Nasal High-flow Oxygen Versus Conventional Oxygen Therapy for Acute Severe Asthma Patients: A Pilot Randomized Controlled Trial.
Ruangsomboon O, Limsuwat C, Praphruetkit N, Monsomboon A, Chakorn T. | Acad Emerg Med. 2021 May;28(5):530-541
DOI: https://doi.org/10.1111/acem.14187  | Télécharger l'article au format  
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : Nasal high flow (NHF) has demonstrated efficacy in relieving dyspnea in various patients with hypoxemic and hypercapnic respiratory failure. It may also reduce dyspnea in patients with acute severe asthma in the emergency department (ED). The aim of the study was to compare the efficacy of NHF with conventional oxygen therapy (COT) in improving dyspnea in acute severe asthma patients with hypoxemia in the ED.

Méthode : This pilot nonblinded randomized controlled trial was conducted involving 37 patients aged ≥ 18 years with acute severe asthma and hypoxemia in the ED of Siriraj Hospital, Bangkok, Thailand (TCTR20180926003). The participants were randomly allocated to receive either COT (n = 18) or NHF (n = 19) for 120 minutes. The primary outcome was comparing the intervention effects on the patients' degree of dyspnea measured using the modified Borg scale (MBS). The secondary outcomes were comparing the interventions based on the numeric rating scale (NRS) of dyspnea, the dyspnea scale assessing accessory muscle use, vital signs, and blood gas results.

Résultats : The intention-to-treat analysis included 37 patients (COT group n = 18 and NHF group n = 19). The baseline mean MBS was 7.8 in both groups. At 120 minutes, the mean (±SD) MBSs in patients receiving COT and NHF were 3.3 (±2.5) and 1.4 (±2.5), respectively (mean difference = 1.9 [95% CI = 0.2 to 3.8], p = 0.043). The trends in NRS and dyspnea score results were similar to those of MBS. Respiratory rates were lower with NHF (mean difference = 4.7 [95% CI = 1.5 to 7.8], p = 0.001). No between- or within-group differences in blood gas results were found.

Conclusion : Nasal high flow reduced the severity of dyspnea and respiratory rate in hypoxemic patients with acute severe asthma in the ED.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit a réduit la gravité de la dyspnée et la fréquence respiratoire chez les patients hypoxémiques souffrant d'asthme aigu sévère aux urgences.

Prehospital Factors Associated With Cervical Spine Injury in Pediatric Blunt Trauma Patients.
Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. | Acad Emerg Med. 2021 May;28(5):553-561
DOI: https://doi.org/10.1111/acem.14176
Keywords: Aucun

ORIGINAL CONTRIBUTION

Introduction : The risk for cervical spine injury (CSI) must be assessed in children who sustain blunt trauma. The Pediatric Emergency Care Applied Research Network (PECARN) retrospectively derived CSI model identifies CSI risk in children based on emergency department (ED) provider observations. The objective of this pilot study was to determine the univariate association of emergency medical services (EMS) provider-observed historical, mechanistic, and physical examination factors with CSI in injured children. Secondarily, we assessed the performance of the previously identified eight PECARN CSI risk factors (PECARN model) based exclusively on EMS provider observation.

Méthode : We conducted a four-center, prospective observational study of children 0 to 17 years old who were transported by EMS after blunt trauma and underwent spinal motion restriction or trauma team activation in the ED. In the ED, EMS providers recorded their observations for a priori determined CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks and test characteristics for the PECARN model based solely on EMS provider observations.

Résultats : Of 1,372 enrolled children, 25 (1.8%) had CSIs. Of the a priori determined CSI risk factors, seven factors had bivariable associations with CSIs: axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. The PECARN model (high-risk motor vehicle collision, diving mechanism, predisposing condition, neck pain, decreased neck mobility, altered mental status, neurologic deficits, and/or substantial torso injury) exhibited the following test characteristics when based on EMS provider observations: sensitivity = 96.0% (95% confidence interval [CI] = 88.3% to 100.0%); negative predictive value = 99.8% (95% CI = 99.4% to 100.0%); specificity = 38.5% (95% CI = 35.9% to 41.1%); and positive predictive value = 2.8% (95% CI = 1.7% to 3.9%).

Conclusion : EMS providers can identify risk factors associated with CSI in injured children who experience blunt trauma. These risk factors may be considered for inclusion in a pediatric CSI decision rule specific to the prehospital setting.

Conclusion (proposition de traduction) : Les fournisseurs de services médicaux d'urgence peuvent identifier les facteurs de risque associés aux lésions de la colonne cervicale chez les enfants blessés qui subissent un traumatisme contondant. Ces facteurs de risque peuvent être envisagés pour l'inclusion dans une règle de décision sur les lésions de la colonne cervicale pédiatrique spécifique au milieu préhospitalier.

Commentaire : Les sept critères qui ressortent sont :
charge (ndlr : compression) axiale, état mental altéré, signes de fracture de la base du crâne, blessure importante au thorax, lésion thoracique importante, détresse respiratoire et diminution de la saturation en oxygène.

Hot Off the Press: Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement.
Morgenstern J, , Heitz C, Bond C, Milne WK. | Acad Emerg Med. 2021 May;28(5):589-592
DOI: https://doi.org/10.1111/acem.14172  | Télécharger l'article au format  
Keywords: Aucun

HOT OFF THE PRESS

Introduction : Early cardiopulmonary resuscitation (CPR) and useof an automated external defibrillator (AED) arekey components of the chain of survival in out-of-hos-pital cardiac arrest (OHCA).1Unfortunately, mostOHCA victims still do not receive bystander CPR,and most individuals trained in basic life support(BLS) do not get opportunities to employ theirskills.2The use of smartphone apps to direct individ-uals trained in BLS to victims of OHCA, as well asto map the location of AEDs, has been suggested asa method to improve OHCA survival rates.3–5Oneprevious study demonstrated an association betweenthe use of an app and the rate of bystander CPR,but there was no statistically significant change in therate of return of spontaneous circulation (ROSC) orsurvival.4A scientific statement from the AmericanHeart Association concludes that “although digitaltools have tremendous poten tial, there is a paucity ofscientific evidence for their effectiveness in improvingECCC [emergency cardiovascular and cerebrovascularcare] to date. Moreover, there is potential for unin-tended consequences, such as incor rect informationbeing provided via mobile apps or social media.

Résultats : Of 4,107 OHCAs in2018, the app was activated 366 times, of which 46patients received treatment from a responder. Treat-ment consisted of CPR in 24 cases, AED use in 18cases, and both in four cases. The rate of ROSCwas higher in patients who received treatment froman app user when compared to those who did notreceive treatment (48% vs. 23%, p < 0.001). Simi-larly, the group that received treatment had highersurvival to hospital discharge (35% vs. 16%,p = 0.004).

Conclusion : Smartphone apps may be a valuable tool in directing emergency medical services to patients in needed, but we lack high-quality evidence that they improve clinical outcomes.

Conclusion (proposition de traduction) : Les applications pour smartphones peuvent être un outil précieux pour diriger les services médicaux d'urgence vers les patients qui en ont besoin, mais nous manquons de preuves de haute qualité qu'elles améliorent les résultats cliniques.

Tranexamic Acid for Traumatic Brain Injury.
Long B, Gottlieb M. | Acad Emerg Med. 2021 May;28(5):595-597
DOI: https://doi.org/10.1111/acem.14163
Keywords: Aucun

THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE

Editorial : Traumatic brain injury (TBI) is a significant cause of morbidity and mortality. In 2014, there were approximately 2.5 million emergency department visits for TBI in the United States, with 56,800 deaths attributed directly to TBI. Among survivors it is estimated millions more live with long-term disability. While one large study demonstrates a mortality benefit (NNT=67) for tranexamic acid (TXA) in multi-system trauma, no primary outcome benefit was demonstrated for TXA in the WOMAN trial of post-partum hemorrhage or in the HALT-IT trial of gastrointestinal bleeding. Here we summarize results from the CRASH-3 trial, as well as from a systematic review combining this trial with data from 6 smaller trials of TXA for TBI.

Conclusion : Based on the above data, TXA does not show any significant benefit in patients with TBI. Administration of TXA after TBI also does not seem to offer any benefit in disability or neurologic functional outcomes. In addition, there may be a small increase in the rate of thromboembolic fatalities associated with this treatment. Therefore, we have assigned a color recommendation of Red (No benefit) to this intervention.

Conclusion (proposition de traduction) : Sur la base des données présentées, l'acide tranexamique ne présente aucun avantage significatif chez les patients présentant une lésion cérébrale traumatique. L'administration d'acide tranexamique après une lésion cérébrale traumatique ne semble pas non plus offrir de bénéfice en termes d'invalidité ou de résultats fonctionnels neurologiques. De plus, il peut y avoir une légère augmentation du taux de décès par accident thromboembolique associés au traitement. Par conséquent, nous avons attribué une recommandation de couleur Rouge (Aucun avantage) à cette intervention.

The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department.
Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, Fuller BM. | Ann Emerg Med. 2021 May;77(5):532-544
DOI: https://doi.org/10.1016/j.annemergmed.2020.10.012  | Télécharger l'article au format  
Keywords: Aucun

AIRWAY/ORIGINAL RESEARCH

Introduction : Awareness with paralysis is a devastating complication for patients receiving mechanical ventilation and risks long-term psychological morbidity. Data from the emergency department (ED) demonstrate a high rate of longer-acting neuromuscular blocking agent use, delayed analgosedation, and a lack of sedation depth monitoring. These practices are discordant with recommendations for preventing awareness with paralysis. Despite this, awareness with paralysis has not been rigorously studied in the ED population. Our objective is to assess the prevalence of awareness with paralysis in ED patients receiving mechanical ventilation.

