytiques peuvent réduire la mortalité suite à une embolie pulmonaire aiguë par rapport à l'héparine (l'efficacité était principalement motivée par un essai avec une EP massive). Le traitement thrombolytique peut être utile pour réduire la récidive des embolies pulmonaires, mais peut provoquer des événements hémorragiques plus importants et mineurs, y compris un accident vasculaire cérébral hémorragique. D'autres études de haute qualité méthodologique sont nécessaires pour évaluer l'innocuité et la rentabilité du traitement thrombolytique pour les personnes atteintes d'embolie pulmonaire.

Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis.
Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. | Cochrane Database Syst Rev.  2021 Apr 10;4(4):CD013155
Keywords: Aucun


Introduction : Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments.
Objectives: To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms.

Méthode : We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices.
Selection criteria: We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation.
Data collection and analysis: We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details.

Résultats : We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life…

Conclusion : Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.

Conclusion (proposition de traduction) : Sur la base de preuves de certitude modérée, les analogues de la somatostatine seuls et les analogues de la vasopressine seuls (avec traitement de soutien) entraînent probablement une mortalité accrue par rapport à la sclérothérapie endoscopique.
Sur la base de preuves de certitude modérée, les analogues de la vasopressine seuls et la ligature en bande seule entraînent probablement moins d'événements indésirables par rapport à la sclérothérapie endoscopique.
Sur la base de preuves de faible certitude, la tamponnade par ballonnet associée à la sclérothérapie peut entraîner une forte augmentation des événements indésirables graves par rapport à la sclérothérapie.
Sur la base de preuves de faible certitude, la sclérothérapie associée à des analogues de la somatostatine peut entraîner de fortes diminutions de la récidive symptomatique par rapport à la sclérothérapie.
Dans les autres comparaisons, les preuves indiquent une incertitude considérable sur les effets des interventions, par rapport à la sclérothérapie.

Critical Care

Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis.
Owen VS, Rosgen BK, Cherak SJ, Ferland A, Stelfox HT, Fiest KM, Niven DJ. | Crit Care.  2021 Apr 16;25(1):146
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment.

Méthode : MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity.

Résultats : Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias.

Discussion : L'incidence des événements indésirables associés à l'administration intraveineuse périphérique d'un vasopresseur est faible. Des recherches supplémentaires sont nécessaires pour examiner les effets de la localisation et de la taille de l'intraveineuse périphérique, du type et de la dose du vasopresseur et des caractéristiques du patient sur la sécurité de l'administration intraveineuse périphérique de vasopresseur.

Conclusion : The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.

Conclusion (proposition de traduction) : Adverse event; Ionotrope; Peripheral intravenous; Safety; Vasoconstrictor; Vasopressor

Critical Care Medicine

The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients.
Lat I, Coopersmith CM, De Backer D; Research Committee of the Surviving Sepsis Campaign; Members of the Surviving Sepsis Campaign Research Committee contributing to this article are as follows; Co-chair, Atlanta, GA; Co-chair, Brussels, Belgium; Manhasset, NY; Consultant, Seattle, WA; Barcelona, Spain; San Francisco, CA; Pune, India; Utrecht, the Netherlands; Chicago, IL; Sao Paulo, Brazil; Atlanta, GA; Dublin, Ireland; New York, NY; Consultant, London. | Crit Care Med.  2021 Apr 1;49(4):623-635
DOI:  | Télécharger l'article au format  
Keywords: Aucun

The Surviving Sepsis Campaign

Introduction : Expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

Méthode : Original article, literature search.
Study selection: Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy.

Conclusion : In the second of a series of manuscripts subsequent to the original article, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.

Conclusion (proposition de traduction) : Dans le deuxième d'une série de manuscrits postérieurs à l'article original, des membres ayant une expertise dans les sujets expliquent les trois priorités identifiées liées à la réanimation liquidienne et aux thérapies vasopressives. Cette analyse résume ce qui est connu et ce qui a été identifié comme étant des recherches en cours et futures.

Current Opinion in Critical Care

Prevention of gastrointestinal bleeding in critically ill patients.
Al-Dorzi HM, Arabi YM. | Curr Opin Crit Care.  2021 Apr 1;27(2):177-182
Keywords: Aucun


Introduction : This review focuses on the current literature on the epidemiology and prevention of stress-induced clinically important gastrointestinal bleeding in ICU patients.

Résultats : The incidence of stress-induced clinically important gastrointestinal bleeding in critically ill patients seems to be decreasing. Observational studies and an exploratory randomized controlled trial suggest that early enteral nutrition may be effective in preventing gastrointestinal bleeding in patients who are not at high risk. Recent systemic reviews and meta-analyses indicate that proton pump inhibitors and H2 receptor antagonists are more effective than placebo in preventing clinically important gastrointestinal bleeding, especially in high-risk and very high-risk patients, but do not reduce mortality. Although observational data suggested an association of proton pump inhibitors and H2 receptor antagonists with Clostridium difficile infection and pneumonia, this association was not confirmed in randomized controlled trials.

Conclusion : The incidence of stress-induced clinically important gastrointestinal bleeding in critically ill patients seems to have decreased over time. Even though stress ulcer prophylaxis in critically ill patients has been a research focus for decades, many questions remain unanswered, such as which groups of patients are likely to benefit and what pharmacologic agent is associated with the best benefit-to-harm ratio.

Conclusion (proposition de traduction) : L'incidence des saignements gastro-intestinaux cliniquement importants induits par le stress chez les patients de réanimation semble avoir diminué avec le temps. Même si la prophylaxie de l'ulcère de stress chez les patients de réanimation fait l'objet de recherches depuis des décennies, de nombreuses questions restent sans réponse, telles que les groupes de patients susceptibles d'en bénéficier et l'agent pharmacologique associé au meilleur rapport bénéfice/risquee.

Emergency Medicine Journal

Effect of tranexamic acid on intracranial haemorrhage and infarction in patients with traumatic brain injury: a pre-planned substudy in a sample of CRASH-3 trial patients.
Mahmood A, Needham K, Shakur-Still H, Harris T, Jamaluddin SF, Davies D, Belli A, Mohamed FL, Leech C, Lotfi HM, Moss P, Lecky F, Hopkins P, Wong D, Boyle A, Wilson M, Darwent M, Roberts I. | Emerg Med J.  2020 Dec 1;38(4):270–8
Keywords: CT/MRI; clinical; emergency department; epidemiology; head; imaging; research; trauma.


Introduction : Early tranexamic acid (TXA) treatment reduces head injury deaths after traumatic brain injury (TBI). We used brain scans that were acquired as part of the routine clinical practice during the CRASH-3 trial (before unblinding) to examine the mechanism of action of TXA in TBI. Specifically, we explored the potential effects of TXA on intracranial haemorrhage and infarction.

Méthode : This is a prospective substudy nested within the CRASH-3 trial, a randomised placebo-controlled trial of TXA (loading dose 1 g over 10 min, then 1 g infusion over 8 hours) in patients with isolated head injury. CRASH-3 trial patients were recruited between July 2012 and January 2019. Participants in the current substudy were a subset of trial patients enrolled at 10 hospitals in the UK and 4 in Malaysia, who had at least one CT head scan performed as part of the routine clinical practice within 28 days of randomisation. The primary outcome was the volume of intraparenchymal haemorrhage (ie, contusion) measured on a CT scan done after randomisation. Secondary outcomes were progressive intracranial haemorrhage (post-randomisation CT shows >25% of volume seen on pre-randomisation CT), new intracranial haemorrhage (any haemorrhage seen on post-randomisation CT but not on pre-randomisation CT), cerebral infarction (any infarction seen on any type of brain scan done post-randomisation, excluding infarction seen pre-randomisation) and intracranial haemorrhage volume (intraparenchymal + intraventricular + subdural + epidural) in those who underwent neurosurgical haemorrhage evacuation. We planned to conduct sensitivity analyses excluding patients who were severely injured at baseline. Dichotomous outcomes were analysed using relative risks (RR) or hazard ratios (HR), and continuous outcomes using a linear mixed model.

Résultats : 1767 patients were included in this substudy. One-third of the patients had a baseline GCS (Glasgow Coma Score) of 3 (n=579) and 24% had unilateral or bilateral unreactive pupils. 46% of patients were scanned pre-randomisation and post-randomisation (n=812/1767), 19% were scanned only pre-randomisation (n=341/1767) and 35% were scanned only post-randomisation (n=614/1767). In all patients, there was no evidence that TXA prevents intraparenchymal haemorrhage expansion (estimate=1.09, 95% CI 0.81 to 1.45) or intracranial haemorrhage expansion in patients who underwent neurosurgical haemorrhage evacuation (n=363) (estimate=0.79, 95% CI 0.57 to 1.11). In patients scanned pre-randomisation and post-randomisation (n=812), there was no evidence that TXA reduces progressive haemorrhage (adjusted RR=0.91, 95% CI 0.74 to 1.13) and new haemorrhage (adjusted RR=0.85, 95% CI 0.72 to 1.01). When patients with unreactive pupils at baseline were excluded, there was evidence that TXA prevents new haemorrhage (adjusted RR=0.80, 95% CI 0.66 to 0.98). In patients scanned post-randomisation (n=1431), there was no evidence of an increase in infarction with TXA (adjusted HR=1.28, 95% CI 0.93 to 1.76). A larger proportion of patients without (vs with) a post-randomisation scan died from head injury (38% vs 19%: RR=1.97, 95% CI 1.66 to 2.34, p<0.0001).

Conclusion : TXA may prevent new haemorrhage in patients with reactive pupils at baseline. This is consistent with the results of the CRASH-3 trial which found that TXA reduced head injury death in patients with at least one reactive pupil at baseline. However, the large number of patients without post-randomisation scans and the possibility that the availability of scan data depends on whether a patient received TXA, challenges the validity of inferences made using routinely collected scan data. This study highlights the limitations of using routinely collected scan data to examine the effects of TBI treatments.

Conclusion (proposition de traduction) : L'acide tranexamique peut prévenir une nouvelle hémorragie chez les patients présentant des pupilles réactives au départ. Ceci est cohérent avec les résultats de l'essai CRASH-3 qui a révélé que l'acide tranexamique réduisait le décès par traumatisme crânien chez les patients ayant au moins une pupille réactive au départ. Cependant, le grand nombre de patients sans scans post-randomisation et la possibilité que la disponibilité des données scintigraphiques dépende du fait qu'un patient ait reçu de l'acide tranexamique, remet en question la validité des inférences faites à l'aide des données scannées collectées en routine. Cette étude met en évidence les limites de l'utilisation des données de numérisation collectées en routine pour examiner les effets des traitements des traumatismes crâniens.

Emergency Radiology

Overuse of brain CT scan for evaluating mild head trauma in adults.
Shobeirian F, Ghomi Z, Soleimani R, Mirshahi R, Sanei Taheri M. | Emerg Radiol.  2021 Apr;28(2):251-257
Keywords: CT scan; Indication; Minor head injury; Traumatic brain injury.

Original Article

Introduction : CT scan is crucial in evaluating head trauma. However, its inappropriate use will cause unnecessary radiation exposure to patient and financial burden to health systems. Our aim is appraising amount of brain CT scans performed in our Emergency Department (ED) for evaluating mild head trauma which are not indicated according to four standardized guidelines as well as analyzing contributing factors.

Méthode : This was a descriptive prospective study. We included randomly selected adult patients under 75 years old with minor head trauma evaluated by brain CT scan at our ED. For all patients, we completed a checklist including demographic data, mechanism of trauma, specialty of the requesting physician, and whether the patient meets the brain CT guidelines criteria. Brain CT overuse was defined as scans performed for patients without criteria of any of the standardized guidelines.

Résultats : We evaluated 170 patients. The mean age of patients was 38.38 ± 19.73 years old. The most common mechanism of trauma was falling (37.6%). The overall brain CT scan overuse was 15.3%. Most of the overused scans were performed in younger patients, and patient's age was inversely correlated to overuse. There was no significant difference based on the mechanism of trauma and the specialty of requesting physician.

Conclusion : Our study accentuates the high frequency of brain CT scan overuse, leading to unnecessary radiation exposure and financial burden on healthcare systems. We emphasize that using a guideline for requesting brain CT scan can eliminate unnecessary scans along with detecting patients with important decisive damages.

Conclusion (proposition de traduction) : Notre étude accentue la fréquence élevée de surutilisation de la tomodensitométrie cérébrale, entraînant une exposition inutile aux rayonnements et un coût financier pour les systèmes de santé. Nous soulignons que l'utilisation d'une directive pour demander une tomodensitométrie cérébrale peut éliminer les examens inutiles ainsi que la détection des patients présentant des dommages décisifs importants.

Thromboembolic complications of COVID-19.
Mui LW, Lau JF, Lee HK. | Emerg Radiol.  2021 Apr;28(2):423-429
DOI:  | Télécharger l'article au format  
Keywords: COVID-19; Computed tomography (CT); Coronavirus; Pulmonary embolism; Thromboembolism; Thrombosis.


Editorial : The symptomology of patients afflicted with novel 2019 coronavirus disease (SARS-CoV-2 or COVID-19) has varied greatly, ranging from the asymptomatic state to debilitating hypoxemic respiratory failure caused by severe atypical viral pneumonia. Patients may also develop a hyper-inflammatory state that can lead to multi-organ failure. It has become increasingly apparent that, as part of the hyper-inflammatory state, COVID-19 infection increases susceptibility to systemic thromboembolic complications that can contribute to rapid clinical deterioration or demise. This article aims to review imaging features of various systemic thrombotic complications in six patients with moderate to severe disease. This case series includes examples of pulmonary embolism, stroke, right ventricular thrombosis, renal vein thrombosis, and aortic thrombosis with leg ischemia.

Conclusion : Experts agree that thrombotic risk is sufficient to recommend venous thromboembolism (VTE) prophy- laxis in severe cases of COVID-19 as long as there is no contraindication.

Conclusion (proposition de traduction) : Les experts conviennent que le risque thrombotique est suffisant pour recommander la prophylaxie de la thrombophlébite veineuse (TVP) dans les cas graves de COVID-19 tant qu'il n'y a pas de contre-indication.

Patients with falls from standing height and head or neck injury may not require body CT in the absence of signs or symptoms of body injury.
Baig A, Drabkin MJ, Khan F, Fogel J, Shah S. | Emerg Radiol. .  2021 Apr;28(2):239-243
Keywords: CT; Emergency radiology; Fall; Radiology; Trauma.

Original Article

Introduction : To determine the rate of clinically impactful body injury among patients who had a fall from standing height with an associated head/neck injury, but without evidence of body injury on physical exam or plain radiographs. We also examine surgical/endovascular intervention related to body injury and mortality rates for head/neck and body injury.

Méthode : Retrospective study of 288 patients with CT evidence of acute head/neck injury that underwent body CT despite the absence of clinical or radiographic evidence of body injury. Predictor variables were age, sex, race/ethnicity, and body mass index (BMI).

Résultats : There were 11.5% (n = 33) with body injury on CT (n = 33). There were 3.1% (n = 9) with clinically impactful body injury. No patient had either surgical/endovascular intervention or mortality related to body injury. Additionally, 8.7% (n = 25) had mortality from head/neck injury. Increased age (OR = 1.05, 95% CI: 1.01, 1.08, p = 0.01) and overweight BMI (25-29.99 kg/m2) (OR = 2.85, 95% CI: 1.07, 7.62, p = 0.04) were each significantly associated with increased odds for mortality from head/neck injury.

Conclusion : Patients with falls from standing height and known head/neck injury had a low rate of clinically impactful body injury. None of the studied variables were associated with increased risk of body injury in this patient population. The low rate of clinically impactful body injury and the lack of any mortality, procedure, or transfusion resulting from body injury suggest that body CT may not be necessary in patients with head/neck injury in the absence of clinical or radiographic evidence of body injury.

Conclusion (proposition de traduction) : Les patients présentant des chutes de leur hauteur et des blessures connues à la tête et au cou présentaient un faible taux de blessures corporelles ayant un impact clinique. Aucune des variables étudiées n'a été associée à un risque accru de lésions corporelles dans cette population de patients. Le faible taux de lésions corporelles ayant un impact clinique et l'absence de mortalité, d'intervention ou de transfusion résultant d'une lésion corporelle suggèrent que la tomodensitométrie corporelle peut ne pas être nécessaire chez les patients présentant une blessure à la tête ou au cou en l'absence de preuves cliniques ou radiographiques de lésion corporelle.