Méthode : This was a single-center, prospective, observational cohort study on 383 mechanically ventilated ED patients. After extubation, we assessed patients for awareness with paralysis by using the modified Brice questionnaire. Three expert reviewers independently adjudicated awareness with paralysis. We report the prevalence of awareness with paralysis (primary outcome); the secondary outcome was perceived threat, a mediator for development of posttraumatic stress disorder.

Résultats :  The prevalence of awareness with paralysis was 2.6% (10/383). Exposure to rocuronium at any point in the ED was significantly different between patients who experienced awareness with paralysis (70%) versus the rest of the cohort (31.4%) (unadjusted odds ratio 5.1; 95% confidence interval 1.30 to 20.1). Patients experiencing awareness with paralysis had higher mean values on the threat perception scale, denoting a higher degree of perceived threat, compared with patients who did not experience awareness with paralysis (13.4 [SD 7.7] versus 8.5 [SD 6.2]; mean difference 4.9; 95% confidence interval 0.94 to 8.8).

Conclusion : Awareness with paralysis occurs in a significant minority of ED patients who receive mechanical ventilation. Potential associations of awareness with paralysis with ED care and increased perceived threat warrant further evaluation.

Conclusion (proposition de traduction) : La paralysie en pleine conscience survient chez une minorité significative de patients admis aux urgences et bénéficiant d'une ventilation mécanique. Les associations potentielles entre la paralysie en pleine conscience et les soins aux urgences et la perception d'une augmentation de la maladie méritent une évaluation plus approfondie.

Commentaire : Voir l'analyse de l'article sur le site Esanum : Induction séquence rapide pour l’intubation aux urgences : Roc(k) the curare ou Keep the Sux ?  . Rédigé par le Pr Nicolas Peschanski, le 14/12/2022.

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

Research

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

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

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

Conclusion (proposition de traduction) : En France, l'évacuation inter-hospitalière des patients COVID-19 ventilés en soins intensifs ne semble pas augmenter la mortalité et pourrait donc être proposée pour gérer les situations de saturation des services de soins intensifs à l'avenir.

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

Research

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

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

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

Conclusion (proposition de traduction) : Malgré des niveaux de PCT plus élevés dans les exacerbations sévères de BPCO causées par une infection bactérienne, la PCT avait une faible précision pour faire la distinction entre une infection bactérienne et non bactérienne. La procalcitonine pourrait ne pas être suffisante en tant que marqueur autonome pour initier un traitement antibiotique dans ce contexte.

High flow nasal oxygen therapy to avoid invasive mechanical ventilation in SARS-CoV-2 pneumonia: a retrospective study.
Bonnet N, Martin O, Boubaya M, Levy V, Ebstein N, Karoubi P, Tandjaoui-Lambiotte Y, Van Der Meersch G, Oziel J, Soulie M, Ghalayini M, Winchenne A, Zahar JR, Ahmed P, Gaudry S, Cohen Y. | Ann Intensive Care. 2021 Feb 27;11(1):37
DOI: https://doi.org/10.1186/s13613-021-00825-5  | Télécharger l'article au format  
Keywords: Acute respiratory failure; COVID-19; High flow nasal canula; Intensive care unit.

Research

Introduction : The efficacy of high flow nasal canula oxygen therapy (HFNO) to prevent invasive mechanical ventilation (IMV) is not well established in severe coronavirus disease 2019 (COVID-19). The aim of this study was to compare the risk of IMV between two strategies of oxygenation (conventional oxygenation and HFNO) in critically ill COVID 19 patients.

Méthode : This was a bicenter retrospective study which took place in two intensive care units (ICU) of tertiary hospitals in the Paris region from March 11, to May 3, 2020. We enrolled consecutive patients hospitalized for COVID-19 and acute respiratory failure (ARF) who did not receive IMV at ICU admission. The primary outcome was the rate of IMV after ICU admission. Secondary outcomes were death at day 28 and day 60, length of ICU stay and ventilator-free days at day 28. Data from the HFNO group were compared with those from the standard oxygen therapy (SOT) group using weighted propensity score.

Résultats : Among 138 patients who met the inclusion criteria, 62 (45%) were treated with SOT alone, and 76 (55%) with HFNO. In HFNO group, 39/76 (51%) patients received IMV and 46/62 (74%) in SOT group (OR 0.37 [95% CI, 0.18-0.76] p = 0.007). After weighted propensity score, HFNO was still associated with a lower rate of IMV (OR 0.31 [95% CI, 0.14-0.66] p = 0.002). Length of ICU stay and mortality at day 28 and day 60 did not significantly differ between HFNO and SOT groups after weighted propensity score. Ventilator-free days at days 28 was higher in HNFO group (21 days vs 10 days, p = 0.005). In the HFNO group, predictive factors associated with IMV were SAPS2 score (OR 1.13 [95%CI, 1.06-1.20] p = 0.0002) and ROX index > 4.88 (OR 0.23 [95%CI, 0.008-0.64] p = 0.006).

Conclusion : High flow nasal canula oxygen for ARF due to COVID-19 is associated with a lower rate of invasive mechanical ventilation.

Conclusion (proposition de traduction) : L'oxygénothérapie nasale à haut débit (Optiflow) dans l'IRA dans l'infection à COVID-19 est associé à un taux plus faible de ventilation mécanique invasive.

Intensive care management of patients with COVID-19: a practical approach.
Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. | Ann Intensive Care. 2021 Feb 18;11(1):36
DOI: https://doi.org/10.1186/s13613-021-00820-w  | Télécharger l'article au format  
Keywords: COVID-19; Circulatory support and invasive ventilation; Intensive care unit.

Review

Introduction : SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.

Conclusion : COVID-19 is one of the most challenging health emergencies we have faced this century. Health professionals are experiencing very difficult times, with limitations of resources and information, which when available needs to be confirmed before integration into clinical practice. To date, there is no proven specific treatment for the management of COVID-19, although studies with promising results have recently emerged. We know already that the lowest rates of mortality are related to better quality of care. Early diagnosis, application of effective therapies and adequate strategies of clinical stratification are needed for better outcomes in COVID-19 patients. We have learned that COVID-19-related respiratory dysfunction has unique characteristics that require individualized management and are aware of the importance of supporting the patients’ hemodynamics because of the high risk of cardiovascular and renal complications. The long duration of this disease poses a challenge for the health system and health professionals. Validated protocols of care are essential when dealing with millions of affected people in different countries and in different levels of care. Until an effective vaccine is widely available, the world will need to adapt to the reality of a pandemic that has come to change all paradigms of modern medicine.

Conclusion (proposition de traduction) : La COVID-19 est l'une des urgences sanitaires les plus difficiles auxquelles nous ayons été confrontés au cours de ce siècle. Les professionnels de la santé vivent des moments très difficiles, avec des ressources et des informations limitées, qui, lorsqu'elles sont disponibles, doivent être confirmées avant l'intégration dans la pratique clinique. À ce jour, il n'existe aucun traitement spécifique éprouvé pour la gestion de la COVID-19, bien que des études aux résultats prometteurs aient récemment vu le jour. Nous savons déjà que les taux de mortalité les plus bas sont liés à une meilleure qualité des soins. Un diagnostic précoce, l'application de thérapies efficaces et des stratégies adéquates de stratification clinique sont nécessaires pour de meilleurs résultats chez les patients COVID-19. Nous avons appris que le dysfonctionnement respiratoire lié à la COVID-19 présente des caractéristiques uniques qui nécessitent une prise en charge individualisée et sommes conscients de l'importance de soutenir l'hémodynamique des patients en raison du risque élevé de complications cardiovasculaires et rénales. La longue durée de cette maladie constitue un défi pour le système de santé et les professionnels de la santé. Des protocoles de soins validés sont essentiels lorsqu'il s'agit de traiter des millions de personnes affectées dans différents pays et à différents niveaux de soins. Jusqu'à ce qu'un vaccin efficace soit largement disponible, le monde devra s'adapter à la réalité d'une pandémie qui est venue changer tous les paradigmes de la médecine moderne.

Commentaire :  Ventilatory support in COVID-19 patients.
PBW predicted body weight, ARDS acute respiratory distress syndrome, BNP brain natriuretic peptide, CPAP continuous positive airways pressure, CT computerized tomography, CVVH continuous venovenous hemofiltration, CRP C-reactive protein, ECMO extracorporeal membrane oxygenation, LDH lactic dehydrogenase, PEEP positive end-expiratory pressure, PPlat plateau pressure, HNFC high-flow nasal cannulas, NIV non-invasive ventilation, PEEP positive end-expiratory pressure, SpO2 peripheral O2 saturation, PaO2 partial pressure of oxygen, Vt tidal volume, V-V venovenous, V-A venous-arterial

Tidal volume according to the 4-point sealing forces of a bag-valve-mask: an adult respiratory arrest simulator-based prospective, descriptive study.
Uhm D, Kim A. | BMC Emerg Med. 2021 May 1;21(1):57
DOI: https://doi.org/10.1186/s12873-021-00451-1  | Télécharger l'article au format  
Keywords: Bag-valve-mask; Tidal volume; Ventilation.

RESEARCH

Introduction : For adequate ventilation during bag-valve-mask ventilation, rescuers should ensure a proper mask seal using the one-handed or two-handed technique. Little is known about the magnitude of sealing forces of a bag-valve-mask needed for adequate ventilation. This study aimed to explore the effect of the 4-point sealing forces of a bag-valve-mask on tidal volume while using the one-handed technique, focusing on the moderating effect of C length (the distance from the thumb to the index finger in the C shape of the one-hand EC grip).

Méthode : A prospective, descriptive simulation study was conducted. A convenience sample of 125 undergraduate paramedic students from two universities was recruited. A self-reported questionnaire was used to collect subjective variables. Tidal volumes, 4-point sealing forces of the mask, peak pressure, and C length of the C shape in the one-hand EC grip were measured using the mechanical lung model under a simulated adult respiratory arrest. Hierarchical regression analysis was used to determine the moderating effect of C length on tidal volume in bag-valve-mask ventilation.