Overuse of brain CT scan for evaluating mild head trauma in adults.
Shobeirian F, Ghomi Z, Soleimani R, Mirshahi R, Sanei Taheri M. | Emerg Radiol.  2021 Apr;28(2):251-257
Keywords: CT scan; Indication; Minor head injury; Traumatic brain injury.

Original Article

Introduction : CT scan is crucial in evaluating head trauma. However, its inappropriate use will cause unnecessary radiation exposure to patient and financial burden to health systems. Our aim is appraising amount of brain CT scans performed in our Emergency Department (ED) for evaluating mild head trauma which are not indicated according to four standardized guidelines as well as analyzing contributing factors.

Méthode : This was a descriptive prospective study. We included randomly selected adult patients under 75 years old with minor head trauma evaluated by brain CT scan at our ED. For all patients, we completed a checklist including demographic data, mechanism of trauma, specialty of the requesting physician, and whether the patient meets the brain CT guidelines criteria. Brain CT overuse was defined as scans performed for patients without criteria of any of the standardized guidelines.

Résultats : We evaluated 170 patients. The mean age of patients was 38.38 ± 19.73 years old. The most common mechanism of trauma was falling (37.6%). The overall brain CT scan overuse was 15.3%. Most of the overused scans were performed in younger patients, and patient's age was inversely correlated to overuse. There was no significant difference based on the mechanism of trauma and the specialty of requesting physician.

Conclusion : Our study accentuates the high frequency of brain CT scan overuse, leading to unnecessary radiation exposure and financial burden on healthcare systems. We emphasize that using a guideline for requesting brain CT scan can eliminate unnecessary scans along with detecting patients with important decisive damages.

Conclusion (proposition de traduction) : Notre étude accentue la fréquence élevée de la surutilisation de la tomodensitométrie cérébrale, entraînant une exposition inutile aux rayonnements et un coût financier pour les systèmes de santé. Nous soulignons que l'utilisation d'une recommandation pour demander un scanner cérébral peut éliminer les scanners inutiles tout en détectant les patients présentant des dommages décisifs importants.

The effect of COVID-19 on emergency department imaging: what can we learn?.
Sharperson C, Hanna TN, Herr KD, Zygmont ME, Gerard RL, Johnson JO. | Emerg Radiol.  2021 Apr;28(2):339-347
DOI:  | Télécharger l'article au format  
Keywords: COVID-19; Emergency Department; SARS-CoV-2; imaging; radiology.

Original Article

Introduction : To investigate the effect of the COVID-19 pandemic on emergency department (ED) imaging.

Méthode : This retrospective study included all ED visits at a four-hospital academic health system in two matched 5-week periods. Demographic information, COVID-19 status, and disposition were reviewed. Type of imaging, acquisition time, and radiology reports were analyzed. Significance level was set at p < 0.05.

Résultats : A 43.2% decrease in ED visits and 12% reduction in overall ED imaging occurred during the pandemic period. Mean age was unchanged, but a shift in gender and racial characteristics was observed (p < 0.001). In the pandemic period, COVID-19 ED patients were older (61.8 ± 16.9 years, p < 0.001) and more likely to be Black (64.2%; p < 0.001) than non-COVID-19 patients. Imaging per ED encounter increased to 2.4 ± 2.8 exams from 1.7 ± 1.1 (p < 0.001). Radiography increased (57.2% vs. 52.4%) as a fraction of total ED imaging, while computed tomography (23.4% vs. 27.2%) and ultrasound (8.5% vs. 9.6%) decreased (pre-pandemic vs. pandemic). COVID-19 ED patients underwent CT and US at a lower rate (11.5% and 5.4%) than non-COVID-19 patients (25.4% and 9.1%). The proportion of imaging study reports concluding "no disease" or "no acute disease" decreased from 56.7 to 40.6% (p < 0.001).

Conclusion : The COVID-19 pandemic led to a significant reduction in ED visits, a shift in patient demographics, and a significant decrease in imaging volume. Additional impact included a significant increase in the proportion of positive imaging studies.

Conclusion (proposition de traduction) : La pandémie de COVID-19 a entraîné une réduction significative des consultations aux urgences, un changement dans la démographie des patients et une diminution significative du volume de demande d'imagerie. L'impact supplémentaire comprenait une augmentation significative de la proportion d'études positives des imageries.

European Journal of Emergency Medicine

Association between alcohol intoxication and mortality in severe traumatic brain injury in the emergency department: a retrospective cohort.
van Wijck SF, Kongkaewpaisan N, Han K, Kokoroskos N, Kongwibulwut M, King DR, van der Wilden GM, Krijnen P, Schipper IB, Velmahos GC. | Eur J Emerg Med.  2021 Apr 1;28(2):97-103
DOI:  | Télécharger l'article au format  
Keywords: Aucun

Original Article

Introduction : Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI).

Méthode : This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication.

Résultats : Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09).

Conclusion : In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, il n'y avait pas d'association indépendante entre l'intoxication alcoolique et une mortalité hospitalière plus élevée chez les patients des urgences avec un traumatisme crânien grave.

Can artificial intelligence and machine learning help reduce the harms of emergency department crowding?.
Hudson GR, Howley N, Boyle A. | Eur J Emerg Med.  2021 Apr 1;28(2):95-96
Keywords: Aucun


Editorial : Emergency department (ED) crowding is widely reported in the news and literature. Such a global problem has multifaceted causes and there is increasing interest in whether artificial intelligence and machine learning can reduce the harms of crowding.
Artificial intelligence is a field of computer science containing machine learning, which uses algorithms to decipher patterns in data. Specifically, given input data, machine learning can forecast the number of ED arrivals and predict which patients will be admitted. This provides a toolkit for manipulating patient flow and avoiding crowding.

Conclusion : There is a notable gap between the capabilities of machine learning and its achievements in practice. In sum, while it may be possible to predict arrivals and admissions accurately, there are questions surrounding the reliability of machine learning methods.
In light of this, we recommend that machine learning studies aimed at alleviating crowding should focus on pre- dicting outflow, such as admissions, as this is a more crit- ical influencer of ED crowding. Within these studies, the data used in machine learning algorithms should be readily available even in smaller EDs to facilitate compa- rability. As an example, we recommend using age, gender, acuity, chief complaint and arrival mode which are used according to the standards in the literature at present, alongside a basic set of observations. Studies should also record the performance of machine learning algorithms as a function of training data set size to improve trans- parency when comparing EDs of different sizes. Taken together, these changes would help to remove the varia- bility between EDs and thus help compare the machine learning methods themselves.

Conclusion (proposition de traduction) : Il existe un écart notable entre les capacités de l'apprentissage automatique et ses réalisations dans la pratique. En résumé, s'il est possible de prédire avec précision les arrivées et les admissions, des questions se posent quant à la fiabilité des méthodes d'apprentissage automatique.
À la lumière de cela, nous recommandons que les études d'apprentissage automatique visant à réduire la surfréquentation se concentrent sur la prévision des sorties, telles que les admissions, car il s'agit d'un facteur d'influence plus critique de la surfréquentation des services d'urgence. Dans ces études, les données utilisées dans les algorithmes d'apprentissage automatique devraient être facilement disponibles même dans les petits services d'urgence pour faciliter la comparabilité. À titre d'exemple, nous recommandons d'utiliser l'âge, le sexe, l'urgence, la plainte principale et le mode d'arrivée qui sont utilisés selon les normes de la littérature à l'heure actuelle, ainsi qu'un ensemble d'observations de base. Les études devraient également enregistrer les performances des algorithmes d'apprentissage automatique en fonction de la taille de l'ensemble de données d'entraînement afin d'améliorer la transparence lors de la comparaison des services d'urgence de différentes tailles. Pris ensemble, ces changements contribueraient à supprimer la variabilité entre les services d'urgence et aideraient ainsi à comparer les méthodes d'apprentissage automatique elles-mêmes.

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:  | 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.

Commentaire :  Algorithme de soins post-réanimation

Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study.
Volpicelli G, Gargani L, Perlini S, Spinelli S and al; on behalf of the International Multicenter Study Group on LUS in COVID-19. | Intensive Care Med.  2021 Apr;47(4):444-454
DOI:  | Télécharger l'article au format  
Keywords: COVID-19; Interstitial pneumonia; Lung ultrasound; SARS-CoV-2.


Introduction : To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient's symptoms and clinical history.

Méthode : This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed.

Résultats : We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23-91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients with objective respiratory failure (99.3%). The HighLUS showed a specificity of 88.8% (CI 85.55-91.65%) that was higher in the mild phenotype (94.4%; CI 90.0-97.0%). At multivariate analysis, the HighLUS was a strong independent predictor of RT-PCR positivity (odds ratio 4.2, confidence interval 2.6-6.7, p < 0.0001).

Conclusion : Combining LUS patterns of probability with clinical phenotypes at presentation can rapidly identify those patients with or without COVID-19 pneumonia at bedside. This approach could support and expedite patients' management during a pandemic surge.

Conclusion (proposition de traduction) : La combinaison des profils de probabilité échographiques pulmonaires et des phénotypes cliniques au moment de la prise en charge permet d’identifier rapidement les patients atteints ou non d’une pneumonie COVID-19 au point d'intervention. Cette approche pourrait appuyer et accélérer la prise en charge des patients en cas de pandémie.

Commentaire : Images représentatives des quatre profils de probabilité chez les patients symptomatiques, montrant la distribution des signes LUS de la pneumonie COVID-19. Première rangée : distribution bilatérale des signes interstitiels typiques du LUS (probabilité élevée) dans un cas RT-PCR positif.
Deuxième rangée : distribution monolatérale des signes interstitiels LUS (probabilité intermédiaire) dans un cas RT-PCR positif.
Troisième rangée : présence de signes atypiques (probabilité alternative) dans un cas présentant une forte consolidation isolée avec bronchogrammes aériens, due à une pneumonie bactérienne, et RT-PCR négative.
Quatrième rangée : absence de signes interstitiels LUS (faible probabilité) dans un cas RT-PCR négatif. Échographie pulmonaire LUS, Maladie coronienne COVID-19 2019, RT-PCR réaction en chaîne transcriptase inverse-polymérase.

Proposition d’algorithme sur l’interprétation des signes échographiques pulmonaires lors de la première approche chez les patients soupçonnés de pneumonie COVID-19.

Schéma proposé pour la prise en charge précoce des patients soupçonnés de COVID-19 pendant une flambée pandémique, selon l’évaluation clinique lors de la présentation et l’attribution du profil de probabilité échographique pulmonaire. La décision finale devrait tenir compte du fait que le protocole permet d’exclure ou d’inclure la COVID-19 comme cause principale des symptômes présents.

Cas d’un patient de 65 ans se plaignant de fièvre, de toux et de fatigue pendant 4 jours, sans signes d’insuffisance respiratoire et présentant une saturation normale en air ambiant.

Internal and Emergency Medicine

Procalcitonin in daily clinical practice: an evergreen tool also during a pandemic.
Russo A, Venditti M, Ceccarelli G, Mastroianni CM, d'Ettorre G. | Intern Emerg Med.  2021 Apr;16(3):541-543
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Editorial : Procalcitonin (PCT) is widely considered an essential tool for identification and monitoring of patients with suspected and proved bacterial infections, to determine clinical severity and to assess the response to antibiotic therapy. Moreover, recent studies demonstrated the association between PCT values and etiology of infection, with higher PCT concentrations detected in Gram-negative etiology, compared to Gram-positive and fungal infections.

Conclusion : In conclusion, the high PCT values reported in COVID- 19 patients could be associated with the severity of infection and not only with the presence of bacterial coinfection or superinfection; for all these reasons, the combination of patient’s clinical status with laboratory tests and imaging is crucial in daily practice to assess the likelihood of bacterial coinfection in patients with COVID-19. PCT should be included in a diagnostic stewardship to apply the well-known strategies for an appropriate antimicrobial prescription.

Conclusion (proposition de traduction) : En conclusion, les valeurs élevées de PCT rapportées chez les patients COVID-19 pourraient être associées à la gravité de l'infection et pas seulement à la présence d'une co-infection bactérienne ou d'une surinfection ; pour toutes ces raisons, la combinaison de l’état clinique du patient avec les tests de laboratoire et l’imagerie est cruciale dans la pratique quotidienne pour évaluer la probabilité de co-infection bactérienne chez les patients atteints de COVID-19. La PCT doit être inclus dans une gestion diagnostique pour appliquer les stratégies bien connues pour une prescription d'antibiotiques appropriée.

Intracranial bruits in meningitis.
Sugiura K, Ihara T. | Intern Emerg Med.  2021 Apr;16(3):777-778
Keywords: Aucun

CE - Physical Examination

Editorial : Intracranial bruits (ICB) are faint, high-pitched, and mostly heard on the orbit in the systolic phase of the cardiovascular cycle. This report discusses a case of Listeria monocytogenes meningitis in a 17-month-old male patient in whom ICB were auscultated. ICB is thought to be caused by compression of blood vessels due to increased intracranial pressure and may serve as an additional sign supporting the diagnosis of meningitis. The present report contains video data on the ICB.

Conclusion : Despite the decrease in morbidity and mortality related to bacterial meningitis in recent years, the disease can still be life-threatening, and early diagnosis is critical for improving outcomes. Although meningeal signs, such as nuchal rigid- ity, are important indicators for diagnosing meningitis, each sign has limited utility. Remarkably, there was no sign other than ICB supporting the diagnosis in the present case. While examinations for most meningeal signs are painful, auscultation of the orbits is not. Furthermore, auscultation for ICB is easily and rapidly performed, requiring only a stethoscope. Ocular auscultation is required to detect ICB, which in turn may serve as an additional sign supporting the diagnosis of meningitis.

Conclusion (proposition de traduction) : Malgré la diminution de la morbidité et de la mortalité liées à la méningite bactérienne ces dernières années, la maladie peut encore menacer le pronostic vital et un diagnostic précoce est essentiel pour améliorer les résultats. Bien que les signes méningés, tels que la raideur méningée, soient des indicateurs importants pour le diagnostic de la méningite, chaque signe a une utilité limitée. Fait remarquable, il n'y avait aucun signe autre que des bruits intracrâniens soutenant le diagnostic dans le cas présent. Bien que les examens de la plupart des signes méningés soient douloureux, l'auscultation des orbites ne l'est pas. De plus, l'auscultation des bruits intracrâniens est facilement et rapidement réalisée, ne nécessitant qu'un stéthoscope. Une auscultation oculaire est nécessaire pour détecter les bruits intracrâniens, qui peuvent à leur tour servir de signe supplémentaire appuyant le diagnostic de méningite.

International Journal of Emergency Medicine

Subarachnoid hemorrhage in the emergency department.
Patel S, Parikh A, Okorie ON. | Int J Emerg Med.  2021 May 12;14(1):31
Keywords: Aneurysmal subarachnoid hemorrhage; Emergency department; Hunt and Hess; Modified Fischer; Neurologic injury; Non-aneurysmal subarachnoid hemorrhages; Subarachnoid hemorrhage.


Introduction : Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician.

Discussion : The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest.

Conclusion : Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.

Conclusion (proposition de traduction) : Les hémorragies sous-arachnoïdiennes sont souvent mal diagnostiquées ; par conséquent, nous croyons qu'il est impératif d'aborder le diagnostic et l'initiation d'une prise en charge précoce dans le service de médecine d'urgence afin de minimiser les mauvais résultats à l'avenir.

Use of sodium bicarbonate in out-of-hospital cardiac arrest: a systematic review and meta-analysis.
Alshahrani MS, Aldandan HW. | Int J Emerg Med.  2021 Apr 13;14(1):21
DOI:  | Télécharger l'article au format  
Keywords: Meta-analysis; Out-of-hospital cardiac arrest; Sodium bicarbonate.

Original Research

Introduction : Out-of-hospital cardiac arrest (OHCA) is a common cause of death worldwide (Neumar et al., Circulation 122:S729-S767, 2010), affecting about 300,000 persons in the USA on an annual basis; 92% of them die (Roger et al., Circulation 123:e18-e209, 2011). The existing evidence about the use of sodium bicarbonate (SB) for the treatment of cardiac arrest is controversial. We performed this study to summarize the evidence about the use of SB in patients with out-of-hospital cardiac arrest (OHCA).

Méthode : We searched PubMed, Scopus, EBSCO, Web of Science, and Cochrane Library, until June 2019, for randomized controlled trials (RCTs) and observational studies that used SB in patients with OHCA. Outcomes of interest were the rate of survival to discharge, return of spontaneous circulation (ROSC), sustained ROSC, and good neurological outcomes at discharge. Odds ratio (OR) with their 95% confidence interval (CI) were pooled in a random or fixed meta-analysis model.

Résultats : A total of 14 studies (four RCTs and 10 observational studies) enrolling 28,412 patients were included; of them, eight studies were included in the meta-analysis. The overall pooled estimate did not favor SB or control in terms of survival rate at discharge (OR= 0.66, 95% CI [0.18, 2.44], p=0.53) and ROSC rate (OR= 1.54, 95% CI [0.38, 6.27], p=0.54), while the pooled estimate of two studies showed that SB was associated with less sustained ROSC (OR= 0.27, 95% CI [0.07, 0.98], p=0.045) and good neurological outcomes at discharge (OR= 0.12, 95% CI [0.09, 0.15], p<0.01).

Conclusion : The current evidence demonstrated that SB was not superior to the control group in terms of survival to discharge and return of spontaneous circulation. Further, SB was associated with lower rates of sustained ROSC and good neurological outcomes.

Conclusion (proposition de traduction) : Les preuves actuelles ont démontré que le bicarbonate de sodium n'était pas supérieur au groupe témoin en termes de survie à la sortie et de reprise d'activité cardiaque spontanée. De plus, le bicarbonate de sodium était associé à de plus faibles taux de reprise d'activité cardiaque spontanée (RACS) soutenue et à de moins bons résultats neurologiques.

Implementation of isopropyl alcohol (IPA) inhalation as the first-line treatment for nausea in the emergency department: practical advantages and influence on the quality of care.
Veldhuis P, Melse M, Mullaart N. | Int J Emerg Med.  2021 Feb 24;14(1):15
DOI:  | Télécharger l'article au format  
Keywords: Emergency department; Implementation outcome measures; Isopropyl alcohol inhalation; Nausea; Quality of care.

Original Research

Introduction : Nasal inhalation of isopropyl alcohol (IPA) seems an effective anti-emetic for the symptomatic treatment of nausea in the emergency department (ED) compared to conventional anti-emetics (Ondansetron and Metoclopramide). However, it is not yet known what the practical consequences are related to the use of IPA in the ED.
Objectives: The purpose of this study was to assess the practical implications for patient care associated with IPA use and to evaluate the viability of permanent implementation of IPA inhalation as a first-line therapy for nausea in the ED.

Méthode : We conducted a prospective, single-center implementation study comparing ED-based care for nauseated patients before (n=106) and after (n=104) the introduction of IPA. We evaluated the treatment process and cost and assessed implementation using a survey based on recommended implementation outcome measures.

Résultats : Comparing baseline phase to implementation phase, we found a significant increase in the percentage of patients receiving nausea treatment (66.0% versus 97.1%; p<0.001) and a reduction in time to treatment initiation (7 versus 1 min, p<0.001). Additionally, IPA introduction was associated with a decrease in the administration of conventional anti-emetics (0.52 versus 0.23 administrations per patient, p<0.001) and a notable drop in treatment cost (€1.33 versus €0.67 per patient). Nurses were content with IPA implementation and regarded definitive implementation as feasible and sustainable.

Conclusion : Implementation of IPA as the first-line nausea treatment in the ED can increase the quality of care and improve care efficiency. Definitive implementation of IPA as a first-line treatment in the ED is both viable and practically feasible.

Conclusion (proposition de traduction) : La mise en œuvre de l'alcool isopropylique comme traitement de première intention des nausées au service des urgences peut augmenter la qualité des soins et améliorer l'efficacité des soins. La mise en œuvre définitive d'alcool isopropylique comme traitement de première intention au service des urgences est à la fois viable et faisable en pratique.

Journal of Anesthesia

Error grid analysis for risk management in the difference between invasive and noninvasive blood pressure measurements.
Juri T, Suehiro K, Uchimoto A, Go H, Fujimoto Y, Mori T, Nishikawa K. | J Anesth.  2021 Apr;35(2):189-196
Keywords: Blood pressure; Error grid analysis; Invasive arterial blood pressure; Noninvasive blood pressure.

Original Article

Introduction : Invasive arterial blood pressure (IAP) and noninvasive blood pressure (NIBP) measurements are both common methods. Recently, a new method of error grid analysis was proposed to compare blood pressure obtained using two measurement methods. This study aimed to compare IAP and NIBP measurements using the error grid analysis and investigate potential confounding factors affecting the discrepancies between IAP and NIBP.

Méthode : Adult patients who underwent general anesthesia in the supine position with both IAP and NIBP measurements were retrospectively investigated. The error grid analyses were performed to compare IAP and NIBP. In the error grid analysis, the clinical relevance of the discrepancies between IAP and NIBP was evaluated and classified into five zones from no risk (A) to dangerous risk (E).

Résultats : Overall, data of 1934 IAP/NIBP measurement pairs from 100 patients were collected. The error grid analysis revealed that the proportions of zones A-E for systolic blood pressure were 96.4%, 3.5%, 0.05%, 0%, and 0%, respectively. In contrast, the proportions for mean blood pressure were 82.5%, 16.7%, 0.8%, 0%, and 0%, respectively. The multiple regression analysis revealed that continuous phenylephrine administration (p = 0.016) and age (p = 0.044) were the significant factors of an increased clinical risk of the differences in mean blood pressure.

Conclusion : The error grid analysis indicated that the differences between IAP and NIBP for mean blood pressure were not clinically acceptable and had the risk of leading to unnecessary treatments. Continuous phenylephrine administration and age were the significant factors of an increased clinical risk of the discrepancies between IAP and NIBP.

Conclusion (proposition de traduction) : L'analyse de grille d'erreur entre la pression artérielle invasive et la pression artérielle non invasive montre que les différences entre la pression artérielle moyenne n'étaient pas cliniquement acceptables et risquaient de conduire à des traitements inutiles. L'administration continue de phényléphrine et l'âge étaient les facteurs significatifs d'un risque clinique accru de divergence entre la pression artérielle invasive et la pression artérielle non invasive.

Commentaire : L'analyse de grille d'erreur de Clarke (CEGA) est une technique courante pour évaluer la précision des algorithmes de prédiction (initialement de la glycémie, dans ce cas elle permet d'évaluer l'effet clinique des différences entre la glycémie réelle et la glycémie prédite).

The ability of pulse oximetry-derived peripheral perfusion index to detect fluid responsiveness in patients with septic shock.
Hasanin A, Karam N, Mukhtar AM, Habib SF. | J Anesth.  2021 Apr;35(2):254-261
Keywords: Fluid challenge; Fluid responsiveness; Peripheral perfusion index; Septic shock.

Original Article

Introduction : Fluid challenge test is a widely used method for the detection of fluid responsiveness in acute circulatory failure. However, detection of the patient's response to the fluid challenge requires monitoring of cardiac output which is not feasible in many settings. We investigated whether the changes in the pulse oximetry-derived peripheral perfusion index (PPI), as a non-invasive surrogate of cardiac output, can detect fluid responsiveness using the fluid challenge test or not.

Méthode : We prospectively enrolled 58 patients with septic shock on norepinephrine infusion. Fluid challenge test, using 200 mL crystalloid solution, was performed in all study subjects. All patients received an additional 300 mL crystalloid infusion to confirm fluid responsiveness. Velocity time integral (VTI) (using transthoracic echocardiography), and PPI were measured at the baseline, after 200 mL fluid challenge, and after completion of 500 mL crystalloids. Fluid responsiveness was defined by 10% increase in the VTI after completion of the 500 mL. The predictive ability of ∆PPI [Calculated as (PPI after 200 mL - baseline PPI)/baseline PPI] to detect fluid responders was obtained using the receiver operating characteristic curve.

Résultats : Forty-two patients (74%) were fluid responders; in whom, the mean arterial pressure, the central venous pressure, the VTI, and the PPI increased after fluid administration compared to the baseline values. ∆PPI showed moderate ability to detect fluid responders [area under receiver operating characteristic curve (95% confidence interval) 0.82 (0.70-0.91), sensitivity 76%, specificity 80%, positive predictive value 92%, negative predictive value 54%, cutoff value ≥ 5%]. There was a significant correlation between ∆PPI and ∆VTI induced by the fluid challenge.

Conclusion : ∆PPI showed moderate ability to detect fluid responsiveness in patients with septic shock on norepinephrine infusion. Increased PPI after 200 mL crystalloid challenge can detect fluid responsiveness with a positive predictive value of 92%; however, failure of the PPI to increase does not exclude fluid responsiveness.

Conclusion (proposition de traduction) : Les modifications de l'indice de perfusion périphérique ont montré une capacité modérée à détecter la réponse au remplissage vasculaire chez les patients présentant un choc septique sous noradrénaline en perfusion. L'augmentation de l'indice de perfusion périphérique après 200 mL de remplissage test aux cristalloïdes peut détecter la réponse hémodynamique avec une valeur prédictive positive de 92 %; cependant, l'échec de l'augmentation de l'indice de perfusion périphérique n'exclut pas la réponse au remplissage vasculaire.

Commentaire : L'indice de perfusion (PI) est le ratio entre le signal pulsatile et le signal non pulsatile du sang artériel au travers du lit capillaire périphérique. L'indice de variabilité pléthysmographique (PVI) est une mesure automatique des changements dynamiques de l’indice de perfusion (PI) qui se produisent pendant le cycle respiratoire.
Plus le PVI est élevé, plus le patient est susceptible de répondre à l'administration de liquides de remplissage.
Le PVI témoigne d'une précision élevée dans la distinction des patients répondeurs et non-répondeurs au remplissage vasculaire. Il constitue une opportunité de mieux gérer le volume de remplissage vasculaire d'un patient afin d'optimiser ses performances cardiaques et la perfusion des organes.

Journal of Critical Care

Development of a machine learning algorithm to predict intubation among hospitalized patients with COVID-19.
Arvind V, Kim JS, Cho BH, Geng E, Cho SK. | J Crit Care.  2021 Apr;62:25-30
DOI:  | Télécharger l'article au format  
Keywords: COVID-19; Intubation; Machine learning; Prediction; Respiratory distress.

Research article

Introduction : The purpose of this study is to develop a machine learning algorithm to predict future intubation among patients diagnosed or suspected with COVID-19.

Méthode : This is a retrospective cohort study of patients diagnosed or under investigation for COVID-19. A machine learning algorithm was trained to predict future presence of intubation based on prior vitals, laboratory, and demographic data. Model performance was compared to ROX index, a validated prognostic tool for prediction of mechanical ventilation.

Résultats : 4087 patients admitted to five hospitals between February 2020 and April 2020 were included. 11.03% of patients were intubated. The machine learning model outperformed the ROX-index, demonstrating an area under the receiver characteristic curve (AUC) of 0.84 and 0.64, and area under the precision-recall curve (AUPRC) of 0.30 and 0.13, respectively. In the Kaplan-Meier analysis, patients alerted by the model were more likely to require intubation during their admission (p < 0.0001).

Conclusion : In patients diagnosed or under investigation for COVID-19, machine learning can be used to predict future risk of intubation based on clinical data which are routinely collected and available in clinical setting. Such an approach may facilitate identification of high-risk patients to assist in clinical care.

Conclusion (proposition de traduction) : Chez les patients diagnostiqués ou en cours d'investigation pour COVID-19, un algorithme d'apprentissage automatique peut être utilisé pour prédire le risque futur d'intubation sur la base de données cliniques qui sont systématiquement collectées et disponibles en milieu clinique. Une telle approche peut faciliter l'identification des patients à haut risque pour aider aux soins cliniques.

Journal of Intensive Care

Association of noninvasive respiratory support with mortality and intubation rates in acute respiratory failure: a systematic review and network meta-analysis.
Yasuda H, Okano H, Mayumi T, Nakane M, Shime N. | J Intensive Care.  2021 Apr 12;9(1):32
DOI:  | Télécharger l'article au format  
Keywords: Acute hypoxic respiratory failure; Conventional oxygen therapy; High-flow nasal cannula; Meta-analysis; Network meta-analysis; Noninvasive ventilation; Systematic review.


Introduction : Noninvasive respiratory support devices may reduce the tracheal intubation rate compared with conventional oxygen therapy (COT). To date, few studies have compared high-flow nasal cannula (HFNC) use with noninvasive positive-pressure ventilation (NPPV). We conducted a network meta-analysis to compare the effectiveness of three respiratory support devices in patients with acute respiratory failure.

Méthode : The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults aged ≥ 16 years with acute hypoxic respiratory failure and randomized-controlled trials that compared two different oxygenation devices (COT, NPPV, or HFNC) before tracheal intubation were included. A frequentist-based approach with a multivariate random-effects meta-analysis was used. The network meta-analysis was performed using the GRADE Working Group approach. The outcomes were short-term mortality and intubation rate.

Résultats : Among 5507 records, 27 studies (4618 patients) were included. The main cause of acute hypoxic respiratory failure was pneumonia. Compared with COT, NPPV and HFNC use tended to reduce mortality (relative risk, 0.88 and 0.93, respectively; 95% confidence intervals, 0.76-1.01 and 0.80-1.08, respectively; both low certainty) and lower the risk of endotracheal intubation (0.81 and 0.78; 0.72-0.91 and 0.68-0.89, respectively; both low certainty); however, short-term mortality or intubation rates did not differ (0.94 and 1.04, respectively; 0.78-1.15 and 0.88-1.22, respectively; both low certainty) between NPPV and HFNC use.

Conclusion : NPPV and HFNC use are associated with a decreased risk of endotracheal intubation; however, there are no significant differences in short-term mortality.

Conclusion (proposition de traduction) : L'utilisation de la VNI et de l'oxygénothérapie nasale à haut débit (ONHD - Optiflow) sont associées à une diminution du risque d'intubation endotrachéale ; cependant, il n'y a pas de différences significatives dans la mortalité à court terme.

Journal of Intensive Care Medicine

Inferior Vena Cava Volume Is an Independent Predictor of Massive Transfusion in Patients With Trauma.
Chien CY, Yan JL, Han ST, Chen JT, Huang TS, Chen YH, Wang CY, Lee YL, Chen KF. | J Intensive Care Med.  2021 Apr;36(4):428-435
Keywords: computed tomography; inferior vena cava; massive transfusion; prediction; trauma.

Original Research

Introduction : Early adequate resuscitation of patients with trauma is crucial in preventing shock and early mortality. Thus, we aimed to determine the performance of the inferior vena cava (IVC) volume and other risk factors and scores in predicting massive transfusion and mortality.

Méthode : We included all patients with trauma who underwent computed tomography (CT) scan of the torso, which included the abdominal area, in our emergency department (ED) from January 2014 to January 2017. We calculated the 3-dimensional IVC volume from the left renal vein to the IVC bifurcation. The primary outcome was the performance of IVC volume in predicting massive transfusion, and the secondary outcome was the performance of IVC volume in predicting 24-hour and 30-day in-hospital mortality.

Résultats : Among the 236 patients with trauma, 7.6% received massive transfusions. The IVC volume and revised trauma score (RTS) were independent predictors of massive transfusion (adjusted odds ratio [OR]: 0.79 vs 1.86, 95% confidence interval [CI], 0.71-0.89 vs 1.4-2.47, respectively). Both parameters showed the good area under the curve (AUC) for the prediction of massive transfusion (adjusted AUC: 0.83 and 0.82, 95% CI, 0.74-0.92 vs 0.72-0.93, respectively). Patients with a large IVC volume (fourth quartile) were less likely to receive massive transfusion than those with a small IVC volume (first quartile, ≥28.29 mL: 0% vs <15.08 mL: 20.3%, OR: 0.13, 95% CI, 0.03-0.66).

Conclusion : The volume of IVC measured on CT scan and RTS are independent predictors of massive transfusion in patients with trauma in the ED.

Conclusion (proposition de traduction) : Le volume de la veine cave inférieure mesuré par tomodensitométrie et le score de traumatisme révisé sont des prédicteurs indépendants de transfusion massive chez les patients traumatisés aux urgences.

Pupillary Light Reflex Is Not Abolished by Epinephrine and Atropine Given During Advanced Cardiac Life Support in Patients Who Achieve Return of Spontaneous Circulation.
Achamallah N, Fried J, Love R, Matusov Y, Sharma R. | J Intensive Care Med.  2021 Apr;36(4):459-465
Keywords: cardiac arrest; epinephrine; prognostication; pupillometry.

Original Research

Introduction : Absence of pupillary light reflex (PLR) is a well-studied indicator of poor neurologic recovery after cardiac arrest. Interpretation of absent PLR is difficult in patients with hypothermia or hypotension, or who have electrolyte or acid-base disturbances. Additionally, many studies exclude patients who receive epinephrine or atropine from their analysis on the basis that these drugs are thought to abolish the PLR. This observational cohort study assessed for presence or absence of PLR in in-hospital cardiac arrest patients who received epinephrine with or without atropine during advanced cardiac life support and achieved return of spontaneous circulation (ROSC).