Résultats : The average C length, peak pressure, and tidal volume were 7.54 (± 1.85) cm, 11.62 (± 5.40) cmH2O, and 321.66 (± 135.18) mL, respectively. The average range of the 4-point sealing forces was 0.03-0.69 N. The apex sealing force was the weakest among the 4-point sealing forces. Hierarchical regression analysis demonstrated that tidal volume accounted for 62.7% of the variance by C length, peak pressure, and apex sealing force during bag-valve-mask ventilation (F = 9.676, p < 0.001). C length moderated the effect of the apex sealing force and peak pressure on the tidal volume, meaning the higher the peak pressure and apex sealing force, the more the tidal volume and the longer the C length.

Conclusion : This first simulation study measuring the 4-point sealing forces during bag-valve-mask ventilation provides effective advice that can be adopted in clinical practice without side effects and underpins the importance of continuous retraining and assessment focused on individual physical characteristics, such as C length and bag-valve-mask sealing forces.

Conclusion (proposition de traduction) : Cette première étude de simulation mesurant les forces d’étanchéité en 4 points lors de la ventilation à l'insufflateur manuel fournit des conseils efficaces applicables en pratique clinique sans effets secondaires et souligne l’importance d’un recyclage continu et d’une évaluation centrée sur les caractéristiques physiques individuelles, telles que la longueur C (distance entre le pouce et l’index en forme de C de la poignée EC d’une main) et les forces d’étanchéité de l'insufflateur manuel.

Commentaire :  Le pouce et index appuient le masque contre le visage et forment un « C ». Les doigts restants saisissent la mâchoire et tirent vers le haut, formant un « E ».

Effect of Phenylephrine Push Before Continuous Infusion Norepinephrine in Patients With Septic Shock.
Hawn JM, Bauer SR, Yerke J, Li M, Wang X, Reddy AJ, Mireles-Cabodevila E, Sacha GL. | Chest. 2021 May;159(5):1875-1883
DOI: https://doi.org/10.1016/j.chest.2020.11.051
Keywords: hemodynamics; sepsis; septic shock; vasopressor.

Research article

Introduction : IV pushes of phenylephrine may be used for patients with septic shock with the intent of rapidly achieving mean arterial pressure (MAP) goals. However, the clinical effectiveness and safety of this approach are unclear.
Research question: In patients with septic shock, is administration of a phenylephrine push before norepinephrine initiation associated with a higher incidence of hemodynamic stability?

Méthode : This retrospective, multicenter cohort study included adult patients with septic shock initiated on norepinephrine. Propensity scores for initial phenylephrine push receipt were generated, and patients receiving an initial phenylephrine push were propensity score-matched 1:2 to those not receiving an initial phenylephrine push. The primary outcome was achievement of hemodynamic stability (defined as maintaining MAP of ≥ 65 mm Hg for at least 6 h without an increase in continuous infusion vasoactive agent dosage) within 3 and 12 h of norepinephrine initiation.

Résultats : Of 1,317 included patients, 181 received an initial phenylephrine push; 141 phenylephrine push patients were matched to 282 patients not receiving a phenylephrine push. More patients who received a phenylephrine push achieved hemodynamic stability at hour 3 than those who did not receive a phenylephrine push (28.4% vs 18.8%; risk difference, 10%; 95% CI, 0.9%-18%). Phenylephrine push receipt was associated independently with hemodynamic stability within 3 h (adjusted OR, 1.8; 95% CI, 1.09-2.97), but not at 12 h (adjusted OR, 1.42; 95% CI, 0.93-2.16). Phenylephrine push receipt was associated independently with higher ICU mortality (adjusted OR, 1.88; 95% CI, 1.1-3.21).

Conclusion : Phenylephrine pushes were associated with a higher incidence of early, but not sustained, hemodynamic stability and were associated independently with higher ICU mortality. Caution is warranted when clinicians are considering the use of phenylephrine pushes in patients with septic shock.

Conclusion (proposition de traduction) : Les bolus de phényléphrine étaient associées à une incidence plus élevée de stabilité hémodynamique précoce, mais non soutenue, et étaient associées indépendamment à une mortalité plus élevée en USI. La prudence est de mise lorsque les cliniciens envisagent d'utiliser des bolus de phényléphrine chez les patients en choc septique.

Non-intubated COVID-19 patients despite high levels of supplemental oxygen.
Chosidow S, Plantefève G, Fraissé M, Mentec H, Cally R, Contou D. | Crit Care. 2021 May 17;25(1):170
DOI: https://doi.org/10.1186/s13054-021-03599-1  | Télécharger l'article au format  
Keywords: ARDS; Acute respiratory failure; COVID-19; ICU; Mechanical ventilation; SARS-CoV-2; Tracheal intubation

Research Letter

Editorial : Many COVID-19 patients with acute hypoxemic respiratory failure may require invasive mechanical ventilation. However, deciding whether and when a patient should be intubated is complex, especially in COVID-19 patients who commonly exhibit severe hypoxemia without clinical signs of respiratory failure (the so-called silent hypoxemia). While clinical signs of respiratory failure seem to be universally acknowledged as intubation criteria, their precise definition is lacking. Some authors have consequently used definite thresholds to guide intubation, but this approach is debated as an individualized strategy may be more adequate. In our ICU, only COVID-19 patients showing persistent signs of respiratory distress associated with profound hypoxemia were intubated.

Conclusion : Despite one hypoxic cardiac arrest (occurring in a patient cared for in the ICU), avoiding intubation might be feasible in some patients with high levels of supplemental oxygen and significant tachypnea. Rather than predefined SpO2 or RR thresholds, clinical acumen appears of paramount importance when deciding to initiate invasive mechanical ventilation.
Our results cannot be generalized to other centers nor to any other respiratory diseases than COVID-19. However, this study strengthens the idea that managing non-intubated patients with respiratory failure is a “clinical art” and that individualized patient care is necessary.

Conclusion (proposition de traduction) : Malgré un arrêt cardiaque hypoxique (survenu chez un patient pris en charge en réanimation), il pourrait être possible d'éviter l'intubation chez certains patients présentant des niveaux élevés d'oxygène d'appoint et une tachypnée importante. Plutôt que des seuils prédéfinis de SpO2 ou de RR, la perspicacité clinique semble d'une importance primordiale lors de la décision d'initier une ventilation mécanique invasive.
Nos résultats ne peuvent être généralisés à d'autres centres ni à aucune autre maladie respiratoire que le COVID-19. Cependant, cette étude renforce l'idée que la prise en charge des patients non intubés souffrant d'insuffisance respiratoire est un «art clinique» et que des soins individualisés sont nécessaires.

Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: do not confound access route and specific drug complications!.
Jouffroy R, Vivien B. | Crit Care. 2021 May 29;25(1):183
DOI: https://doi.org/10.1186/s13054-021-03605-6  | Télécharger l'article au format  
Keywords: Aucun

Letter

Editorial : Owen et al. recently reported in the Journal a low incidence of adverse events associated with peripheral intravenous vasopressor administration in a systematic review and meta-analysis. While the authors must be congratulated for their interesting review on this relevant question, we think that their findings require some caution.

Conclusion : (...) Beyond these limitations, we fully agree with Owen et al. that the adverse events’ incidence and sever- ity after peripheral vasopressors administration are low. Because the rate of adverse events resulting from periph- eral vasopressor administration is not different from those from central lines, there is no reason to delay their use, especially for the sicker patients cared for in the prehospital and/or in-hospital setting.

Conclusion (proposition de traduction) : (...) Au-delà de ces limites, nous sommes entièrement d'accord avec Owen et al. que l'incidence et la gravité des événements indésirables après l'administration de vasopresseurs périphériques sont faibles. Étant donné que le taux d'événements indésirables résultant de l'administration de vasopresseurs périphériques n'est pas différent de ceux des cathéters centraux, il n'y a aucune raison de retarder leur utilisation, en particulier pour les patients les plus malades pris en charge dans le cadre préhospitalier et/ou hospitalier.

Commentaire : Owen VS, Rosgen BK, Cherak SJ, Ferland A, Stelfox HT, Fiest KM, et al. Adverse events associated with administration of vasopressor medica‐ tions through a peripheral intravenous catheter: a systematic review and meta‐analysis. Crit Care. 2021;25:146  .

Clinical outcomes and safety of passive leg raising in out-of-hospital cardiac arrest: a randomized controlled trial.
Azeli Y, Bardají A, Barbería E, Lopez-Madrid V, Bladé-Creixenti J, Fernández-Sender L, Bonet G, Rica E, Álvarez S, Fernández A, Axelsson C, Jiménez-Herrera MF. | Crit Care.. 2021 May 25;25(1):176
DOI: https://doi.org/10.1186/s13054-021-03593-7  | Télécharger l'article au format  
Keywords: Adverse effect; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest; Passive leg raising.

Research

Introduction : There are data suggesting that passive leg raising (PLR) improves hemodynamics during cardiopulmonary resuscitation (CPR). This trial aimed to determine the effectiveness and safety of PLR during CPR in out-of-hospital cardiac arrest (OHCA).

Méthode : We conducted a randomized controlled trial with blinded assessment of the outcomes that assigned adults OHCA to be treated with PLR or in the flat position. The trial was conducted in the Camp de Tarragona region. The main end point was survival to hospital discharge with good neurological outcome defined as cerebral performance category (CPC 1-2). To study possible adverse effects, we assessed the presence of pulmonary complications on the first chest X-rays, brain edema on the computerized tomography (CT) in survivors and brain and lungs weights from autopsies in non-survivors.