Méthode : Pupil size and reactivity were assessed in adult patients who had an in-hospital cardiac arrest, received epinephrine with or without atropine, and achieved ROSC. Measurements were taken using a NeurOptics NPi-200 infrared pupillometer.

Résultats : Forty patients had pupillometry performed within 1 hour (median: 6 minutes) after ROSC. Of these only 1 (2.5%) patient had nonreactive pupils at first measurement after ROSC. The remaining 39 (97.5%) had reactive pupils. Of the 19 patients who had pupils checked within 3 minutes of ROSC, 100% had reactive pupils. Degree of pupil responsiveness was not correlated with cumulative dose of epinephrine. Ten patients received atropine in addition to epinephrine, including the sole patient with nonreactive pupils. The remaining 9 (90%) had reactive pupils.

Conclusion : Epinephrine and atropine do not abolish the PLR in patients who achieve ROSC after in-hospital cardiac arrest. Lack of pupillary response in the post-arrest patient should not be attributed to these drugs.

Conclusion (proposition de traduction) : L'épinéphrine et l'atropine n'abolissent pas le réflexe pupillaire à la lumière chez les patients qui récupèrent une activité circulatoire spontanée après un arrêt cardiaque à l'hôpital. L'absence de réponse pupillaire chez le patient après arrêt cardiaque ne doit pas être attribuée à ces médicaments.

Journal of the American Medical Association

Oral Antiplatelet Therapy After Acute Coronary Syndrome: A Review.
Kamran H, Jneid H, Kayani WT, Virani SS, Levine GN, Nambi V, Khalid U. | JAMA.  2021 Apr 20;325(15):1545-1555
Keywords: Aucun


Introduction : Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the United States with an annual incidence of approximately 1 million. Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS.

Résultats : In 2016, the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommended aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS. Since these recommendations were published, new randomized clinical trials have studied different regimens and durations of antiplatelet therapy. Recommendations vary according to the risk of bleeding. If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established. If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable. A high risk of bleeding traditionally is defined as a 1-year risk of serious bleeding (either fatal or associated with a ≥3-g/dL drop in hemoglobin) of at least 4% or a risk of an intracranial hemorrhage of at least 1%. Patients at higher risk are 65 years old or older; have low body weight (BMI <18.5), diabetes, or prior bleeding; or take oral anticoagulants. The newest P2Y12 inhibitors, prasugrel and ticagrelor, are more potent, with high on-treatment residual platelet reactivity of about 3% vs 30% to 40% with clopidogrel and act within 30 minutes compared with 2 hours for clopidogrel. Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack because of an increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel, P = .002) and should avoid prescribing it to patients older than 75 years or who weigh less than 60 kg. The ISAR-REACT-5 trial found that prasugrel reduced rates of death, myocardial infarction, or stroke at 1 year compared with ticagrelor among patients with ACS undergoing percutaneous coronary intervention (9.3% vs 6.9%, P = .006) with no significant difference in bleeding. Recent trials suggested that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes.

Conclusion : Dual antiplatelet therapy reduces rates of cardiovascular events in patients with acute coronary syndrome. Specific combinations and duration of dual antiplatelet therapy should be based on patient characteristics-risk of bleeding myocardial ischemia.

Conclusion (proposition de traduction) : La bithérapie antiagrégante plaquettaire réduit le taux d’événements cardiovasculaires chez les patients atteints d’un syndrome coronarien aigu. Les associations spécifiques et la durée de traitement par bithérapie antiagrégante plaquettaire devraient être basées sur les caractéristiques et les risques d’ischémie myocardique hémorragique du patient.

Management of Acute Coronary Syndromes in Patients Without Persistent ST-Segment Elevation.
Anchan R, Cifu AS, Paul J. | JAMA.  2021 Apr 20;325(15):1556-1557
Keywords: Aucun

JAMA Clinical Guidelines Synopsis

Editorial : Over a 20-year period, French registry data identified that the mortality of patients presenting with ACS substantially decreased, in part due to improved early invasive interventions and newer pharmacologic therapies. From 2010 to 2015, patients presenting with ST segment elevation ACS demonstrated a 22% reduction in 6-month mortality. However, in patients with NSTE-ACS, 6-month mortality demonstrated a plateau and 3%increase across the same period. An updated guideline is useful to review the evidence underpinning recommendations regarding diagnostic test timing, pharmacotherapy, and balancing harms and benefits.

• In patients with suspected non–ST-segment elevation acute coronary syndromes , a 0-hour/1-hour high-sensitivity cardiac troponin assay algorithm is recommended to decrease time to clinical decision-making while providing high sensitivity and diagnostic accuracy (class I, level B).
• Routine pretreatment with a P2Y12 receptor inhibitor is no longer recommended in patients with non–ST-segment elevation acute coronary syndromes with unknown coronary anatomy and planned early invasive angiography (class III, level A).
• In patients who proceed to percutaneous coronary intervention, prasugrel is the preferred P2Y12 receptor inhibitor over ticagrelor (class IIa, level B).
• In patients with atrial fibrillation and non–ST-segment elevation acute coronary syndromes taking an oral anticoagulant, triple antithrombotic therapy with aspirin, clopidogrel, and a direct oral anticoagulant should be administered for up to 1week, with deescalation to dual antithrombic therapy with clopidogrel and a direct oral anticoagulant (class I, level A).

Conclusion (proposition de traduction) : PRINCIPALES RECOMMANDATIONS
• Chez les patients avec suspicion de syndrome coronarien aigus san élévation du segment ST, un algorithme de dosage de la troponine cardiaque à haute sensibilité de 0 heure/1 heure est recommandé pour réduire le temps nécessaire à la prise de décision clinique tout en offrant une sensibilité et une précision diagnostiques élevées (classe I, niveau B).
• Le prétraitement systématique avec un inhibiteur des récepteurs P2Y12 n'est plus recommandé chez les patients présentant un syndrome coronarien aigu sans élévation du segment ST avec une anatomie coronaire inconnue et une angiographie invasive précoce planifiée (classe III, niveau A).
• Chez les patients qui bénéficient d'une intervention coronarienne percutanée, le prasugrel est l'inhibiteur des récepteurs P2Y12 préféré au ticagrélor (classe IIa, niveau B).
• Chez les patients qui présentent une fibrillation atriale et un syndrome coronarien aigu sans élévation du segment ST prenant un anticoagulant oral, une trithérapie antithrombotique par de l'aspirine, du clopidogrel et un anticoagulant oral direct doit être administrée pendant une durée maximale d'une semaine, avec désescalade vers une bithérapie antithrombique par le clopidogrel et un anticoagulant oral direct (classe I, niveau A).

Commentaire : Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. Published online August 29, 2020  .

Journal of the American Medical Association Internal Medicine

Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis.
Goulden R, Rowe BH, Abrahamowicz M, Strumpf E, Tamblyn R. | JAMA Intern Med.  2021 Apr 5:e210916
Keywords: Aucun

Original Investigation

Introduction : Radiocontrast has long been thought of as nephrotoxic; however, a number of recent observational studies found no evidence of an association between intravenous contrast and kidney injury. Because these studies are at high risk of confounding and selection bias, alternative study designs are required to enable more robust evaluation of this association. Objective: To determine whether intravenous radiocontrast exposure is associated with clinically significant long-term kidney impairment, using a study design that permits stronger causal interpretation than existing observational research.

Méthode : This cohort study included all emergency department patients aged 18 years or older undergoing D-dimer testing between 2013 and 2018 in the Canadian province of Alberta. A fuzzy regression discontinuity design was used, exploiting the fact that individuals just either side of the eligibility cutoff for computed tomographic pulmonary angiogram (CTPA)-typically 500 ng/mL-have markedly different probabilities of contrast exposure, but should otherwise be similar with respect to potential confounders. Exposures: Intravenous contrast in the form of a CTPA. Main outcomes and measures: Estimated glomerular filtration rate (eGFR) up to 6 months following the index emergency department visit.

Résultats : During the study period 156 028 individuals received a D-dimer test. The mean age was 53 years, 68 206 (44%) were men and 87 822 (56%) were women, and the mean baseline eGFR level was 86 mL/min/1.73 m2. Patients just above and below the CTPA eligibility cutoff were similar in terms of measured confounders. There was no evidence for an association of contrast with eGFR up to 6 months later, with a mean change in eGFR of -0.4 mL/min/1.73 m2 (95% CI, -4.9 to 4.0) associated with CTPA exposure. There was similarly no evidence for an association with need for kidney replacement therapy (risk difference [RD], 0.07%; 95% CI, -0.47% to 0.61%), mortality (RD, 0.3%; 95% CI, -2.9% to 3.2%), and acute kidney injury (RD, 4.3%; 95% CI, -2.7% to 12.9%), though the latter analysis was limited by missing data. Subgroup analyses were potentially consistent with harm among patients with diabetes (mean eGFR change -6.4 mL/min/1.73 m2; 95% CI, -15.4 to 0.2), but not among those with other reported risk factors for contrast-induced nephropathy; these analyses, however, were relatively underpowered.

Conclusion : Using a cohort study design and analysis that permits stronger causal interpretation than existing observational research, we found no evidence for a harmful effect on kidney function of intravenous contrast administered for CTPA in an emergency setting.

Conclusion (proposition de traduction) : En utilisant une conception d'étude de cohorte et une analyse qui permet une interprétation causale plus forte que la recherche observationnelle existante, nous n'avons trouvé aucune preuve d'un effet nocif sur la fonction rénale du contraste intraveineux administré pour une angiographie pulmonaire tomodensitométrique dans un contexte d'urgence.

Pediatric Emergency Care

Missed Diagnosis of Anaphylaxis in Patients With Pediatric Urticaria in the Emergency Department.
Jung WS, Kim SH, Lee H. | Pediatr Emerg Care.  2021 Apr 1;37(4):199-203
Keywords: Aucun

Original Article

Introduction : This study was to determine the characteristics of missed diagnosis of pediatric anaphylaxis that were registered as urticaria only at the emergency department (ED) by comparing those who had only urticaria symptoms with those who had both anaphylaxis and urticaria symptoms.

Méthode : Subjects were classified into missed anaphylaxis and urticaria group according to whether satisfied anaphylaxis diagnostic criteria or not. Anaphylaxis group, those who were initially registered as anaphylaxis with urticaria and anaphylaxis symptoms simultaneously, were further investigated.

Résultats : The missed anaphylaxis group included 37 patients of 1051 pediatric urticaria patients. The anaphylaxis group included 11 patients. The time from symptom onset to ED arrival in the missed anaphylaxis group was shorter than the urticaria group. More patients in the missed anaphylaxis group had a history of past food allergy. Seafood, egg, and milk were more common causes of allergy in the missed anaphylaxis group; however, idiopathic causes were more common in the urticaria group. Symptom was more severe in the missed anaphylaxis group than the urticaria group. More treatments except antihistamine were performed at ED in the missed anaphylaxis group. Cardiovascular symptoms were more common in the anaphylaxis group than the missed anaphylaxis group.

Conclusion : Of all pediatric urticaria patients, 3.5% of patients were not registered as anaphylaxis although they had anaphylaxis symptoms. Missed diagnosis of anaphylaxis in pediatric urticaria patients at ED was associated with a history of past food allergy, milk, egg, and seafood as causes of allergy, treated with fluid administration, steroid, and epinephrine.

Conclusion (proposition de traduction) : Parmi tous les patients souffrant d'urticaire en pédiatrie, 3,5 % des patients n'étaient pas enregistrés comme présentant une anaphylaxie bien qu'ils présentaient des symptômes d'anaphylaxie. Le diagnostic manqué d'anaphylaxie chez les patients souffrant d'urticaire en pédiatrie aux urgences était associé à des antécédents d'allergie alimentaire, le lait, les œufs et les fruits de mer comme causes d'allergie, traités par remplissage vasculaire, stéroïdes et adrénaline.

Pediatric Esophageal Foreign Body: Possible Role for Digital Tomosynthesis.
Johansen A, Conners GP, Lee J, Robinson AL, Chew WL, Chan SS. | Pediatr Emerg Care.  2021 Apr 1;37(4):208-212
Keywords: Aucun

Original article

Introduction : Foreign body (FB) ingestion is a common reason for emergency department visits, affecting more than 80,000 children in the United States annually. Whereas most ingested FBs are coins or other radiopaque objects, some are radiolucent FBs such as food. Digital tomosynthesis (DTS) is a radiographic technique that produces cross-sectional images with in-plane resolution similar to that of traditional radiographs. Our pilot study evaluated the sensitivity and specificity of DTS to detect FB in comparison to esophagram and clinical impression.

Méthode : This was a retrospective review on patients aged 0 to 18 years with suspected esophageal FB who received an esophagram with DTS at our institution between January 2014 and June 2016. Digital tomosynthesis images were analyzed by 3 readers for identification of FB impaction and compared with esophagram and discharge diagnosis. This study was approved by our local institutional review board.

Résultats : A total of 17 patients underwent an esophagography with DTS for suspected esophageal FB, of which 9 (53%) were suspected of having an FB on esophagram. Compared with esophagram, DTS had a sensitivity of 44%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 62%. Compared with clinical impression, DTS had a sensitivity of 33%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 38%.

Conclusion : This pilot study showed that chest DTS has a very high positive predictive value, compared with esophagram and clinical impression, in detecting radiolucent esophageal FBs in children. Chest DTS is a promising modality for ruling in the presence of a radiolucent esophageal FB.

Conclusion (proposition de traduction) : Cette étude pilote a montré que le scanner thoracique a une valeur prédictive positive très élevée, par rapport à l'œsophagramme et à l'impression clinique, dans la détection de corps étrangers œsophagiens radiotransparents chez les enfants. Le scanner thoracique est une modalité prometteuse pour statuer en présence d'un corps étranger oesophagien radiotransparent.

Prognostic Factors of Children Admitted to a Pediatric Intensive Care Unit After an Episode of Drowning.
Salas Ballestín A, de Carlos Vicente JC, Frontera Juan G, Sharluyan Petrosyan A, Reina Ferragut CM, González Calvar A, Clavero Rubio MDC, Fernández de la Ballina A. | Pediatr Emerg Care.  2021 Apr 1;37(4):e192-e195
Keywords: Aucun

Original article

Introduction : The aim of this study was to evaluate the prognostic factors of patients admitted to a pediatric intensive care unit (PICU) after drowning.

Méthode : Retrospective observational study from January 1992 to December 2004 and prospective study from January 2005 to December 2015 were conducted in a tertiary children's hospital PICU. The data analyzed refer to the patient, event, type of resuscitation performed, and clinical situation after resuscitation and at arrival to the PICU; results of additional tests; and clinical evolution and neurological status at discharge from the PICU (categorized as death, severe encephalopathy, or normal). The considered potential prognostic factors were whether drowning was witnessed, the type of initial resuscitation, Glasgow Coma Scale score at admission, pupil status and reactivity, and pH.

Résultats : One hundred thirty-one patients were registered. Mortality was 16.7%, and 8.3% had significant neurological sequelae. The clearest factor associated with poor outcome was the type of initial resuscitation performed. All patients who did not require cardiopulmonary resuscitation (CPR), or only basic CPR, had good outcomes; 96.3% of those who required advanced CPR with epinephrine administration had poor outcomes. Patients who needed advanced resuscitation with administration of epinephrine had lower temperature, Glasgow Coma Scale score, pH, and bicarbonate at admission and higher level of glucose. In this group, there was also a higher incidence of seizures, acute respiratory distress syndrome, hemodynamic compromise, and acute renal failure.

Conclusion : The need for advanced CPR with epinephrine administration on the scene predicts poor neurological outcome (severe encephalopathy or death) in drowned children.

Conclusion (proposition de traduction) : La nécessité d'une RCP médicalisée avec administration d'adrénaline sur les lieux prédit une issue neurologique médiocre (encéphalopathie sévère ou décès) chez les enfants noyés.

Recognition, Evaluation, and Management of Pediatric Hereditary Angioedema.
Krack AT, Bernstein JA, Ruddy RM. | Pediatr Emerg Care.  2021 Apr 1;37(4):218-223
Keywords: Aucun

CME Review Article

Editorial : Hereditary angioedema (HAE) is a rare, often underrecognized genetic disorder caused by either a C1 esterase inhibitor deficiency (type 1) or mutation (type 2). This leads to overproduction of bradykinin resulting in vasodilation, vascular leakage, and transient nonpitting angioedema occurring most frequently in the face, neck, upper airway, abdomen, and/or extremities. Involvement of the tongue and laryngopharynx has been associated with asphyxiation and death. Hereditary angioedema is an autosomal-dominant condition; therefore, there is a 50% chance an offspring will inherit this disorder. Any patient presenting with isolated angioedema should be screened with a C4 measurement, as 25% of cases have no family history of HAE. All patients with HAE will have a functional deficiency of C1 esterase inhibitor. Contributors that delay the diagnosis of HAE include recognition delay by clinicians who confuse this condition with histaminergic angioedema, the disease's varied presentations, and limitations to timely testing. Pediatric emergency clinicians should be knowledgeable about how to distinguish between bradykinin- and histamine-mediated angioedema, as there are significant differences in the diagnostic testing, treatment, and clinical response between these 2 different conditions. Evidence indicates that early diagnosis and treatment of HAE reduces morbidity and mortality. Clinician recognition of the mechanistically different problems will ensure patients are appropriately referred to an expert for outpatient management.

Conclusion : Hereditary angioedema, a bradykinin-mediated angioedema, is an underrecognized disease that carries a significant risk of morbidity and mortality. Highly variable natural history of disease, symptom overlap with histamine-mediated angioedema, and limitations in timely referral and testing contribute to delayed diagnosis. Recent advances in pathophysiologic understanding have spurred the development of several effective on-demand and prophylactic therapies with improvement of outcomes. Emergency providers should be able to distinguish bradykinin-mediated from histaminergic angioedema, initiate appropriate diagnostic workups and on-demand therapies for acute attacks, and counsel patients and parents on expected response to therapies and outpatient monitoring. Arranging consultation with an HAE expert, which is usually an allergist and less commonly a hematologist, is critical to ensure effective outpatient management and follow-up.

Conclusion (proposition de traduction) : L'angio-œdème héréditaire, angio-œdème médié par la bradykinine, est une maladie sous-reconnue qui comporte un risque important de morbidité et de mortalité. L'histoire naturelle très variable de la maladie, le chevauchement des symptômes avec l'angio-œdème à médiation par l'histamine (ndlr : oedème de Quincke) et les limitations de l'orientation et des tests en temps opportun contribuent à retarder le diagnostic. Les progrès récents dans la compréhension physiopathologique ont stimulé le développement de plusieurs thérapeutiques ponctuelles et prophylactiques efficaces avec une amélioration des résultats. Les urgentistes doivent être en mesure de distinguer l'angio-œdème médié par la bradykinine, de lancer des bilans diagnostiques appropriés et des thérapeutiques ponctuelles pour les crises aiguës, et de conseiller les patients et les parents sur la réponse attendue aux thérapeutiques et au suivi ambulatoire. Organiser une consultation avec un expert en angio-œdème héréditaire, qui est généralement un allergologue et moins souvent un hématologue, est essentiel pour assurer une prise en charge et un suivi ambulatoires efficaces.


Is birth out-of-hospital associated with mortality and morbidity by seven years of age?.
Ovaskainen K, Ojala R, Gissler M, Luukkaala T, Tammela O. | PLoS One. 2021 Apr 21;16(4):e0250163.  2021 Apr 21;16(4):e0250163
DOI:  | Télécharger l'article au format  
Keywords: Aucun


Introduction : Compared to in-hospital births, the long-term outcome of children born out-of-hospital, planned or unplanned, is poorly studied. This study aimed to examine mortality and morbidity by seven years of age in children born out-of-hospital compared to those born in-hospital.

Méthode : This study was registered retrospectively and included 790 136 children born in Finland between 1996 and 2013. The study population was divided into three groups according to birth site: in-hospital (n = 788 622), planned out-of-hospital (n = 176), and unplanned out-of-hospital (n = 1338). Data regarding deaths, hospital visits, reimbursement of medical expenses, and disability allowances was collected up to seven years of age or by the year-end of 2018. The association between birth site and childhood morbidity was determined using multivariable-adjusted Cox hazard regression analysis.

Résultats : No deaths were reported during the first seven years after birth in the children born out-of-hospital. The percentage of children with hospital visits due to infection by seven years of age was lower in those born planned out-of-hospital and in the combined planned out-of-hospital and unplanned out-of-hospital group compared to those born in-hospital. Furthermore, the percentage of children with hospital visits and who received disability allowances due to neurological or mental disorders was higher among those born unplanned out-of-hospital and out-of-hospital in total when compared to those born in-hospital. In the multivariable-adjusted Cox proportional hazard regression analysis, the hazard ratio for hospital visits due to asthma and/or allergic diseases (HR 0.84; 95% CI 0.72-0.98) was lower in children born out-of-hospital when compared to those born in-hospital. A similar decreased risk was found due to infections (HR 0.76; 95% CI 0.68-0.84). However, the risk for neurological or mental health disorders was similar between the children born in-hospital and out-of-hospital.

Conclusion : Morbidity related to asthma or allergic diseases and infections by seven years of age appeared to be lower in children born out-of-hospital. Birth out-of-hospital seemed to not be associated with increased risk for neurological morbidity nor early childhood mortality. Our study groups were small and heterogeneous and because of this the results need to be interpreted with caution.

Conclusion (proposition de traduction) : La morbidité liée à l'asthme ou aux maladies allergiques et aux infections à l'âge de sept ans semblait être plus faible chez les enfants nés en dehors de l'hôpital. Les naissances en dehors de l'hôpital ne semblent pas être associées à un risque accru de morbidité neurologique ni de mortalité de la petite enfance. Nos groupes d'étude étaient petits et hétérogènes et pour cette raison, les résultats doivent être interprétés avec prudence.

Prehospital and Disaster Medicine

Blood Glucose Levels Combined with Triage Revised Trauma Score Improve the Outcome Prediction in Adults and in Elderly Patients with Trauma.
Covino M, Zaccaria R, Bocci MG, Carbone L, Torelli E, Fuorlo M, Piccioni A, Santoro M, Sandroni C, Franceschi F. | Prehosp Disaster Med.  2021 Apr;36(2):175-182
Keywords: Revised Trauma Score; blood glucose level; elderly; trauma triage.

Original Research

Introduction : This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma.

Méthode : This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient's death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score.

Résultats : Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001.

Conclusion : Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years.

Conclusion (proposition de traduction) : Les résultats ont montré que le glucose pouvait être utilisé efficacement lors du triage au service des urgences pour la stratification du risque de décès au service des urgences et à l'admission des patients traumatisés en unité de soins intensifs, et il pourrait réduire le sous-triage d'environ 20 % par rapport au score de traumatologie révisé du triage. En comparant l'aire sous la courbe ROC, le score de glucose combiné au Revised Trauma Score est significativement plus performant que le Triage Revised Trauma Score et donne de meilleurs résultats chez les patients ≥ 65 ans.

Commentaire : Courbe ROC et aire sous la courbe ROC (AUC)  .
L'aire sous la courbe ROC (ou Area Under the Curve, AUC) peut être interprétée comme la probabilité que, parmi deux sujets choisis au hasard, un malade et un non-malade, la valeur du marqueur soit plus élevée pour le malade que pour le non-malade. Par conséquent, une AUC de 0,5 (50 %) indique que le marqueur est non-informatif. Une augmentation de l'AUC indique une amélioration des capacités discriminatoires, avec un maximum de 1,0 (100 %).

Bag-Valve-Mask versus Laryngeal Mask Airway Ventilation in Cardiopulmonary Resuscitation with Continuous Compressions: A Simulation Study.
Dundar ZD, Ayranci MK, Kocak S, Girisgin AS. | Prehosp Disaster Med.  2021 Apr;36(2):189-194
Keywords: bag-valve-mask; cardiopulmonary resuscitation; continuous compression; laryngeal mask airway; ventilation.

Original Research

Introduction : The 2017 International Liaison Committee on Resuscitation (ILCOR) guideline recommends that Emergency Medical Service (EMS) providers can perform cardiopulmonary resuscitation (CPR) with synchronous or asynchronous ventilation until an advanced airway has been placed. In the current literature, limited data on CPR performed with continuous compressions and asynchronous ventilation with bag-valve-mask (BVM) are available. Study objective: In this study, researchers aimed to compare the effectiveness of asynchronous BVM and laryngeal mask airway (LMA) ventilation during CPR with continuous chest compressions.

Méthode : Emergency medicine residents and interns were included in the study. The participants were randomly assigned to resuscitation teams with two rescuers. The cross-over simulation study was conducted on two CPR scenarios: asynchronous ventilation via BVM during a continuous chest compression and asynchronous ventilation via LMA during a continuous chest compression in cardiac arrest patient with asystole. The primary endpoints were the ventilation-related measurements.

Résultats : A total of 92 volunteers were included in the study and 46 CPRs were performed in each group. The mean rate of ventilations of the LMA group was significantly higher than that of the BVM group (13.7 [11.7-15.7] versus 8.9 [7.5-10.3] breaths/minute; P <.001). The mean volume of ventilations of the LMA group was significantly higher than that of the BVM group (358.4 [342.3-374.4] ml versus 321.5 [303.9-339.0] ml; P = .002). The mean minute ventilation volume of the LMA group was significantly higher than that of the BVM group (4.88 [4.15-5.61] versus 2.99 [2.41-3.57] L/minute; P <.001). Ventilations exceeding the maximum volume limit occurred in two (4.3%) CPRs in the BVM group and in 11 (23.9%) CPRs in the LMA group (P = .008).

Conclusion : The results of this study show that asynchronous BVM ventilation with continuous chest compressions is a reliable and effective strategy during CPR under simulation conditions. The clinical impact of these findings in actual cardiac arrest patients should be evaluated with further studies at real-life scenes.

Conclusion (proposition de traduction) : Les résultats de cette étude montrent que la ventilation asynchrone à l'insufflateur manuel avec compressions thoraciques continues est une stratégie fiable et efficace pendant la RCP dans des conditions de simulation. L'impact clinique de ces résultats chez les patients atteints d'un arrêt cardiaque doit être évalué par des études complémentaires sur des scènes de la vie réelle.

Commentaire : Insufflateur manuel ou ballon autoremplisseur à valve unidirectionnelle (connu sous le sigle BAVU).

Prehospital Emergency Care

Clinical Characteristics of Patients Undergoing Needle Thoracostomy in a Canadian Helicopter Emergency Medical Service.
Newton G, Reay G, Laing CM, King-Shier K. | Prehosp Emerg Care.  2021 Apr 19:1-12
Keywords: air ambulance; needle decompression; pneumothorax; prehospital; thoracostomy.


Introduction : Needle thoracostomy (NT) can be a life-saving procedure when used to treat tension pneumothorax. However, there is some question regarding the efficacy of NT in the prehospital setting. Failure to treat tension pneumothorax in a helicopter emergency medical service (HEMS) setting may prove especially deleterious to the patient due to gas expansion with increasing altitude. This study's objective was to identify the characteristics of patients treated with NT in a Canadian HEMS setting and the factors that may influence outcomes following NT use.

Méthode : This was a retrospective chart review of prehospital records from a Canadian HEMS service. Patients aged 18 years and older who underwent at least one NT attempt using a 14-gauge 8.3 cm needle from 2012 to 2018 were identified. Charts were reviewed to collect demographic data, NT procedural characteristics, vital signs, and clinical response metrics. Descriptive statistics were used to characterize the study sample and overall event characteristics. Binary logistic regression was performed to identify variables associated with a clinical response to the initial NT treatment.

Résultats : 163 patients (1.3%) of 12,407 patients attended received NT. A positive clinical response to NT was recorded in 37% (n = 77) of the total events (n = 208), the most common of which was an improvement in blood pressure (BP) (18.8%, n = 39). Initial NT was associated with a low likelihood of clinical improvement in patients presenting with blunt trauma (OR = 0.18; p = .021; 95% CI [.04, .77]), CPR prior to NT (OR = 0.14; p = .02; 95% CI [.03, .73]), or in those who received bilateral NT treatment (OR = 0.13; p < .01; 95% CI [.05, .37]). A pretreatment BP < 90 mmHg was predictive of a positive clinical response to initial NT (OR = 3.33; p = .04; 95% CI [1.09, 10.20]).

Conclusion : Only a small portion of patients in the setting of a Canadian HEMS service were treated with NT. Patients most likely to receive NT were males who had suffered blunt trauma. NT may have questionable benefit for patients presenting with blunt trauma, in cardiac arrest, or requiring bilateral NT.

Conclusion (proposition de traduction) : Seule une petite partie des patients dans le cadre d'un service médical d'urgence héliporté canadien a été traitée par thoracostomie à l'aiguille. Les patients les plus susceptibles de bénéficier d'une thoracostomie à l'aiguille étaient des hommes qui avaient subi un traumatime fermé. La thoracostomie à l'aiguille peut avoir des avantages discutables pour les patients présentant un traumatisme fermé, un arrêt cardiaque ou nécessitant une thoracostomie bilatérale à l'aiguille.


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, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. | Resuscitation.  2021 Apr;161:220-269
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

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.

Commentaire : Algorithme de soins post-réanimation.

Evidence update for the treatment of anaphylaxis.
Dodd A, Hughes A, Sargant N, Whyte AF, Soar J, Turner PJ. | Resuscitation.  2021 Apr 23;163:86-96
DOI:  | Télécharger l'article au format  
Keywords: Adrenaline; Anaphylaxis; Antihistamine; Corticosteroids; Resuscitation.


Editorial : The Resuscitation Council UK has updated its Guideline for healthcare providers on the Emergency treatment of anaphylaxis. As part of this process, an evidence review was undertaken by the Guideline Working Group, using an internationally-accepted approach for adoption, adaptation, and de novo guideline development based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework, referred to as GRADE-ADOLOPMENT. A number of significant changes have been made, which will be reflected in the updated Guideline. These include: emphasis on repeating intramuscular adrenaline doses after 5 min if symptoms of anaphylaxis do not resolve; corticosteroids (e.g. hydrocortisone) no longer being routinely recommended for the emergency treatment of anaphylaxis; interventions for reactions which are refractory to initial treatment with adrenaline; a recommendation against the use of antihistamines for the acute management of anaphylaxis; and guidance relating to the duration of observation following anaphylaxis, and timing of discharge.

Conclusion : We used the GRADE-ADOLOPMENT process to evaluate current evidence for the emergency treatment of anaphylaxis, incorporating a public consultation, to inform the updated 2021 Resuscitation Council UK Anaphylaxis Guideline.

Conclusion (proposition de traduction) : Nous avons utilisé le processus GRADE-ADOLOPMENT pour évaluer les données probantes actuelles pour le traitement d'urgence de l'anaphylaxie, en intégrant une consultation publique, pour informer la mise à jour de la ligne directrice sur l'anaphylaxie du 2021 Resuscitation Council UK.

European Resuscitation Council Guidelines 2021: Executive summary European Resuscitation Council Guidelines 2021: Executive summary.
Olasveengen T, Soar J, Lott C, Van de Voorde P, Madar J, Zideman D, Mentzelopoulos S, Bossaert L, Greif R, Monsieurs K, Svavarsdóttir H, Nolan JP; European Resuscitation Council Guideline Collaborators. | Resuscitation.  2021 Apr;161:1-60
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

Commentaire : Algorithme de réanimation cardiopulmonaire médicalisé.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe.
Gräsner JT, Herlitz J, Tjelmeland IBM, Wnent J, Masterson S, Lilja G, Bein B, Böttiger BW, Rosell-Ortiz F, Nolan JP, Bossaert L, Perkins GD. | Resuscitation.  2021 Apr;161:61-79
DOI:  | Télécharger l'article au format  
Keywords: Cardiac arrest; Epidemiology; Incidence of cardiac arrest

European Resuscitation Council Guidelines for Resuscitation

Editorial : In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Commentaire : Résumé infographique de l'épidémiologie

European Resuscitation Council Guidelines 2021: Systems saving lives.
Semeraro F, Greif R, Böttiger BW, Burkart R, Cimpoesu D, Georgiou M, Yeung J, Lippert F, S Lockey A, Olasveengen TM, Ristagno G, Schlieber J, Schnaubelt S, Scapigliati A, G Monsieurs K. | Resuscitation.  2021 Apr;161:80-97
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

Commentaire : Résumé infographique du système qui sauve des vies

European Resuscitation Council Guidelines 2021: Basic Life Support.
Olasveengen TM, Semeraro F, Ristagno G, Castren M, Handley A, Kuzovlev A, Monsieurs KG, Raffay V, Smyth M, Soar J, Svavarsdottir H, Perkins GD. | Resuscitation.  2021 Apr;161:98-114
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : Life support guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include cardiac arrest recognition, alerting emergency services, chest compressions, rescue breaths, automated external defibrillation (AED), CPR quality measurement, new technologies, safety, and foreign body airway obstruction.