Résultats : In total, 588 randomized cases were included, 301 were treated with PLR and 287 were controls. Overall, 67.8% were men and the median age was 72 (IQR 60-82) years. At hospital discharge, 3.3% in the PLR group and 3.5% in the control group were alive with CPC 1-2 (OR 0.9; 95% CI 0.4-2.3, p = 0.91). No significant differences in survival at hospital admission were found in all patients (OR 1.0; 95% CI 0.7-1.6, p = 0.95) and among patients with an initial shockable rhythm (OR 1.7; 95% CI 0.8-3.4, p = 0.15). There were no differences in pulmonary complication rates in chest X-rays [7 (25.9%) vs 5 (17.9%), p = 0.47] and brain edema on CT [5 (29.4%) vs 10 (32.6%), p = 0.84]. There were no differences in lung weight [1223 mg (IQR 909-1500) vs 1239 mg (IQR 900-1507), p = 0.82] or brain weight [1352 mg (IQR 1227-1457) vs 1380 mg (IQR 1255-1470), p = 0.43] among the 106 autopsies performed.

Conclusion : In this trial, PLR during CPR did not improve survival to hospital discharge with CPC 1-2. No evidence of adverse effects has been found.

Conclusion (proposition de traduction) : Dans cet essai, le relèvement passif des jambes pendant la RCP n'a pas amélioré la survie à la sortie de l'hôpital avec CPC 1-2. Aucune preuve d'effets indésirables n'a été trouvée.

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort.
Phillips N, Rasmussen K, McGuire S, Abel K-A, Acworth J, Askin G, et al. | Emerg Med J [Internet]. 2021 May 1;38(5):330 LP – 337
DOI: http://dx.doi.org/10.1136/emermed-2020-210325  | Télécharger l'article au format  
Keywords: Aucun

Original research

Introduction : Clinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population

Méthode : A single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.

Résultats : 1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%).

Conclusion : CSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

Conclusion (proposition de traduction) : Les lésions du rachis cervical étaient rares (0,5 % de notre cohorte), cependant 40 % des enfants ont eu une imagerie. Les règles de décision clinique ont été conçues pour guider les décisions en matière d’imagerie ; si elles étaient appliquées strictement à l’imagerie, les règles de décision clinique évaluées dans la présente étude augmenteraient les taux d’imagerie. La projection des taux varient considérablement selon la règle de décision clinique appliquée. Ces résultats soulignent la nécessité d’une règle de décision clinique validée spécifique à la pédiatrie pour l’imagerie cervicale.

Commentaire : Messages clés
Ce que l’on sait déjà à ce sujet
• Chez l’adulte, des règles de décision clinique bien établies, telles que la règle NEXUS et la règle canadienne C-Spine, peuvent être utilisées pour guider la décision de réalisation d’une imagerie médicale ou non pour une éventuelle lésion cervicale.
• Chez les enfants, la validité des règles de décision clinique principalement dérivées des adultes est limitée et un outil de risque pédiatrique pour les lésions cervicales du &aquo; Pediatric Emergency Care Applied Research Network » (PECARN) est en cours d’élaboration.
• L’efficacité de ces outils chez les enfants, y compris leur impact potentiel sur les taux de réalisation d'une imagerie médicale, n’a pas été suffisamment étudiée.
Ce que cette étude ajoute
• Dans une étude de cohorte prospective monocentrique portant sur 973 enfants âgés de moins de 16 ans présentant une possible lésion du rachis cervical, les lésions confirmées par radiographie du rachis cervical ont été rares (0,5 %).
• L’utilisation des outils NEXUS, canadienne C-Spine et PECARN pour guider la décision de réalisation d’une imagerie ou non pourrait faire passer le taux d’imagerie de base de 41 % à entre 44 % à 68 %.

Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review.
Aziz S, Foster E, Lockey DJ, Christian MD. | Emerg Med J. 2021 May 1;38(5):349 LP – 354
DOI: https://doi.org/10.1136/emermed-2020-210305
Keywords: airway; anaesthesia; helicopter retrieval; pre-hospital; rsi.

Original research

Introduction : This study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician-paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention.

Méthode : A retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician-paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km2.

Résultats : Over 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate 'primary' cricothyroidotomy was performed in 17 patients (23.6%), and 'rescue' cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%).

Conclusion : This study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service.

Conclusion (proposition de traduction) : Cette étude identifie un certain nombre d'indications conduisant à une cricothyroïdotomie d'urgence à la fois comme procédure primaire ou après l'échec de l'intubation. La principale indication de cricothyroïdotomie d'urgence dans notre service était, comme solution de ventilation de secours dans l'échec de la laryngoscopie direct en raison de la présence d'un saignement important au niveau des voies aériennes supérieures. Malgré des niveaux élevés de réussite de la procédure de cricothyroïdotomie, 56,9 % des patients étaient déjà en arrêt cardiaque traumatique pendant la cricothyroïdotomie, et la mortalité globale chez les patients traumatisés nécessitant cette procédure était de 88,9 % dans notre service.

Subarachnoid hemorrhage in the emergency department.
Patel S, Parikh A, Okorie ON. | Int J Emerg Med. 2021;14:31
DOI: https://doi.org/10.1186/s12245-021-00353-w  | Télécharger l'article au format  
Keywords: Aucun

Review

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 fréquemment mal diagnostiquées ; par conséquent, nous pensons 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.

EPICANCER-Cancer Patients Presenting to the Emergency Departments in France: A Prospective Nationwide Study.
Peyrony O, Fontaine JP, Beaune S, Khoury A, Truchot J, Balen F, Vally R, Schmitt J, Ben Hammouda K, Roussel M, Borzymowski C, Vallot C, Sanh V, Azoulay E, Chevret S. | J Clin Med. 2020 May 17;9(5):1505
DOI: https://doi.org/10.3390/jcm9051505  | Télécharger l'article au format  
Keywords: cancer; emergency department; epidemiology.

Article

Introduction : We aimed to estimate the prevalence of cancer patients who presented to Emergency Departments (EDs), report their chief complaint and identify the predictors of 30-day all-cause mortality.

Méthode : We undertook a prospective, cross-sectional study during three consecutive days in 138 EDs and performed a logistic regression to identify the predictors of 30-day mortality in hospitalized patients.

Résultats : A total of 1380 cancer patients were included. The prevalence of cancer patients among ED patients was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal disorders (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of cases, of which 13.4% died at day 30. Variables independently associated with a higher mortality at day 30 were male gender (Odds Ratio (OR), 1.63; 95% CI, 1.04-2.56), fatigue (OR, 1.65; 95% CI, 1.01-2.67), poor performance status (OR, 3.00; 95% CI, 1.87-4.80), solid malignancy (OR, 3.05; 95% CI, 1.26-7.40), uncontrolled malignancy (OR, 2.27; 95% CI, 1.36-3.80), ED attendance for a neurological disorder (OR, 2.38; 95% CI, 1.36-4.19), high shock-index (OR, 1.80; 95% CI, 1.03-3.13) and oxygen therapy (OR, 2.68; 95% CI, 1.68-4.29).

Conclusion : Cancer patients showed heterogeneity among their reasons for ED attendance and a high need for hospitalization and case fatality. Malignancy and general health status played a major role in the patient outcomes. This study suggests that the emergency care of cancer patients may be complex. Thus, studies to assess the impact of a dedicated oncology curriculum for ED physicians are warranted.

Conclusion (proposition de traduction) : Les patients cancéreux ont montré une hétérogénéité parmi leurs motifs pour consulter les urgences et un besoin élevé d'hospitalisation et de létalité. La malignité et l'état de santé général ont joué un rôle majeur dans les résultats des patients. Cette étude suggère que les soins d'urgence des patients atteints de cancer peuvent être complexes. Ainsi, des études visant à évaluer l'impact d'un programme d'études dédié à l'oncologie pour les médecins du service d'urgence sont justifiées.

Mortality and clinical outcomes in patients with COVID-19 pneumonia treated with non-invasive respiratory support: A rapid review.
Radovanovic D, Coppola S, Franceschi E, Gervasoni F, Duscio E, Chiumello DA, Santus P. | J Crit Care. 2021 May 21;65:1-8. 2021 May 21;65:1-8
DOI: https://doi.org/10.1016/j.jcrc.2021.05.007  | Télécharger l'article au format  
Keywords: COVID-19; Continuous positive airway pressure; Intubation; Mortality; Non-invasive ventilation; Respiratory failure.

Review article

Introduction : Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been widely employed to treat acute respiratory failure secondary to COVID-19 pneumonia, but their role in terms of efficacy and safety are still debated. The aim of this review was to analyse mortality and intubation rates in COVID-19 patients treated with NIV/CPAP.

Méthode : Rapid review methodology was applied to include all the studies published since December-2019 until November-2020 with available data on in-hospital mortality in COVID-19 patients treated with NIV or CPAP.

Résultats : 23 manuscripts were included (4776 patients, 66% males, 46% with hypertension). 46% of patients received non-invasive respiratory support, of which 48.4% with CPAP, 46% with NIV, and 4% with either CPAP or NIV. Non-invasive respiratory support failed in 47.7% of patients, of which 26.5% were intubated and 40.9% died. In-hospital mortality was higher in patients treated with NIV compared with CPAP (35.1% vs. 22.2%). Complications were under-reported, but mostly not related to CPAP/NIV treatment.

Conclusion : CPAP and NIV appear equally and frequently applied in patients with COVID-19 pneumonia, but associated with high mortality. Robust evidence is urgently needed to confirm the clinical efficacy of non-invasive respiratory support in COVID-19-related ARDS.

Conclusion (proposition de traduction) : La CPAP et la VNI semblent applicables de manière égale et fréquente chez les patients présentant une pneumopathie à COVID-19, mais associées à une mortalité élevée. Des preuves solides sont nécessaires de toute urgence pour confirmer l'efficacité clinique de l'assistance respiratoire non invasive dans le SDRA lié à la COVID-19.

Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial.
Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, Montomoli J, Falò G, Tonetti T, Cutuli SL, Pintaudi G, Tanzarella ES, Piervincenzi E, Bongiovanni F, Dell'Anna AM, Delle Cese L, Berardi C, Carelli S, Bocci MG, Montini L, Bello G, Natalini D, De Pascale G, Velardo M, Volta CA, Ranieri VM, Conti G, Maggiore SM, Antonelli M; COVID-ICU Gemelli Study Group. | JAMA. 2021 May 4;325(17):1731-1743
DOI: https://doi.org/10.1001/jama.2021.4682
Keywords: Aucun

Randomized Controlled Trial

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

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

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

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

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

Commentaire : Ventilation non invasive au casque telle qu'utilisée dans l'essai :

Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial.
Roquilly A, Moyer JD, Huet O, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Jeantrelle C, Vermeersch V, Gaillard T, Cinotti R, Demeure Dit Latte D, Mahe PJ, Vourc'h M, Martin FP, Chopin A, Lerebourg C, Flet L, Chiffoleau A, Feuillet F, Asehnoune K; Atlanrea Study Group and the Société Française d’Anesthésie Réanimation (SFAR) Research Network. | JAMA. 2021 May 25;325(20):2056-2066
DOI: https://doi.org/10.1001/jama.2021.5561
Keywords: Aucun

Original Investigation

Introduction : Fluid therapy is an important component of care for patients with traumatic brain injury, but whether it modulates clinical outcomes remains unclear.
Objective: To determine whether continuous infusion of hypertonic saline solution improves neurological outcome at 6 months in patients with traumatic brain injury.

Méthode : Multicenter randomized clinical trial conducted in 9 intensive care units in France, including 370 patients with moderate to severe traumatic brain injury who were recruited from October 2017 to August 2019. Follow-up was completed in February 2020.
Interventions: Adult patients with moderate to severe traumatic brain injury were randomly assigned to receive continuous infusion of 20% hypertonic saline solution plus standard care (n = 185) or standard care alone (controls; n = 185). The 20% hypertonic saline solution was administered for 48 hours or longer if patients remained at risk of intracranial hypertension.
Main outcomes and measures : The primary outcome was Extended Glasgow Outcome Scale (GOS-E) score (range, 1-8, with lower scores indicating worse functional outcome) at 6 months, obtained centrally by blinded assessors and analyzed with ordinal logistic regression adjusted for prespecified prognostic factors (with a common odds ratio [OR] >1.0 favoring intervention). There were 12 secondary outcomes measured at multiple time points, including development of intracranial hypertension and 6-month mortality.

Résultats : Among 370 patients who were randomized (median age, 44 [interquartile range, 27-59] years; 77 [20.2%] women), 359 (97%) completed the trial. The adjusted common OR for the GOS-E score at 6 months was 1.02 (95% CI, 0.71-1.47; P = .92). Of the 12 secondary outcomes, 10 were not significantly different. Intracranial hypertension developed in 62 (33.7%) patients in the intervention group and 66 (36.3%) patients in the control group (absolute difference, -2.6% [95% CI, -12.3% to 7.2%]; OR, 0.80 [95% CI, 0.51-1.26]). There was no significant difference in 6-month mortality (29 [15.9%] in the intervention group vs 37 [20.8%] in the control group; absolute difference, -4.9% [95% CI, -12.8% to 3.1%]; hazard ratio, 0.79 [95% CI, 0.48-1.28]).

Conclusion : Among patients with moderate to severe traumatic brain injury, treatment with continuous infusion of 20% hypertonic saline compared with standard care did not result in a significantly better neurological status at 6 months. However, confidence intervals for the findings were wide, and the study may have had limited power to detect a clinically important difference.

Conclusion (proposition de traduction) : Chez les patients présentant un traumatisme crânien modéré à sévère, le traitement par perfusion continue de sérum salé hypertonique à 20 % par rapport aux soins standard n'a pas permis d'améliorer significativement l'état neurologique à 6 mois. Cependant, les intervalles de confiance pour les résultats étaient larges et l'étude peut avoir eu une puissance limitée pour détecter une différence cliniquement importante.

Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial.
Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, Montomoli J, Falò G, Tonetti T, Cutuli SL, Pintaudi G, Tanzarella ES, Piervincenzi E, Bongiovanni F, Dell'Anna AM, Delle Cese L, Berardi C, Carelli S, Bocci MG, Montini L, Bello G, Natalini D, De Pascale G, Velardo M, Volta CA, Ranieri VM, Conti G, Maggiore SM, Antonelli M; COVID-ICU Gemelli Study Group. | JAMA. 2021 May 4;325(17):1731-1743
DOI: https://doi.org/10.1001/jama.2021.4682  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19.
Objective: To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone.

Méthode : Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200).
Interventions: Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55).
Main outcomes and measures: The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay.

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

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

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

Diagnosis and Management of Headache: A Review.
Robbins MS | JAMA. 2021 May 11;325(18):1874-1885
DOI: https://doi.org/10.1001/jama.2021.1640
Keywords: Aucun

Review

Introduction : Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide.

Méthode : Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appe

Conclusion : Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.

Conclusion (proposition de traduction) : Les céphalées touchent environ 90 % des personnes au cours de leur vie. Parmi les céphalées primaires, la migraine est la plus débilitante et peut être traitée de manière aiguë avec des analgésiques, des anti-inflammatoires non stéroïdiens, des triptans, des gépants et du lasmiditan.

Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial.
Roquilly A, Moyer JD, Huet O, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Jeantrelle C, Vermeersch V, Gaillard T, Cinotti R, Demeure Dit Latte D, Mahe PJ, Vourc'h M, Martin FP, Chopin A, Lerebourg C, Flet L, Chiffoleau A, Feuillet F, Asehnoune K; Atlanrea Study Group and the Société Française d’Anesthésie Réanimation (SFAR) Research Network.. | JAMA. 2021 May 25;325(20):2056-2066
DOI: https://doi.org/10.1001/jama.2021.5561  | Télécharger l'article au format  
Keywords: Aucun

Original Investigation

Introduction : Fluid therapy is an important component of care for patients with traumatic brain injury, but whether it modulates clinical outcomes remains unclear.
Interventionsx: To determine whether continuous infusion of hypertonic saline solution improves neurological outcome at 6 months in patients with traumatic brain injury.

Méthode : Multicenter randomized clinical trial conducted in 9 intensive care units in France, including 370 patients with moderate to severe traumatic brain injury who were recruited from October 2017 to August 2019. Follow-up was completed in February 2020.
Interventions: Adult patients with moderate to severe traumatic brain injury were randomly assigned to receive continuous infusion of 20% hypertonic saline solution plus standard care (n = 185) or standard care alone (controls; n = 185). The 20% hypertonic saline solution was administered for 48 hours or longer if patients remained at risk of intracranial hypertension.
Main outcomes and measures: The primary outcome was Extended Glasgow Outcome Scale (GOS-E) score (range, 1-8, with lower scores indicating worse functional outcome) at 6 months, obtained centrally by blinded assessors and analyzed with ordinal logistic regression adjusted for prespecified prognostic factors (with a common odds ratio [OR] >1.0 favoring intervention). There were 12 secondary outcomes measured at multiple time points, including development of intracranial hypertension and 6-month mortality.

Résultats : Among 370 patients who were randomized (median age, 44 [interquartile range, 27-59] years; 77 [20.2%] women), 359 (97%) completed the trial. The adjusted common OR for the GOS-E score at 6 months was 1.02 (95% CI, 0.71-1.47; P = .92). Of the 12 secondary outcomes, 10 were not significantly different. Intracranial hypertension developed in 62 (33.7%) patients in the intervention group and 66 (36.3%) patients in the control group (absolute difference, -2.6% [95% CI, -12.3% to 7.2%]; OR, 0.80 [95% CI, 0.51-1.26]). There was no significant difference in 6-month mortality (29 [15.9%] in the intervention group vs 37 [20.8%] in the control group; absolute difference, -4.9% [95% CI, -12.8% to 3.1%]; hazard ratio, 0.79 [95% CI, 0.48-1.28]).

Conclusion : Among patients with moderate to severe traumatic brain injury, treatment with continuous infusion of 20% hypertonic saline compared with standard care did not result in a significantly better neurological status at 6 months. However, confidence intervals for the findings were wide, and the study may have had limited power to detect a clinically important difference.

Conclusion (proposition de traduction) : Chez les patients présentant des lésions cérébrales traumatiques modérées à graves, le traitement par perfusion continue de sérum salé hypertonique à 20 % par rapport aux soins standard n'a pas entraîné d'amélioration significative de l'état neurologique à 6 mois. Cependant, les intervalles de confiance pour les résultats étaient larges et l'étude peut avoir eu une puissance limitée pour détecter une différence cliniquement importante.

Pulmonary embolism and pregnancy.
Rossignol M, Rigouzzo A. | Prat Anesth Réanim. 2021 Mai;25:67-91
DOI: https://doi.org/10.1016/j.pratan.2021.04.003
Keywords: Pulmonary embolism; Pregnancy

Mise au point

Editorial : La grossesse et le post-partum sont des périodes où le risque d’embolie pulmonaire est augmenté du fait d’une hypercoagulabilité, d’une stase veineuse et de traumatismes vasculaires éventuels. La physiopathologie de l’embolie pulmonaire fait intervenir une redistribution de la perfusion responsable d’hypoxémie et dans les formes graves une hypertension artérielle pulmonaire responsable de dilatation et d’ischémie du ventricule droit. Certaines parturientes (syndrome des antiphospholipides, mutation du facteur V ou du facteur II) sont particulièrement à risque. Ce risque peut être apprécié à l’aide de score (Dargaud, Strathege) qui permet d’adapter la stratégie de prévention. Le seuil des D-dimères permettant d’éliminer le diagnostic augmente avec l’évolution de la grossesse. La réalisation d’un angioscanner thoracique est possible, malgré la grossesse, de même que l’IRM. Le traitement repose sur les HBPM qui ne passent pas la barrière placentaire. Les antivitamines K sont contre-indiqués au cours de la grossesse. La fibinolyse au cours des formes graves est exceptionnelle mais possible ainsi que le recours à l’ECMO.