Commentaire : Algorithme des gestes élémentaires de survie

European Resuscitation Council Guidelines 2021: Adult advanced life support.
Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. | Resuscitation.  2021 Apr;161:115-151
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Commentaire : Résumé de la réanimation cardio-pulmonaire médicalisée

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances.
Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J; ERC Special Circumstances Writing Group Collaborators. | Resuscitation.  2021 Apr;161:152-219
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Commentaire : Résumé infographique des circonstances spéciales

European Resuscitation Council Guidelines 2021: First aid.
Zideman DA, Singletary EM, Borra V, Cassan P, Cimpoesu CD, De Buck E, Djärv T, Handley AJ, Klaassen B, Meyran D, Oliver E, Poole K. | Resuscitation.  2021 Apr;161:270-290
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Commentaire : Résumé infographique des messages clés relatifs aux premiers secours.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth.
Madar J, Roehr CC, Ainsworth S, Ersdal H, Morley C, Rüdiger M, Skåre C, Szczapa T, Te Pas A, Trevisanuto D, Urlesberger B, Wilkinson D, Wyllie JP. | Resuscitation.  2021 Apr;161:291-326
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Commentaire : NLS algorithme.

European Resuscitation Council Guidelines 2021: Paediatric Life Support.
Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. | Resuscitation.  2021 Apr;161:327-387
DOI:  | Télécharger l'article au format  
Keywords: Advanced life support; Bag-mask ventilation; Basic life support; CPR; Cardiac arrest; Circulatory failure; Defibrillation; Infant; Oxygen; Paediatric; Pediatric; Respiratory failure; Resuscitation child; Shock.

European Resuscitation Council Guidelines for Resuscitation

Editorial : These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Commentaire : Algorithme de réanimation cardiopulmonaire en pédiatrie.

European Resuscitation Council Guidelines 2021: Education for resuscitation.
Greif R, Lockey A, Breckwoldt J, Carmona F, Conaghan P, Kuzovlev A, Pflanzl-Knizacek L, Sari F, Shammet S, Scapigliati A, Turner N, Yeung J, Monsieurs KG. | Resuscitation.  2021 Apr;161:388-407
DOI:  | Télécharger l'article au format  
Keywords: Basic and advanced life support; Education, Simulation; Faculty development; Resuscitation; Technology enhanced learning.

European Resuscitation Council Guidelines for Resuscitation

Editorial : These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

Commentaire : Résumé de l'éducation infographique.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions.
Mentzelopoulos SD, Couper K, Voorde PV, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. | Resuscitation.  2021 Apr;161:408-432
DOI:  | Télécharger l'article au format  
Keywords: Aucun

European Resuscitation Council Guidelines for Resuscitation

Editorial : These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Commentaire : Messages clés relatifs à l'éthique dans les lignes directrices 2021.

A systematic review and meta-analysis of the effect of routine early angiography in patients with return of spontaneous circulation after Out-of-Hospital Cardiac Arrest.
Nikolaou NI, Netherton S, Welsford M, Drennan IR, Nation K, Belley-Cote E, Torabi N, Morrison LJ; International Liaison Committee on Resuscitation Advanced Life Support Task Force (ILCOR). | Resuscitation.  2021 Apr 7;163:28-48
Keywords: Cardiac arrest; Coronary angiography; Percutaneous coronary intervention; Post resuscitation care; Return of spontaneous circulation; ST-segment-elevation; Shockable; Without-ST-segment elevation.


Introduction : Early coronary angiography (CAG) has been reported in individual studies and systematic reviews to significantly improve outcomes of patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA).

Méthode : We undertook a systematic review and meta-analysis to evaluate the impact of early CAG on key clinical outcomes in comatose patients after ROSC following out-of-hospital CA of presumed cardiac origin. We searched the PubMED, EMBASE, CINAHL, ERIC and Cochrane Central Register of Controlled Trials databases from 1990 until April 2020. Eligible studies compared patients undergoing early CAG to patients with late or no CAG. When randomized controlled trials (RCTs) existed for a specific outcome, we used their results to estimate the effect of the intervention. In the absence of randomized data, we used observational data. We excluded studies at high risk of bias according to the Robins-I tool from the meta-analysis. The GRADE system was used to assess certainty of evidence at an outcome level.

Résultats : Of 3738 citations screened, 3 randomized trials and 41 observational studies were eligible for inclusion. Evidence certainty across all outcomes for the RCTs was assessed as low. Randomized data showed no benefit from early as opposed to late CAG across all critical outcomes of survival and survival with favourable neurologic outcome for undifferentiated patients and for patient subgroups without ST-segment-elevation on post ROSC ECG and shockable initial rhythm.

Conclusion : These results do not support routine early CAG in undifferentiated comatose patients and patients without STE on post ROSC ECG after OHCA.

Conclusion (proposition de traduction) : Ces résultats ne sont pas en faveur de l'angiographie coronaire précoce systématique chez les patients comateux indifférenciés et les patients sans élévation du segment ST sur l'ECG après un retour à une activité circulatoire spontanée (RACS) dans l'arrêt cardiaque extrahospitalier.

Evidence update for the treatment of anaphylaxis.
Dodd A, Hughes A, Sargant N, Whyte AF, Soar J, Turner PJ. | Resuscitation.  2021 Apr 23;163:86-96
DOI:  | Télécharger l'article au format  
Keywords: Adrenaline; Anaphylaxis; Antihistamine; Corticosteroids; Resuscitation.


Editorial : The Resuscitation Council UK has updated its Guideline for healthcare providers on the Emergency treatment of anaphylaxis. As part of this process, an evidence review was undertaken by the Guideline Working Group, using an internationally-accepted approach for adoption, adaptation, and de novo guideline development based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework, referred to as GRADE-ADOLOPMENT. A number of significant changes have been made, which will be reflected in the updated Guideline. These include: emphasis on repeating intramuscular adrenaline doses after 5 min if symptoms of anaphylaxis do not resolve; corticosteroids (e.g. hydrocortisone) no longer being routinely recommended for the emergency treatment of anaphylaxis; interventions for reactions which are refractory to initial treatment with adrenaline; a recommendation against the use of antihistamines for the acute management of anaphylaxis; and guidance relating to the duration of observation following anaphylaxis, and timing of discharge.

Conclusion : 1. Adrenaline is recommend as the first line treatment for anaphylaxis. 2. Adrenaline should be administered early once symptoms of anaphylaxis have been recognized or suspected. 3. The intramuscular (IM) route is recommended for initial adrenaline treatment for anaphylaxis. The intravenous (IV) route is not recommended for initial management of anaphylaxis, except in the perioperative setting (as an alternative to IM adrenaline) by those skilled and experienced in its use.  In such circumstances, adrenaline should preferably be administered as an IV infusion and not as a bolus dose. Titrate the administration of adrenaline (by any route) against clinical response. 4. Subsequent doses of adrenaline should be given every 5min, titrated to clinical response, in patients whose symptoms are refractory to initial treatment. Where respiratory and/or cardiovascular features of anaphylaxis persist despite 2 appropriate doses of adrenaline (administered by IM or IV route), seek urgent expert help (e.g. from experienced critical care clinicians) to establish an intravenous adrenaline infusion to treat refractory anaphylaxis. Low dose intravenous adrenaline infusions appear to be effective and safe to treat refractory anaphylaxis. 5. In the presence of anaphylaxis with haemodynamic compromise, intravenous (IV) crystalloid fluids should be infused. For anaphylaxis refractory to initial treatment with adrenaline, an IV fluid bolus (crystalloid) is recommended as an adjunct to improve drug distribution. 6. We suggest that antihistamines are not used as part of the initial emergency treatment for anaphylaxis - antihistamines have no role in treating respiratory or cardio- vascular symptoms of anaphylaxis. We suggest antihistamines are used to treat skin symptoms which often occur as part of allergic reactions including anaphylaxis - their use must not delay management of respiratory or cardiovascular symptoms of anaphylaxis. 7. We suggest against the routine use of corticosteroids to treat anaphylaxis. We suggest corticosteroids may be used as a third line intervention to treat underlying asthma or shock. 8. Beta-2 agonists (such as salbutamol) may be useful as an adjunct treatment for lower respiratory symptoms caused by anaphylaxis, following initial treatment with IM adrenaline.

Conclusion (proposition de traduction) : 1. L'adrénaline est recommandée comme traitement de première intention de l'anaphylaxie. 2. L'adrénaline doit être administrée tôt une fois que les symptômes d'anaphylaxie ont été reconnus ou suspectés. 3. La voie IM est recommandée pour le traitement initial à l'adrénaline de l'anaphylaxie. La voie IV n'est pas recommandée pour la prise en charge initiale de l'anaphylaxie, sauf en contexte périopératoire (comme alternative à l'adrénaline IM) par les personnes qualifiées et expérimentées dans son utilisation. Dans de telles circonstances, l'adrénaline doit de préférence être administrée en perfusion IV et non en bolus. Titrer l'administration d'adrénaline (par n'importe quelle voie) en fonction de la réponse clinique. 4. Les doses suivantes d'adrénaline doivent être administrées toutes les 5 minutes, en fonction de la réponse clinique, chez les patients dont les symptômes sont réfractaires au traitement initial. Lorsque les caractéristiques respiratoires et/ou cardiovasculaires de l'anaphylaxie persistent malgré 2 doses appropriées d'adrénaline (administrées par voie IM ou IV), demander l'aide urgente d'un expert pour établir une perfusion d'adrénaline intraveineuse pour traiter l'anaphylaxie réfractaire. Les perfusions d'adrénaline intraveineuse à faible dose semblent être efficaces et sûres pour traiter l'anaphylaxie réfractaire. 5. En présence d'anaphylaxie avec compromis hémodynamique, des liquides cristalloïdes IV doivent être perfusés. Pour l'anaphylaxie réfractaire au traitement initial par adrénaline, un bolus de liquide IV (cristalloïde) est recommandé en complément pour améliorer la distribution du médicament. 6. Nous suggérons que les antihistaminiques ne soient pas utilisés dans le cadre du traitement d'urgence initial de l'anaphylaxie - les antihistaminiques n'ont aucun rôle dans le traitement des symptômes respiratoires ou cardiovasculaires de l'anaphylaxie. Nous suggérons que les antihistaminiques soient utilisés pour traiter les symptômes cutanés qui surviennent souvent dans le cadre de réactions allergiques, y compris l'anaphylaxie - leur utilisation ne doit pas retarder la gestion des symptômes respiratoires ou cardiovasculaires de l'anaphylaxie. 7. Nous déconseillons l'utilisation systématique de corticostéroïdes pour traiter l'anaphylaxie. Nous suggérons que les corticostéroïdes puissent être utilisés comme intervention de troisième intention pour traiter l'asthme ou le choc sous-jacent.

Commentaire : Suite de la traduction :
8. Les bêta-2 agonistes (tels que le salbutamol) peuvent être utiles comme traitement d'appoint des symptômes des voies respiratoires inférieures provoqués par l'anaphylaxie, après un traitement initial par adrénaline IM. En présence de symptômes respiratoires persistants dans l'anaphylaxie, les bêta-2 agonistes (qu'ils soient inhalés ou parentéraux) ne doivent pas être utilisés comme alternative à un traitement parentéral ultérieur par adrénaline.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Point-of-care ultrasound of the heart and lungs in patients with respiratory failure: a pragmatic randomized controlled multicenter trial.
Riishede M, Lassen AT, Baatrup G, Pietersen PI, Jacobsen N, Jeschke KN, Laursen CB. | Scand J Trauma Resusc Emerg Med.  2021 Apr 26;29(1):60
DOI:  | Télécharger l'article au format  
Keywords: Diagnostic accuracy; Emergency department; High acuity; Point–of-care ultrasound; Respiratory disease; Ultrasound.

Original research

Introduction : Point-of-care ultrasound is a focus oriented tool for differentiating among cardiopulmonary diseases. Its value in the hands of emergency physicians, with various ultrasound experience, remains uncertain. We tested the hypothesis that, in emergency department patients with signs of respiratory failure, a point-of-care cardiopulmonary ultrasound along with standard clinical examination, performed by emergency physicians with various ultrasound experience would increase the proportion of patients with presumptive diagnoses in agreement with final diagnoses at four hours after admission compared to standard clinical examination alone.

Méthode : In this prospective multicenter superiority trial in Danish emergency departments we randomly assigned patients presenting with acute signs of respiratory failure to intervention or control in a 1:1 ratio by block randomization. Patients received point-of-care cardiopulmonary ultrasound examination within four hours from admission. Ultrasound results were unblinded for the treating emergency physician in the intervention group. Final diagnoses and treatment were determined by blinded review of the medical record after the patients´ discharge.

Résultats : From October 9, 2015 to April 5, 2017, we randomized 218 patients and included 211 in the final analyses. At four hours we found; no change in the proportion of patients with presumptive diagnoses in agreement with final diagnoses; intervention 79·25% (95% CI 70·3-86·0), control 77·1% (95% CI 68·0-84·3), an increased proportion of appropriate treatment prescribed; intervention 79·3% (95% CI 70·3-86·0), control 65·7% (95% CI 56·0-74·3) and of patients who spent less than 1 day in hospital; intervention n = 42 (39·6%, 25·8 38·4), control n = 25 (23·8%, 16·5-33·0). No adverse events were reported.

Conclusion : Focused cardiopulmonary ultrasound added to standard clinical examination in patients with signs of respiratory failure had no impact on the diagnostic accuracy, but significantly increased the proportion of appropriate treatment prescribed and the proportion of patients who spent less than 1 day in hospital.

Conclusion (proposition de traduction) : L'échographie cardiopulmonaire ajoutée à l'examen clinique standard chez les patients présentant des signes d'insuffisance respiratoire n'a eu aucun impact sur la précision du diagnostic, mais a significativement augmenté la proportion de traitements appropriés prescrits et la proportion de patients ayant passé moins d'un jour à l'hôpital.

Falls in ED patients: do elderly patients on direct oral anticoagulants bleed less than those on vitamin K antagonists?.
Müller M, Chanias I, Nagler M, Exadaktylos AK, Sauter TC. | Scand J Trauma Resusc Emerg Med.  2021 Apr 6;29(1):56
DOI:  | Télécharger l'article au format  
Keywords: Anticoagulants; Bleeding; Direct oral anticoagulants; Fall; Intra cranial bleeding; Syncope; Vitamin K antagonist.

Original research

Introduction : Falls from standing are common in the elderly and are associated with a significant risk of bleeding. We have compared the proportional incidence of bleeding complications in patients on either direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA).

Méthode : Our retrospective cohort study compared elderly patients (≥65 years) on DOAC or VKA oral anticoagulation who presented at the study site - a Swiss university emergency department (ED) - between 01.06.2012 and 01.07.2017 after a fall. The outcomes were the proportional incidence of any bleeding complication and its components (e.g. intracranial haemorrhage), as well as procedural and clinical parameters (length of hospital stay, admission to intensive care unit, in-hospital-mortality). Uni- and multivariable analyses were used to compare the studied outcomes.

Résultats : In total, 1447 anticoagulated patients were included - on either VKA (n = 1021) or DOAC (n = 426). There were relatively more bleeding complications in the VKA group (n = 237, 23.2%) than in the DOAC group (n = 69, 16.2%, p = 0.003). The difference persisted in multivariable analysis with 0.7-fold (95% CI: 0.5-0.9, p = 0.014) lower odds for patients under DOAC than under VKA for presenting with any bleeding complications, and 0.6-fold (95% 0.4-0.9, p = 0.013) lower odds for presenting with intracranial haemorrhage. There were no significant differences in the other studied outcomes.

Conclusion : Among elderly, anticoagulated patients who had fallen from standing, those under DOACs had a lower proportional incidence of bleeding complications in general and an even lower incidence of intracranial haemorrhage than in patients under VKAs.

Conclusion (proposition de traduction) : Parmi les patients âgés sous anticoagulants qui étaient tombés de leur hauteur, ceux sous AOD avaient une incidence proportionnelle plus faible de complications hémorragiques en général et une incidence encore plus faible d'hémorragie intracrânienne que chez les patients sous AVK.


Evaluation of the Initiation Timing of Hydrocortisone in Adult Patients With Septic Shock.
Sacha GL, Chen AY, Palm NM, Duggal A. | Shock.  2021 Apr 1;55(4):488-49
Keywords: Aucun

Clinical Science Aspects

Introduction : Clinical studies evaluating the use of hydrocortisone in patients with septic shock are heterogeneous in design with conflicting results. The appropriate time in which to initiate hydrocortisone after shock onset is unknown. This study sought to compare clinical outcomes including vasopressor duration and mortality in patients with septic shock who received hydrocortisone based on timing of initiation after shock onset.

Méthode : Retrospective cohort study of patients between 2011 and 2017 admitted to 10 medical, surgical, and neurosciences intensive care units (ICUs) at a large, tertiary care academic medical center. Adult patients with vasopressor-dependent septic shock who received hydrocortisone were included. Patients were divided into five timing cohorts based on time after shock onset: 0-6, 6-12, 12-24, 24-48, or >48 h. The primary outcome was days alive and free from vasopressors.

Résultats : One thousand four hundred seventy patients were included: 567 (38.6%) received hydrocortisone between 0 and 6 h, 231 (15.7%) 6 and 12 h, 260 (17.7%) 12 and 24 h, 195 (13.3%) 24 and 48 h, and 217 (14.8%) >48 h after shock onset. Patients who received hydrocortisone earlier were sicker at baseline with higher APACHE III scores, lactate concentrations, and norepinephrine requirements. On univariate analysis, days alive and free from vasopressors did not significantly differ amongst the timing groups (median 3.3 days for 0-6 h; 1.9 for 6-12 h; 1.9 for 12-24 h; 0 for 24-48 h; 0 for >48 h; P = 0.39); similarly, ICU mortality did not differ. On multivariable linear regression, timing of hydrocortisone was independently associated with more days alive and free from vasopressors when comparing initiation within 0 to 6 h with >48 h (beta-coefficient 2.8 days [95% CI 0.8-4.7]), 6-12 h with >48 h (2.5 days [95% CI 0.2-4.7]), and 12-24 h with >48 h (2.3 days [95% CI 0.2-4.5]). On multivariable logistic regression, timing of hydrocortisone was associated with reduced ICU mortality when comparing receipt within 0 to 6 h of shock onset to >48 h after shock onset (OR 0.6, 95% CI 0.4-0.8).

Conclusion : In patients in whom hydrocortisone is prescribed for vasopressor-dependent septic shock, timing is crucial and hydrocortisone should be started within the first 12 h after shock onset.

Conclusion (proposition de traduction) : hez les patients chez qui l'hydrocortisone est prescrite pour un choc septique vasopresseur-dépendant, le moment est crucial et l'hydrocortisone doit être débutée dans les 12 premières heures suivant le début du choc.


Early Apixaban Use Following Stroke in Patients With Atrial Fibrillation: Results of the AREST Trial.
Labovitz AJ, Rose DZ, Fradley MG, Meriwether JN, Renati S, Martin R, Kasprowicz T, Murtagh R, Kip K, Beckie TM, Stoddard M, Bozeman AC, McTigue T, Kirby B, Tran N, Burgin WS; AREST Investigators. | Stroke.  2021 Apr;52(4):1164-1171
Keywords: atrial fibrillation; ischemic stroke; safety; secondary prevention; warfarin.

Clinical Trial

Introduction : It is unknown when to start anticoagulation after acute ischemic stroke (AIS) from atrial fibrillation (AF). Early anticoagulation may prevent recurrent infarctions but may provoke hemorrhagic transformation as AF strokes are typically larger and hemorrhagic transformation-prone. Later anticoagulation may prevent hemorrhagic transformation but increases risk of secondary stroke in this time frame. Our aim was to compare early anticoagulation with apixaban in AF patients with stroke or transient ischemic attack (TIA) versus warfarin administration at later intervals.

Méthode : AREST (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was an open-label, randomized controlled trial comparing the safety of early use of apixaban at day 0 to 3 for TIA, day 3 to 5 for small-sized AIS (<1.5 cm), and day 7 to 9 for medium-sized AIS (≥1.5 cm, excluding full cortical territory), to warfarin, in a 1:1 ratio at 1 week post-TIA, or 2 weeks post-AIS.

Résultats : Although AREST ended prematurely after a national guideline focused update recommended direct oral anticoagulants over warfarin for AF, it revealed that apixaban had statistically similar yet generally numerically lower rates of recurrent strokes/TIA (14.6% versus 19.2%, P=0.78), death (4.9% versus 8.5%, P=0.68), fatal strokes (2.4% versus 8.5%, P=0.37), symptomatic hemorrhages (0% versus 2.1%), and the primary composite outcome of fatal stroke, recurrent ischemic stroke, or TIA (17.1% versus 25.5%, P=0.44). One symptomatic intracerebral hemorrhage occurred on warfarin, none on apixaban. Five asymptomatic hemorrhagic transformation occurred in each arm.

Conclusion : Early initiation of anticoagulation after TIA, small-, or medium-sized AIS from AF does not appear to compromise patient safety. Potential efficacy of early initiation of anticoagulation remains to be determined from larger pivotal trials.

Conclusion (proposition de traduction) : L'initiation précoce de l'anticoagulation après un accident ischémique transitoire, un AVC ischémique aigu de petite ou de moyenne taille par fibrillation atriale ne semble pas compromettre la sécurité du patient. L'efficacité potentielle de l'initiation précoce de l'anticoagulation reste à être déterminée à partir d'essais pivots plus importants.

Comparative Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients.
Zhu W, Ye Z, Chen S, Wu D, He J, Dong Y, Lip GYH, Liu C. | Stroke.  2021 Apr;52(4):1225-1233
Keywords: anticoagulants; apixaban; atrial fibrillation; propensity score; safety.

Original Contribution

Introduction : Several observational studies have compared the effect of the non-vitamin K antagonist oral anticoagulants to each other in patients with atrial fibrillation. However, confounding by indication is a major problem when comparing non-vitamin K antagonist oral anticoagulant treatments in some of these studies. This meta-analysis was conducted to compare the effectiveness and safety between non-vitamin K antagonist oral anticoagulant and non-vitamin K antagonist oral anticoagulant by only including the propensity score matching studies.

Méthode : We systematically searched the PubMed and Ovid databases until May 2020 to identify relevant observational studies. Hazard ratios (HRs) and 95% CIs of the reported outcomes were collected and then pooled by a random-effects model complemented with an inverse variance heterogeneity or quality effects model.

Résultats : A total of 17 retrospective cohort studies were included in this meta-analysis. Compared with dabigatran use, the use of rivaroxaban was significantly associated with increased risks of stroke or systemic embolism (HR, 1.16 [95% CI, 1.05-1.29]) and major bleeding (HR, 1.32 [95% CI, 1.24-1.41]), whereas the use of apixaban was associated with a reduced risk of major bleeding (HR, 0.78 [95% CI, 0.67-0.90]) but not stroke or systemic embolism (HR, 0.84 [95% CI, 0.56-1.28]). Compared with rivaroxaban use, the use of apixaban was associated with a decreased risk of major bleeding (HR, 0.63 [95% CI, 0.54-0.73]) but not stroke or systemic embolism (HR, 0.83 [95% CI, 0.67-1.04]). Reanalyses with the inverse variance heterogeneity or quality effects model produced similar results as the random-effects model.

Conclusion : Current observational comparisons with propensity score matching methods suggest that apixaban might be a better choice compared with dabigatran or rivaroxaban for stroke prevention in atrial fibrillation patients.

Conclusion (proposition de traduction) : Les comparaisons observationnelles actuelles avec les méthodes d'appariement du score de propension suggèrent que l'apixaban pourrait être un meilleur choix par rapport au dabigatran ou au rivaroxaban pour la prévention des AVC chez les patients présentant une fibrillation atriale.

Risk Factors for Intracerebral Hemorrhage in Patients With Atrial Fibrillation on Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention.
Paciaroni M, Agnelli G, Giustozzi M and al.. | Stroke.  2021 Apr;52(4):1450-1454
Keywords: atrial fibrillation; cerebral hemorrhage; logistic models; risk factors; white matter.

Brief Reports

Introduction : Clinical trials on stroke prevention in patients with atrial fibrillation have consistently shown clinical benefit from either warfarin or non–vitamin K antagonist oral anticoagulants (NOACs). NOAC-treated patients have consistently reported to be at lower risk for intracerebral hemorrhage (ICH) than warfarin-treated patients. The aims of this prospective, multicenter, multinational, unmatched, case-control study were (1) to investigate for risk factors that could predict ICH occurring in patients with atrial fibrillation during NOAC treatment and (2) to evaluate the role of CHA2DS2-VASc and HAS-BLED scores in the same setting.

Méthode : Cases were consecutive patients with atrial fibrillation who had ICH during NOAC treatment. Controls were consecutive patients with atrial fibrillation who did not have ICH during NOAC treatment. As within the CHA2DS2-VASc and HAS-BLED scores there are some risk factors in common, several multivariable logistic regression models were performed to identify independent prespecified predictors for ICH events.

Résultats : Four hundred nineteen cases (mean age, 78.8±8.1 years) and 1526 controls (mean age, 76.0±10.3 years) were included in the study. From the different models performed, independent predictors of ICH were increasing age, concomitant use of antiplatelet agents, active malignancy, high risk of fall, hyperlipidemia, low clearance of creatinine, peripheral artery disease, and white matter changes. Low doses of NOACs (given according to label or not) and congestive heart failure were inversely associated with the risk of ICH. HAS-BLED and CHA2DS2-VASc scores performed poorly in predicting ICH with areas under the curves of 0.496 (95% CI, 0.468–0.525) and 0.530 (95% CI, 0.500–0.560), respectively.

Conclusion : Several risk factors were associated to ICH in patients treated with NOACs for stroke prevention but not HAS-BLED and CHA2DS2-VASc scores.

Conclusion (proposition de traduction) : Plusieurs facteurs de risque ont été associés à une hémorragie intracérébrale chez les patients traités avec des AOD pour la prévention des accidents vasculaires cérébraux, mais pas les scores HAS-BLED et CHA2DS2-VASc.

Commentaire : Chez les patients atteints de FA traités par AOD, l'âge, l'utilisation concomitante d'antiagrégants plaquettaires, la présence d'un cancer en évolution, un risque élevé de chute, une hyperlipidémie, une faible clairance de la créatinine, une maladie artérielle périphérique et des modifications de la substance blanche à la neuroimagerie ont été associés à un risque accru d'hémorragie intracérébrale. De faibles doses d'AOD (données selon le laboratoire ou non) et l'insuffisance cardiaque congestive étaient inversement associées au risque d'hémorragie intracérébrale. Les scores HAS-BLED et CHA2DS2-VASc se sont révélés médiocres pour la prédiction de l'hémorragie intracérébrale.

The American Journal of Emergency Medicine

Outcomes of new-onset atrial fibrillation in patients with sepsis: A systematic review and meta-analysis of 225,841 patients.
Xiao FP, Chen MY, Wang L, He H, Jia ZQ, Kuai L, Zhou HB, Liu M, Hong M. | Am J Emerg Med.  2021 Apr;42:23-30
Keywords: Arrhythmia; Atrial fibrillation; Meta-analysis; Mortality; Sepsis; Stroke.

Original Contribution

Introduction : The outcomes of new-onset atrial fibrillation (AF) during sepsis are inconsistent and inconclusive. This meta-analysis aims to provide a comprehensive description of the impact of new-onset AF on the prognosis of sepsis.

Méthode : Three electronic databases (PubMed, Embase, and the Cochrane Library) were searched for relevant studies. Meta-analysis was performed using odds ratios (OR) and 95% confidence intervals (CI) as effect measures.

Résultats : A total of 225,841 patients from 13 individual studies were incorporated to the meta-analysis. The summary results revealed that new-onset AF during sepsis was associated with increased odds of in-hospital mortality (pooled OR: 2.09; 95% CI: 1.53-2.86; p < 001), post-discharge mortality (pooled OR: 2.44; 95% CI: 1.81-3.29; p < .001), and stroke (pooled OR:1.88; 95% CI: 1.13-3.14; p < .05). Results also indicated that the incidence of new-onset AF varied from 1.9% for mild sepsis to 46.0% for septic shock. Furthermore, compared to those without AF, people with new-onset AF had longer ICU and hospital stays, as well as a higher recurrence of AF.

Conclusion : New-onset AF is frequently associated with adverse outcomes in patients with sepsis. This is a clinical issue that warrants more attention and should be managed appropriately to prevent poor prognosis.

Conclusion (proposition de traduction) : La FA paroxystique est fréquemment associée à des résultats indésirables chez les patients présentant une septicémie. Il s'agit d'un problème clinique qui mérite plus d'attention et doit être géré de manière appropriée pour éviter un mauvais pronostic.

Glasgow Coma Scale score of more than four on admission predicts in-hospital survival in patients after out-of-hospital cardiac arrest.
Nadolny K, Bujak K, Obremska M, Zysko D, Sterlinski M, Szarpak L, Kubica J, Ladny JR, Gasior M.. | Am J Emerg Med.  2021 Apr;42:90-94
Keywords: Emergency medical team; Glasgow coma scale; Out-of-hospital cardiac arrest; Resuscitation; Return of spontaneous circulation; Sudden cardiac arrest.

Original contribution

Introduction : The aim of the study was to assess the usefulness of the Glasgow Coma Scale (GCS) score assessed by EMS team in predicting survival to hospital discharge in patients after out-of-hospital cardiac arrest (OHCA).

Méthode : Silesian Registry of OHCA (SIL-OHCA) is a prospective, population-based regional registry of OHCAs. All cases of OHCAs between the 1st of January 2018 and the 31st of December 2018 were included. Data were collected by EMS using a paper-based, Utstein-style form. OHCA patients aged ≥18 years, with CPR attempted or continued by EMS, who survived to hospital admission, were included in the current analysis. Patients who did not achieve return of spontaneous circulation (ROSC) in the field, with missing data on GCS after ROSC or survival status at discharge were excluded from the study.

Résultats : Two hundred eighteen patients with OHCA, who achieved ROSC, were included in the present analysis. ROC analysis revealed GCS = 4 as a cut-off value in predicting survival to discharge (AUC 0.735; 95%CI 0.655-0.816; p < 0.001). Variables significantly associated with in-hospital survival were young age, short response time, witnessed event, previous myocardial infarction, chest pain before OHCA, initial shockable rhythm, coronary angiography, and GCS > 4. On the other hand, epinephrine administration, intubation, the need for dispatching two ambulances, and/or a physician-staffed ambulance were associated with a worse prognosis. Multivariable logistic regression analysis revealed GCS > 4 as an independent predictor of in-hospital survival after OHCA (OR of 6.4; 95% CI 2.0-20.3; p < 0.0001). Other independent predictors of survival were the lack of epinephrine administration, previous myocardial infarction, coronary angiography, and the patient's age.

Conclusion : The survival to hospital discharge after OHCA could be predicted by the GCS score on hospital admission.

Conclusion (proposition de traduction) : La survie à la sortie de l'hôpital après un arrêt cardiaque préhospitalier pourrait être prédite par le score de Glasgow à l'admission à l'hôpital.

The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study.
Tekin E, Gur A, Bayraktar M, Ozlu I, Celik BK. | Am J Emerg Med.  2021 Apr;42:103-109
Keywords: Emergency department; Intradermal sterile water injection; Low back pain; Pain management.

Original contribution

Introduction : Low back pain (LBP) is a common musculoskeletal complaint among emergency department (ED) admissions. In this study, it was aimed to compare the effectiveness of systemic treatment with intradermal sterile water injection (ISWI) treatment protocol combined with systemic therapy in patients with LBP of unclear chronicity.

Méthode : A prospective randomized, unblinded, controlled clinical study was conducted on patients admitted to the ED for LBP of unclear chronicity. One hundred twelve patients were randomly assigned to two groups; Group ISWI (n = 56) administered ISWI in the LBP region of patients along with systemic intravenous dexketoprofen therapy, while the other group (n = 56) received only systemic intravenous dexketoprofen therapy. The treatment methods' effectiveness was compared by measuring the pain intensity with the Visual Analog Scale (VAS) at admission, 10th minutes, 20th minutes, 30th minutes, and 24 h later. Also, opioid and analgesic consumptions in 24 h after treatment and patient satisfactions were compared.

Résultats : In the treatment of LBP, ISWI treatment was found to be more effective in relieving pain than systemic therapy alone (p < 0.001). Also, it was observed that opioid consumption in the ED and analgesic consumption within 24 h after treatments were decreased in the ISWI group (p < 0.001). The patient satisfaction in the ED was statistically increased (p < 0.001).

Conclusion : In this unblinded study, ISWI with systemic therapy improved pain outcomes more than systemic therapy alone. Further research is needed to determine whether this was due entirely to placebo effect.

Conclusion (proposition de traduction) : Dans cette étude en simple aveugle, l'injection d'eau stérile intradermique associé à un traitement systémique a plus amélioré les résultats sur la douleur que le traitement systémique seul. Des recherches supplémentaires sont nécessaires pour déterminer si cela était entièrement dû à l'effet placebo.