Conclusion (proposition de traduction) : La grossesse et le post-partum augmentent le risque d’EP à l’origine d’une morbi-mortalité, dont l’incidence ne diminue pas, depuis une dizaine d’années. Ce risque est évolutif et doit être périodiquement réévalué à la recherche de facteurs de risques additionnels médicaux, biologiques et obstétricaux. En cas de suspicion faible d’EP, les signes cliniques couplés au dosage des D-dimères pourraient permettre d’éviter certains examens radiologiques. Le diagnostic d’EP est fait par angioscanner, dont la réalisation est possible à tous les stades de la grossesse et le traitement par HBPM doit être débuté précocement avant la certitude diagnostique. Les AVK sont globalement contre-indiqués, pendant la grossesse, mais pas pendant l’allaitement (warfarine [Coumadine^®]). Les AOD sont possibles en post-partum en l’absence d’allaitement. Devant une EP grave avec choc cardiogénique, la thrombolyse doit être discutée ainsi que le recours à l’assistance circulatoire de type ECMO.

Commentaire : Pour information (ANSM - Médicaments - risques médicamenteux - publié le 30/11/2018 - mis à jour le 23/04/2021  ) :
• De manière générale, la spécialité fluindione (Préviscan) est à présent réservée au renouvellement du traitement des patients équilibrés par fluindione, en raison du risque immuno-allergique, rare mais souvent sévère, présent le plus souvent au cours des 6 premiers mois du traitement. L’initiation de traitement par fluindione (Préviscan) n’est plus autorisée à partir du 1^er décembre 2018.
• Par ailleurs, l’utilisation des antivitamines K est désormais contre-indiquée au cours de la grossesse, sauf chez les femmes enceintes portant une valve cardiaque mécanique qui présentent un risque thromboembolique élevé et pour lesquelles les bénéfices potentiels du traitement l’emportent sur les risques. En cas de poursuite d'un traitement par antivitamine K pendant la grossesse, la patiente doit être pleinement informée des risques pour le foetus.

Analgesic Efficacy of Intranasal Ketamine Versus Intranasal Fentanyl for Moderate to Severe Pain in Children: A Prospective, Randomized, Double-Blind Study.
Quinn K, Kriss S, Drapkin J, Likourezos A, Pushkar I, Brady J, Yasavolian M, Chitnis SS, Motov S, Fromm C. | Pediatr Emerg Care. 2021 May 1;37(5):250-254
DOI: https://doi.org/10.1097/pec.0000000000001556
Keywords: Aucun

Original Article

Introduction : This study aimed to compare analgesic efficacy of intranasal (IN) ketamine to IN fentanyl for moderate to severe pain in children in a pediatric emergency department.

Méthode : A prospective, randomized, double-blinded, noninferiority study evaluating children aged 3 to 17 years in a pediatric emergency department with acute moderate to severe pain was conducted. Patients received either 1 mg/kg of IN ketamine or 1.5 μg/kg of IN fentanyl and were evaluated after 10, 20, 30, and 60 minutes. The primary outcome was the degree of pain reduction after 20 minutes.

Résultats : Twenty-two patients were enrolled (11 in each group). Underlying pain conditions represented were musculoskeletal injury (73%) and abdominal pain (27%). At 20 minutes after analgesia, there was no significant difference in pain scores between the fentanyl (median, 2; range, 0-8) and ketamine groups (median, 4; range, 0-7; P = 0.20). The ketamine group showed a significantly greater rate of adverse effects, 73% versus 9% (P = 0.002), and throughout the course of the study period, 7 patients in the ketamine group (64%) group showed some degree of sedation versus no one in the fentanyl group (P = 0.004).

Conclusion : There was insufficient power to support the analgesic noninferiority of IN ketamine at a dose of 1 mg/kg compared with IN fentanyl at a dose of 1.5 μg/kg in children experiencing painful conditions at 20 minutes after administration. Intranasal ketamine was found to be inferior to IN fentanyl in relieving pain at 10 minutes and was found to have significantly greater rates of sedation and dizziness.

Conclusion (proposition de traduction) : La puissance n'était pas suffisante pour soutenir la non-infériorité analgésique de la kétamine IN à la dose de 1 mg/kg par rapport au fentanyl IN à la dose de 1,5 g/kg chez les enfants souffrant d'affections douloureuses 20 minutes après l'administration. La kétamine intranasale s'est avérée inférieure au fentanyl intranasale pour soulager la douleur à 10 minutes et s'est avérée avoir des taux significativement plus élevés de sédation et d'étourdissements.

Effects of Glucocorticoids on Hospitalized Children With Anaphylaxis.
Okubo Y, Michihata N, Morisaki N, Yoshida K, Matsui H, Fushimi K, Yasunaga H. | Pediatr Emerg Care. 2021 May 1;37(5):255-259
DOI: https://doi.org/10.1097/pec.0000000000001544
Keywords: Aucun

Original Article

Introduction : The benefits of glucocorticoid treatment and recent trends of adjunctive treatments during episodes of anaphylaxis remain unclear.
Objectives: The aims of this study were to investigate the recent practice patterns and compare the effects of glucocorticoid for children hospitalized with anaphylaxis.

Méthode : Using the Japanese Diagnosis Procedure Combination inpatient database, we compared the length of hospital stay, risk of 10-day readmission, and total hospitalization cost between the steroid and nonsteroid groups. We also evaluated recent trends of adjunctive treatments for anaphylaxis.

Résultats : From 2010 to 2014, the proportions of H1-receptor antagonist use increased from 65.1% to 71.8% (Ptrend = 0.02). The proportions of H2-receptor antagonist use showed an upward trend, ranging from 12.8% to 16.7% (Ptrend = 0.01). No significant change in glucocorticoid use was observed (from 86.7% to 82.6%; Ptrend = 0.08). Stabilized inverse probability-weighting analyses showed that the total length of hospital stay was 0.39 days longer in the steroid group than in the nonsteroid group (95% confidence interval, 0.29-0.49 days). Total hospitalization cost was greater in the steroid group than in the nonsteroid group (difference, ¥3896; 95% confidence interval, ¥2464-¥5562). No significant difference in risk of 10-day readmission was observed between the groups. Instrumental variable analyses showed similar results to stabilized inverse probability-weighting analyses.

Conclusion : We observed increasing trends of H1- and H2-receptor antagonist use. Length of hospital stay and total hospitalization cost were greater in the steroid group than in the nonsteroid group, whereas readmission risks were similar between the 2 groups.

Conclusion (proposition de traduction) : Nous avons observé des tendances croissantes d'utilisation des antagonistes des récepteurs H1 et H2. La durée d'hospitalisation et le coût total d'hospitalisation étaient plus élevés dans le groupe stéroïde que dans le groupe non stéroïde, alors que les risques de réadmission étaient similaires entre les 2 groupes.

Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence.
Robitaille-Fortin M, Norman S, Archer T, Mercier E. | Prehosp Disaster Med. 2021 May 25:1-10
DOI: https://doi.org/10.1017/s1049023x21000509
Keywords: decompression; pneumothorax; prehospital; thoracic injuries; thoracostomy.

Systematic Review

Introduction : Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting.

Méthode : A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system.

Résultats : A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart.

Conclusion : Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.

Conclusion (proposition de traduction) : Sur la base d'études observationnelles avec un faible niveau de preuves, la décompression thoracique préhospitalière à l'aiguille doit être effectuée à l'aide d'une aiguille > 7 cm de longueur avec une approche latérale ou antérieure. Bien que la thoracostomie au doigt soit une approche diagnostique et thérapeutique intéressante, les preuves sur les taux de réussite et les complications sont limitées. Des études de haute qualité sont nécessaires pour déterminer l'approche optimale de décompression thoracique applicable en milieu extra-hospitalier.

Endotracheal Tube Cuff Pressure - Comparison of the Two Filling Methods - Simulated Test.
Ilczak T, Ćwiertnia M, Białoń P, Szlagor M, Kudłacik B, Rak M, Bialka S, Ubych A, Stasicki A, Waksmańska W, Bujok J, Mikulska M, Bobiński R, Kawecki M. | Prehosp Disaster Med. 2021 Apr 30:1-5
DOI: https://doi.org/10.1017/s1049023x21000406
Keywords: cuff pressure; intubation; paramedic.

Original Research

Introduction : Tracheal intubation is the optimal method for opening up airways. Performed correctly, it prevents stomach contents from entering the respiratory tract and allows asynchronous cardiopulmonary resuscitation (CPR) to be conducted during sudden cardiac arrest. An important element of correct intubation is proper inflation of the endotracheal tube cuff. Research has shown that when medical personnel use the palpation technique, the cuff is usually inflated incorrectly. This can result in numerous health complications for the patient.

Méthode : This research was conducted in 2020 on a group of paramedics participating in the 15th International Winter Championship of Medical Rescuers in Bielsko-Biala (Poland). The aim of the research was to assess two methods of inflating the endotracheal tube cuff. Method A involved inflating the cuff using a syringe and assessing the pressure in the control cuff using the palpation technique. Method B involved inflating the cuff using a manometer. During the inflation, both the cuff inflation pressure and the time required to complete the procedure were recorded. Analysis was also conducted on whether completion of certified Advanced Life Support (ALS) and Advanced Cardiovascular Life Support (ACLS) training had any influence on the effectiveness of the inflation procedure.

Résultats : The research showed that paramedics using Method B significantly more often inflated the endotracheal tube cuff to the correct pressure than those using Method A. However, when Method B was used, the procedure took longer to conduct. The study also showed that completion of certified ALS or ACLS training did not have a significant influence on proper inflation of the cuff. Those who had completed certified training courses took significantly longer to inflate the endotracheal tube cuff when using Method A.

Conclusion : Inflation of the endotracheal tube cuff by use of a syringe, followed by the palpation technique for assessing the inflation of the cuff balloon, is ineffective. Paramedic teams should be equipped with manometers to be used for inflating the endotracheal tube cuff.