Commentaire :  Injection intradermique d'eau stérile dans la lombalgie aux urgences

Association between laboratory parameters and CT severity in patients infected with Covid-19: A retrospective, observational study.
Yilmaz A, Sabirli R, Seyit M, Ozen M, Oskay A, Cakmak V, Goren T, Turkcuer I. | Am J Emerg Med.  2021 Apr;42:110-114
DOI:  | Télécharger l'article au format  
Keywords: COVID-19; CT severity; D-dimer; Ferritin.

Original contribution

Introduction : Patients diagnosed with COVID-19 have presented to emergency departments (EDs) worldwide with a wide range of symptoms. In this study we reported the clinical, laboratory and radiological features of the cases diagnosed with COVID-19.

Méthode : This is a single-center, retrospective, descriptive, and observational study. The patients who have admitted to ED between March 11 and May 31, 2020 and diagnosed COVID-19 infection.

Résultats : 130 (73 male and 57 female) patients with COVID-19 polymerase chain reaction (PCR) positive test were included in the study. The average age of the study group was calculated as 52.63 ± 17.95 year. While 15.4% of the patients were asymptomatic, the most common symptom was identified as cough (46.2%), followed by dyspnea (23.1%), fever (17.7%). The computed tomography (CT) severity scores proved significantly higher in the patients with hypertension and coronary artery disease (CAD) than in those without these diseases (p = 0.010 and p = 0.042, respectively). The moderate positive correlation between serum ferritin level and CT severity score is another finding worth noting (rho = 0.530 and p = 0.0001). In a similar vein, the high level of D-dimer in the CT-positive group and its positive moderate correlation with CT severity (rho = 0.375 and p = 0.0001).

Conclusion : In our study, serum ferritin and D-dimer levels were observed to be high in the CT-positive group and have moderate positive correlation with CT severity. We thus argue that D-dimer and ferritin levels measured at the time of admission to the ED can be taken into consideration to predict radiological severity.

Conclusion (proposition de traduction) : Dans notre étude, les taux sériques de ferritine et de D-dimères ont été observés comme étant élevés dans le groupe positif pour la tomodensitométrie et ont une corrélation positive modérée avec la gravité de la tomographie calculée. Nous soutenons donc que les niveaux de D-dimères et de ferritine mesurés au moment de l'admission aux urgences peuvent être pris en compte pour prédire la gravité radiologique.

Tenecteplase for thrombolysis in stroke patients: Systematic review with meta-analysis.
Oliveira M, Fidalgo M, Fontão L, Antão J, Marques S, Afreixo V, Gregório T. | Am J Emerg Med.  2021 Apr;42:31-37
Keywords: Aucun


Introduction : Alteplase is an approved treatment for acute ischemic stroke. Tenecteplase is a genetically modified form of alteplase, with lower cost and a more favourable pharmacokinetic profile allowing bolus injection. The aim of this study was to compare both drugs in adult patients with acute ischemic stroke undergoing thrombolysis.

Méthode : PubMed and CENTRAL were searched for observational and experimental studies comparing both drugs in the population of interest. Additional studies were sought in clinical trial registries and by means of reference check. The efficacy outcomes of interest were functional status at 3 months, recanalization and early neurological improvement (ENI). The safety outcomes of interest were cerebral haemorrhage (ICH), symptomatic ICH and mortality. The effect measure of interest was the absolute risk difference (ARD). Effect measures for each outcome were pooled across studies using random effect models.

Résultats : Eight studies were included, involving 2031 patients. Overall, there were no differences in terms of good or excellent functional outcome (ARR = 0.07 and 0.03 respectively, p > 0.05 for both comparisons) but tenecteplase patients showed higher rates of recanalization (ARD = 0.11, 95% CI [0.01;0.20]) and ENI (ARD = 0.10, 95% CI [0.02;0.17]). There were no differences between groups in terms of ICH (ARD = -0.02, 95% CI [-0.06;0.01]), symptomatic ICH (ARD = 0.00, 95% CI [-0.01;0.02]) or death (ARD = 0.00, 95% CI [-0.03;0.03]).

Conclusion : Tenecteplase is an alternative to alteplase for stroke thrombolysis, with lower cost and a more favourable pharmacokinetic profile.

Conclusion (proposition de traduction) : La ténectéplase est une alternative à l'alteplase dans la thrombolyse de l'AVC, avec un coût moindre et un profil pharmacocinétique plus favorable.

The Journal of Emergency Medicine

Association Between Mode of Transportation and Outcomes in Penetrating Trauma Across Different Prehospital Time Intervals: A Matched Cohort Study.
Colnaric J, Bachir R, El Sayed M. | J Emerg Med.  2021 Apr;60(4):460-470
Keywords: helicopter EMS; mode of transport; penetrating injury; prehospital time; survival.

Selected Topics: Aeromedical Emergencies

Introduction : National guidelines do not provide recommendations concerning optimal dispatch time for helicopter emergency medical services (HEMS) in the United States.
Objectives: This study describes the association between mode of transport (ground vs. helicopter) and survival of patients with penetrating injury across different prehospital time intervals and proposes evidence-based time-related dispatch criteria for HEMS.

Méthode : A retrospective matched cohort study was conducted using the 2015 National Trauma Data Bank. Adult patients (age ≥ 16 years) with penetrating injuries were included. Patients transported via HEMS were selected and matched (1 to 1) for 17 variables to patients transported by ground ambulance (GEMS). Bivariate analyses were conducted to compare characteristics and outcomes (survival to hospital discharge) of patients across different prehospital time intervals.

Résultats : Each group consisted of 949 patients. Overall survival rate was similar in both groups (90.6% for HEMS vs. 87.9% for GEMS, p = 0.054). Patients transported by HEMS had significantly higher survival compared with those transported by GEMS (92.5% for HEMS vs. 87.0% for GEMS, p = 0.002) in the 0-60-min time interval from dispatch to arrival to hospital, and more specifically, in the 31-60-min interval (92.2% vs. 85.2%, p = 0.001). No difference in survival between the two groups was observed in the shortest (0-30 min) or in the extended prehospital time intervals (>60 min).

Conclusion : In adult patients with penetrating trauma, HEMS transport was associated with improved survival in a specific total prehospital time interval (31 to 60 min). This finding can help emergency medicine service administrators develop evidence-based HEMS dispatch criteria.

Conclusion (proposition de traduction) : Chez les patients adultes présentant un traumatisme pénétrant, le transport par un service médical d'urgence héliporté a été associé à une amélioration de la survie dans un intervalle de temps préhospitalier total spécifique (31 à 60 min). Ces résultats peuvent aider les administrateurs des services de médecine d'urgence à élaborer des critères de répartition des services médicaux d'urgence hélicportés fondés sur des données probantes.

The Journal of Trauma and Acute Care Surgery

Tourniquet application by schoolchildren-a randomized crossover study of three commercially available models.
El Bashtaly A, Khalil E, Méthot F, Ledoux-Hutchinson L, Franc JM, Homier V. | J Trauma Acute Care Surg.  2021 Apr 1;90(4):666-672
Keywords: Aucun


Introduction : Life-threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there are no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children.

Méthode : A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10 to 12 years (5th-6th grade). A total of 181 students were invited to participate; 96 obtained parental approval and were recruited. Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, the students selected their favorite model. The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference.

Résultats : The mechanical advantage tourniquet (MAT) outperformed the combat application tourniquet (CAT) and the stretch wrap and tuck tourniquet (SWATT) in terms of success rate (MAT, 67%; CAT, 44%; SWATT, 24%; p < 0.0001), time to application (MAT, 57 seconds; CAT, 80 seconds; SWATT, 90 seconds; p < 0.0001), and preference (MAT, 64%; CAT, 30%; SWATT, 6%; p < 0.0001).

Conclusion : In this study, the MAT performs better in terms of success rate, time to application, and preference when used by school-aged children. This study can be helpful when facilities are purchasing tourniquets for use by students.

Conclusion (proposition de traduction) : Dans cette étude, le Mechanical Advantage Tourniquet (MAT, Pyng Medical, Richmond, BC) fonctionne mieux en termes de taux de réussite, de délai d'application et de préférence lorsqu'il est utilisé par des enfants d'âge scolaire. Cette étude peut être utile lorsque les établissements achètent des garrots à l'usage des élèves.

Commentaire : 

Direct admission versus transfer to a tertiary hospital for definitive management of lower extremity injuries: Systematic review and meta-analysis.
Klifto KM, Azoury SC, Othman S, Klifto CS, Levin LS, Kovach SJ. | J Trauma Acute Care Surg.  2021 Apr 1;90(4):756-765
Keywords: Aucun


Introduction : Delays in definitive management for traumatic lower extremity injuries may result in morbidity. We compared patients with lower extremity injuries directly admitted to a tertiary hospital for definitive care with patients transferred to that hospital following initial treatment elsewhere.

Méthode : PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were searched. Participants sustained lower extremity injuries, definitively treated at a tertiary hospital. Interventions were direct admission to a tertiary hospital for definitive care and patients transferred to that hospital for definitive care after initial management at another location. PRISMA, Cochrane, and grading of recommendations assessment, development and evaluation certainty-evidence guidelines were implemented.

Résultats : Nineteen studies published from 1991 to 2020 compared 3,367 patients directly admitted with 1,046 patients transferred to a hospital for definitive management of lower extremity injuries. Direct admission to a tertiary center, compared with transfer, decreased time to first definitive surgical procedure (standard mean difference, -0.36; 95% confidence interval [CI], -0.57 to -0.16; p = 0.0006; participants, 788; studies, 6; I2 = 34%; high-certainty evidence) and wound infections (risk ratio [RR], 0.38; 95% CI, 0.19-0.77; p = 0.007; participants, 475; studies, 7; I2 = 27%; high-certainty evidence). Risks for diabetic patients (RR, 0.87; 95%CI, 0.77-0.98; p = 0.03; participants, 2,973; studies, 4; I2 = 0%; moderate-certainty evidence), total number of surgeries (standard mean difference, -0.69; 95% CI, -1.02 to -0.36; p < 0.0001; participants, 259; studies, 4; I2 = 35%; moderate-certainty evidence), osteomyelitis (RR, 0.47; 95% CI, 0.28-0.80; p = 0.006; participants, 212; studies, 2; I2 = 0%; moderate-certainty evidence), and total complications (RR, 0.47; 95% CI, 0.32-0.67; p < 0.0001; participants, 729; studies, 5; I2 = 32%; moderate-certainty evidence) are likely lower for direct admits compared with transfers. Direct admission may reduce risks for systemic infections (RR, 0.08; 95% CI, 0.01-0.51; p = 0.007; participants, 198; studies, 2; I2 = 0%; low-certainty evidence), venous thromboembolism (RR, 0.09; 95% CI, 0.01-0.73; p = 0.02; participants, 94; studies, 1; low-certainty evidence), and postoperative bleeding (RR, 0.74; 95% CI, 0.59-0.93; p = 0.01; participants, 2,725; studies, 3; I2 = 0%; low-certainty evidence), compared with transfer.

Conclusion : Earlier admission to a definitive tertiary center avoids morbidity associated with transfer delays.

Conclusion (proposition de traduction) : L'admission anticipée dans un centre tertiaire définitif évite la morbidité associée aux retards de transfert.

The New England Journal of Medicine

Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery.
Sentilhes L, Sénat MV, Le Lous M, Winer N, Rozenberg P, Kayem G, Verspyck E, Fuchs F, Azria E, Gallot D, Korb D, Desbrière R, Le Ray C, Chauleur C, de Marcillac F, Perrotin F, Parant O, Salomon LJ, Gauchotte E, Bretelle F, Sananès N, Bohec C, Mottet N, Legendre G, Letouzey V, Haddad B, Vardon D, Madar H, Mattuizzi A, Daniel V, Regueme S, Roussillon C, Benard A, Georget A, Darsonval A, Deneux-Tharaux C; Groupe de Recherche en Obstétrique et Gynécologie. | N Engl J Med.  2021 Apr 29;384(17):1623-1634
Keywords: Aucun

Original article

Introduction : Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive.

Méthode : In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion.

Résultats : Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P = 0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P = 0.08).

Conclusion : Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes.

Conclusion (proposition de traduction) : Chez les femmes qui ont subi une césarienne et ont reçu des agents utérotoniques prophylactiques, le traitement avec l'acide tranexamique a entraîné une incidence significativement plus faible de perte de sang estimée calculée supérieure à 1000 ml ou de transfusion de globules rouges au deuxième jour par rapport au placebo, mais il n'a pas entraîné une incidence plus faible des résultats cliniques secondaires liés aux hémorragies.

Commentaire : Voir l'analyse de l'article sur le site dela SFAR : Tranexamic acid for the prevention of blood loss after cesarean delivery  . Rédigé par le Dr MP Bonnet, le 5 juillet 2021.

Postpartum Hemorrhage.
Bienstock JL, Eke AC, Hueppchen NA. | N Engl J Med.  2021 Apr 29;384(17):1635-1645
Keywords: Aucun

Review Article

Editorial : Postpartum hemorrhage continues to be the leading preventable cause of maternal illness and death globally. Worldwide, postpartum hemorrhage accounts for 8% of maternal deaths in developed regions of the world and 20% of maternal deaths in developing regions. The United States has one of the highest maternal mortality rates among developed countries, with approximately 11% of all maternal deaths associated with postpartum hemorrhage. During the period from 1993 through 2014, the rate of postpartum hemorrhage (which was defined as blood loss >1000 ml after vaginal or cesarean delivery) requiring a blood transfusion4 increased from approximately 8 cases per 10,000 deliveries to 40 per 10,000 deliveries in the United States.

Conclusion : Postpartum hemorrhage remains a clinically significant cause of maternal complications and death; worldwide, one woman dies from postpartum hemorrhage every 7 minutes. Therefore, prompt identification of patients who are at risk for postpartum hemorrhage, routine active management of the third stage of labor, expeditious assessment of blood loss, appropriate patient monitoring, and management of postpartum hemorrhage are important.

Conclusion (proposition de traduction) : L’hémorragie du post-partum demeure une cause cliniquement significative de complications et de décès maternels ; dans le monde, une femme meurt d’hémorragie du post-partum toutes les 7 minutes. Par conséquent, il est important d’identifier rapidement les patientes à risque d’hémorragie du post-partum, de prendre en charge activement la troisième phase du travail, d’évaluer rapidement les pertes sanguines, d’assurer une surveillance appropriée des patientes et de prendre en charge l’hémorragie du post-partum.

Commentaire : Dépistage, évaluation et prise en charge de l’hémorragie du post-partum (HPP).

Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure.
Schjørring OL, Klitgaard TL, Perner A and al; HOT-ICU Investigators. | N Engl J Med.  2021 Apr 8;384(14):1301-1311
Keywords: Aucun


Introduction : Patients with acute hypoxemic respiratory failure in the intensive care unit (ICU) are treated with supplemental oxygen, but the benefits and harms of different oxygenation targets are unclear. We hypothesized that using a lower target for partial pressure of arterial oxygen (Pao2) would result in lower mortality than using a higher target.

Méthode : In this multicenter trial, we randomly assigned 2928 adult patients who had recently been admitted to the ICU (≤12 hours before randomization) and who were receiving at least 10 liters of oxygen per minute in an open system or had a fraction of inspired oxygen of at least 0.50 in a closed system to receive oxygen therapy targeting a Pao2 of either 60 mm Hg (lower-oxygenation group) or 90 mm Hg (higher-oxygenation group) for a maximum of 90 days. The primary outcome was death within 90 days.

Résultats : At 90 days, 618 of 1441 patients (42.9%) in the lower-oxygenation group and 613 of 1447 patients (42.4%) in the higher-oxygenation group had died (adjusted risk ratio, 1.02; 95% confidence interval, 0.94 to 1.11; P = 0.64). At 90 days, there was no significant between-group difference in the percentage of days that patients were alive without life support or in the percentage of days they were alive after hospital discharge. The percentages of patients who had new episodes of shock, myocardial ischemia, ischemic stroke, or intestinal ischemia were similar in the two groups (P = 0.24).

Conclusion : Among adult patients with acute hypoxemic respiratory failure in the ICU, a lower oxygenation target did not result in lower mortality than a higher target at 90 days.

Conclusion (proposition de traduction) : Chez les patients adultes présentant une insuffisance respiratoire aiguë en hypoxémie en soins intensifs, un objectif d’oxygénation plus faible n’a pas entraîné une mortalité plus faible qu’un objectif plus élevé à 90 jours.

Mois d'avril 2021