Conclusion (proposition de traduction) : Le gonflage du ballonnet du tube endotrachéal à l'aide d'une seringue, suivi de la technique de palpation pour évaluer le gonflage du ballonnet du ballonnet, est inefficace. Les équipes paramédicales doivent être équipées de manomètres à utiliser pour gonfler le ballonnet du tube endotrachéal.

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality.
Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Léguillier T, Gueye-Ngalgou P, Vivien B. | Prehosp Emerg Care. 2021 May-Jun;25(3):317-324
DOI: https://doi.org/10.1080/10903127.2020.1763532
Keywords: Septic shock; antibiotic therapy; mortality; prehospital setting.

Article

Introduction : Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting.

Méthode : From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality.

Résultats : Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016).

Conclusion : In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.

Conclusion (proposition de traduction) : Dans cette étude rétrospective, l'antibiothérapie préhospitalière réduit la mortalité à 30 jours des patients en choc septique pris en charge par l'USIC. D'autres études seront nécessaires pour confirmer l'effet bénéfique d'une antibiothérapie préhospitalière associée ou non à une optimisation hémodynamique préhospitalière pour améliorer la survie des patients en choc septique.

The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team.
Abid ES, McNamara J, Hall P, Miller KA, Monuteaux M, Kleinman ME, Nagler J. | Prehosp Emerg Care. 2021 May-Jun;25(3):325-332
DOI: https://doi.org/10.1080/10903127.2020.1761492
Keywords: airway; critical care transport; intubation; pediatrics; videolaryngoscopy.

Article

Introduction : Endotracheal intubation may be required for the transport of critically ill neonates and children. Data suggest that first pass success (FPS) is associated with lower rates of complications. Thus, understanding factors associated with FPS can have important implications for clinical outcomes. We aimed to determine the impact of videolaryngoscopy (VL) on FPS by a pediatric critical care transport team (CCTT).

Méthode : We performed a retrospective cross-sectional study on pediatric patients (≤ 18 years of age) requiring endotracheal intubation by a tertiary care-based pediatric CCTT between 2011 and 2019. Patients were categorized as neonatal (≤ 28 days of age, either preterm or term) or pediatric (> 28 days of age). All intubation attempts using VL were performed with the C-MAC videolaryngoscope. Our primary outcome was rate of FPS. Descriptive statistics of patient, provider, and procedure characteristics were calculated. Multivariate regression was used to test the association between FPS and type of laryngoscope (video versus direct) adjusting for significant clinical predictors.

Résultats : Over the study period, 135 patients were intubated by the CCTT. Sixty percent of these patients were neonates, and 40% were pediatric. The overall FPS rate was 61%, with lower rates in neonates (54%) and higher rates in pediatric patients (70%). Use of videolaryngoscopy increased over the study period. First pass success rate using the C-MAC videolaryngoscope was 72% compared to 42% for direct laryngoscopy across the whole study population. In adjusted analyses, FPS using VL was significantly higher in the pediatric patient population (aOR 12.42 [95%CI 3.33, 46.29]), but not in neonates (aOR 1.08 [0.44, 2.63]). Use of VL increased significantly over the study period.

Conclusion : We found use of a C-MAC videolaryngoscope by a critical care transport team was associated with improved FPS during endotracheal intubation of pediatric patients but not neonates, after controlling for other patient and provider characteristics. In addition to the impact on FPS, use of VL may offer additional educational and quality benefits.

Conclusion (proposition de traduction) : Nous avons constaté que l'utilisation d'un vidéolaryngoscope C-MAC par une équipe de transport de soins intensifs était associée à une amélioration du FPS pendant l'intubation endotrachéale des patients pédiatriques mais pas des nouveau-nés, après contrôle des autres caractéristiques des patients et des prestataires. En plus de l'impact sur le FPS, l'utilisation de la LV peut offrir des avantages supplémentaires en matière d'éducation et de qualité.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review.
Dainty KN, Atkins DL, Breckwoldt J, Maconochie I, Schexnayder SM, Skrifvars MB, Tijssen J, Wyllie J, Furuta M, Aickin R, Acworth J, Atkins D, Couto TB, Guerguerian AM, Kleinman M, Kloeck D, Nadkarni V, Ng KC, Nuthall G, Ong YG, Reis A, Rodriguez-Nunez A, Schexnayder S and al.; International Liaison Committee on Resuscitation’s (ILCOR) Pediatric; Neonatal Life Support Task Force; Education, Implementation and Teams Task Force. . | Resuscitation. 2021 May;162:20-34
DOI: https://doi.org/10.1016/j.resuscitation.2021.01.017
Keywords: Cardiac arrest; Family presence; Neonatology; Pediatric resuscitation; Systematic review.

Review

Introduction : Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted.
Objective: To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation.

Méthode : Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020.
Study selection: 3200 titles were retrieved in the initial search; 36 ultimately included for review. Data extraction: Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology.

Résultats : The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority. Limitations: English language only; lack of randomized control trials; quality of the publications.

Conclusion : Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes.

Conclusion (proposition de traduction) : Les parents souhaitent avoir la possibilité d'être présents, mais les opinions et les points de vue sur la présence de la famille varient considérablement d'un prestataire de soins à l'autre. Ce sujet nécessite de toute urgence une recherche comparative de haute qualité pour mesurer l'impact réel de la présence familiale sur les résultats des patients, des familles et du personnel.

Commentaire : Voir le commentaire de l'article par Lemoine S, Chabernaud JL, Jost D, Prunet B. Re: Family Presence during Resuscitation in Paediatric Cardiac Arrest: A Systematic Review. Offering Parents the Choice to View Resuscitation of their Child in Case of Sudden Cardiac Arrest. Resuscitation. 2021 May 7:S0300-9572(21)00177-5  .

Machine learning can support dispatchers to better and faster recognize out-of-hospital cardiac arrest during emergency calls: A retrospective study.
Byrsell F, Claesson A, Ringh M, Svensson L, Jonsson M, Nordberg P, Forsberg S, Hollenberg J, Nord A. | Resuscitation. 2021 May;162:218-226
DOI: https://doi.org/10.1016/j.resuscitation.2021.02.041  | Télécharger l'article au format  
Keywords: Artificial intelligence; Dispatcher; Emergency calls; Emergency medical dispatch centres; Machine learning; Out-of-hospital cardiac arrest (OHCA).

Rapid Response Systems

Introduction : Fast recognition of out-of-hospital cardiac arrest (OHCA) by dispatchers might increase survival. The aim of this observational study of emergency calls was to (1) examine whether a machine learning framework (ML) can increase the proportion of calls recognizing OHCA within the first minute compared with dispatchers, (2) present the performance of ML with different false positive rate (FPR) settings, (3) examine call characteristics influencing OHCA recognition.

Méthode : ML can be configured with different FPR settings, i.e., more or less inclined to suspect an OHCA depending on the predefined setting. ML OHCA recognition within the first minute is evaluated with a 1.5 FPR as the primary endpoint, and other FPR settings as secondary endpoints. ML was exposed to a random sample of emergency calls from 2018. Voice logs were manually audited to evaluate dispatchers time to recognition.

Résultats : Of 851 OHCA calls, the ML recognized 36% (n = 305) within 1 min compared with 25% (n = 213) by dispatchers. The recognition rate at any time during the call was 86% for ML and 84% for dispatchers, with a median time to recognition of 72 versus 94 s. OHCA recognized by both ML and dispatcher showed a 28 s mean difference in favour of ML (P < 0.001). ML with higher FPR settings reduced recognition times.

Conclusion : ML recognized a higher proportion of OHCA within the first minute compared with dispatchers and has the potential to be a supportive tool during emergency calls. The optimal FPR settings need to be evaluated in a prospective study.

Conclusion (proposition de traduction) : Le cadre d'apprentissage automatique a reconnu une proportion plus élevée d'arrêts cardiaques extra-hospitaliers dans la première minute par rapport aux répartiteurs et a le potentiel d'être un outil de soutien lors des appels d'urgence. Les paramètres optimaux de taux de faux positifs doivent être évalués dans une étude prospective.

Airway strategy and chest compression quality in the Pragmatic Airway Resuscitation Trial.
Wang HE, Jaureguibeitia X, Aramendi E, Jarvis JL, Carlson JN, Irusta U, Alonso E, Aufderheide T, Schmicker RH, Hansen ML, Huebinger RM, Colella MR, Gordon R, Suchting R, Idris AH. | Resuscitation. 2021 May;162:93-98
DOI: https://doi.org/10.1016/j.resuscitation.2021.01.043
Keywords: Airway management; Cardiopulmonary arrest; Emergency medical service; Intubation.

Clinical paper

Introduction : Chest compression (CC) quality is associated with improved out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART).

Méthode : We analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques and a graphical user interface to calculate CC quality measures and defined interruptions as pauses in chest compressions longer than 3 s. We determined CC fraction, rate and interruptions (number and total duration) for the entire resuscitation and compared differences between LT and ETI using t-tests. We repeated the analysis stratified by time before, during and after airway insertion as well as by successive 3-min time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between bag-valve-mask (BVM-only) vs. ETI or LT.

Résultats : Of 3004 patients enrolled in PART, CPR process data were available for 1996 (1001 LT, 995 ETI). Mean CPR analysis duration were: LT 22.6 ± 10.8 min vs. ETI 25.3 ± 11.3 min (p < 0.001). Mean CC fraction (LT 88% vs. ETI 87%, p = 0.05) and rate (LT 114 vs. ETI 114 compressions per minute (cpm), p = 0.59) were similar between LT and ETI. Median number of CC interruptions were: LT 11 vs. ETI 12 (p = 0.001). Total CC interruption duration was lower for LT than ETI (LT 160 vs. ETI 181 s, p = 0.002); this difference was larger before airway insertion (LT 56 vs. ETI 78 s, p < 0.001). There were no differences in CC quality when stratified by 3-min time epochs.

Conclusion : In the PART trial, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. CC quality may be associated with OHCA airway management.

Conclusion (proposition de traduction) : Dans l'essai PART, par rapport à l'intubation endotrachéale, le masque laryngé était associée à une durée totale d'interruption des compressions thoraciques plus courte, mais pas aux autres mesures de qualité des compressions thoraciques. La qualité de la compression thoracique peut être associée à la prise en charge des voies aériennes en cas d'arrêt cardiorespiratoire extra-hospitalier.

Video laryngoscopy for out of hospital cardiac arrest.
Huebinger RM, Stilgenbauer H, Jarvis JL, Ostermayer DG, Schulz K, Wang HE. | Resuscitation. 2021 May;162:143-148
DOI: https://doi.org/10.1016/j.resuscitation.2021.02.031
Keywords: Cardiac arrest; Intubation; Out-of-hospital cardiac arrest; Video laryngoscopy.

Clinical paper

Introduction : Endotracheal intubation is an import component of out-of-hospital cardiac arrest (OHCA) resuscitation. In this analysis, we evaluate the association of video laryngoscopy (VL) with first pass success and return of spontaneous circulation (ROSC) using a national OHCA cohort.

Méthode : We analyzed 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record. We included all adult, non-traumatic cardiac arrests undergoing endotracheal intubation. We defined VL and direct laryngoscopy (DL) based on paramedic recorded intubation device. The primary outcomes were first pass success, ROSC, and sustained ROSC. Using multivariable, mixed models, we determined the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC in the field for greater than 20 min), fitting agency as a random intercept and adjusting for confounders.

Résultats : We included 22,132 patients cared for by 914 EMS agencies, including 5702 (25.7%) VL and 16,430 (74.2%) DL. Compared to DL, VL had a lower rate of bystander CPR, but other characteristics were similar between the groups. VL exhibited higher first pass success than DL (75.1% v 69.5%, p < .001). On mixed model analysis, VL was associated with a higher first pass success (OR 1.5, CI 1.3-1.6) but not ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2).

Conclusion : While associated with higher FPS, VL was not associated with increased rate of ROSC. The role of VL in OHCA remains unclear.

Conclusion (proposition de traduction) : Bien qu'associée à un plus grand nombre de faux positifs, l'utilisation de la vidéo-laryngoscopie n'était pas associée à un taux accru de retour de une récupération cardiaque spontanée. Le rôle de la vidéo-laryngoscopie dans l'arrêt cardiaque extra-hospitalier reste incertain.

Automatic external defibrillator provided by unmanned aerial vehicle (drone) in Greater Paris: A real world-based simulation.
Derkenne C, Jost D, Miron De L'Espinay A, Corpet P, Frattini B, Hong V, Lemoine F, Jouffroy R, Roquet F, Marijon E, Beganton F, Stibbe O, Lemoine S, Salome M, Kedzierewicz R, Prunet B; Paris Fire Brigade Cardiac Arrest Task Force. | Resuscitation. 2021 May;162:259-265
DOI: https://doi.org/10.1016/j.resuscitation.2021.03.012
Keywords: Defibrillation; Out-of-hospital cardiac arrest; Simulation; Unmanned aerial vehicles.

Simulation and Education

Introduction : To reduce the delay in defibrillation of out-of-hospital cardiac arrest (OHCA) patients, recent publications have shown that drones equipped with an automatic external defibrillator (AED) appear to be effective in sparsely populated areas. To study the effectiveness of AED-drones in high-density urban areas, we developed an algorithm based on emergency dispatch parameters for the rate and detection speed of cardiac arrests and technical and meteorological parameters.

Méthode : We ran a numerical simulation to compare the actual time required by the Basic Life Support team (BLSt) for OHCA patients in Greater Paris in 2017 to the time required by an AED-drone. Endpoints were the proportion of patients with "AED-drone first" and the defibrillation time gained. We built an open-source website (https://airborne-aed.org/) to allow modelling by modifying one or more parameters and to help other teams model their own OHCA data.

Résultats : Of 3014 OHCA patients, 72.2 ± 0.7% were in the "no drone flight" group, 25.8 ± 0.2% in the "AED-drone first" group, and 2.1 ± 0.2% in the "BLSt-drone first" group. When a drone flight was authorized, it arrived an average 190 s before BLSt in 93% of cases. The possibility of flying the drone during the aeronautical night improved the results of the "AED-drone first" group the most (+60%).

Conclusion : In our very high-density urban model, at most 26% of OHCA patients received an AED from an AED-drone before BLSt. The flexible parameters of our website model allows evaluation of the impact of each choice and concrete implementation of the AED-drone.

Conclusion (proposition de traduction) : Dans notre modèle urbain à très haute densité, au plus 26 % des patients en arrêt cardiaque extra-hospitalier ont reçu un défibrillateur automatisé externe à partir d'un drone-défibrillateur automatisé externe avant l'équipe de secouristes. Les paramètres flexibles de notre modèle de site Web permettent d'évaluer l'impact de chaque choix et de mettre en œuvre concrètement le drone-éfibrillateur automatisé externe.

Rapid sequence induction: where did the consensus go?.
Avery P, Morton S, Raitt J, Lossius HM, Lockey D. | Scand J Trauma Resusc Emerg Med. 2021 May 13;29(1):64
DOI: https://doi.org/10.1186/s13049-021-00883-5  | Télécharger l'article au format  
Keywords: Apnoeic oxygenation; Emergency anaesthesia; Governance; Rapid sequence induction; Standard operating procedures; Video laryngoscopy.

Review

Introduction : Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI - training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment.

Conclusion : The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles - rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

Conclusion (proposition de traduction) : La pratique de l'induction à séquence rapide dans la pratique actuelle des urgences est très éloignée des descriptions originales de la procédure. Malgré cela, les principes - délivrance rapide d'une voie aérienne définitive et prévention de l'aspiration - restent très pertinents et les indications de l'induction à séquence rapide demeurent relativement inchangées.

The Prognostic Value of Lactate in Cardiac Intensive Care Unit Patients With Cardiac Arrest and Shock.
Burstein B, Vallabhajosyula S, Ternus B, Barsness GW, Kashani K, Jentzer JC. | Shock. 2021 May 1;55(5):613-619
DOI: https://doi.org/10.1097/shk.0000000000001582
Keywords: Aucun

Clinical Science Aspects

Introduction : Lactate is a prognostic marker in critically ill patients, although currently available illness severity scores do not include lactate as a predictive parameter. We sought to describe the association between lactate and hospital mortality in patients admitted to the cardiac intensive care unit (CICU) with cardiac arrest (CA) and shock.

Méthode : Retrospective observational analysis of Mayo Clinic CICU patients admitted from 2007 to 2018 with measured lactate on admission, including patients with and without CA or shock. We examined hospital mortality as a function of admission lactate in patients. Multivariable logistic regression was used to determine predictors of hospital mortality.

Résultats : We included 3,042 patients with a median age of 70 years (IQR 60-80), including 41% females, 26% with CA, and 39% with shock. The median APACHE-IV predicted mortality was 24% (IQR 11-51%), and the median admission lactate was 1.8 mmol/L (IQR 1.1-3.0). Hospital mortality occurred in 23% of patients and rose progressively with higher admission lactate, including in patients with and without CA or shock. After multivariable adjustment for clinical characteristics, therapies, and illness severity, a higher lactate remained associated with increased hospital mortality (adjusted OR 1.13 per mmol/L, 95% CI 1.06-1.20, P < 0.001).

Conclusion : Admission lactate levels are strongly associated with increased hospital mortality among CICU patients, including those with and without CA or shock. The prognostic value of lactate levels is independent of established ICU prognostic scores and dependent on admission diagnosis, which may help inform clinicians caring for CICU patients.

Conclusion (proposition de traduction) : Les taux de lactate à l'admission sont fortement associés à une mortalité hospitalière accrue chez les patients en USIC, y compris ceux avec et sans arrêt ou choc cardiaque. La valeur pronostique des taux de lactate est indépendante des scores pronostiques établis en USI et dépend du diagnostic d'admission, ce qui peut aider à informer les cliniciens qui s'occupent des patients en USIC.

SARS-CoV-2 and Stroke Characteristics: A Report From the Multinational COVID-19 Stroke Study Group.
Shahjouei S, Tsivgoulis G, Farahmand G and al.. | Stroke. 2021 May;52(5):e117-e130
DOI: https://doi.org/10.1161/strokeaha.120.032927  | Télécharger l'article au format  
Keywords: Aucun

CLINICAL AND POPULATION SCIENCES

Introduction : Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale.

Méthode : We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes.

Résultats : Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were <55 years of age, and 105 (24.4%) patients had no identifiable vascular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 patients) had large vessel occlusion; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median National Institutes of Health Stroke Scale (8 [3–17] versus 11 [5–17]; P=0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P<0.001) in countries with middle-to-high health expenditure when compared with countries with lower health expenditure. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%) were asymptomatic at the time of admission for SARS-CoV-2 infection.

Conclusion : We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

Conclusion (proposition de traduction) : Nous avons observé un taux considérablement plus élevé d'occlusions de gros vaisseaux, un taux beaucoup plus faible d'occlusions de petits vaisseaux et d'infarctus lacunaires, et un nombre considérable d'AVC chez les jeunes par rapport aux études de population avant la pandémie. Le taux de thrombectomie mécanique était significativement plus faible dans les pays où les dépenses de santé étaient moindres.

CPR by foot. An alternative in special circumstances? A randomized simulation study.
Otero-Agra M, Santiago-Urgal N, Hermo-Gonzalo MT, Fernández-Méndez M, Fernández-Méndez F. | Am J Emerg Med. 2021 May;43:1-6
DOI: https://doi.org/10.1016/j.ajem.2020.12.086
Keywords: CPR by foot; CPR in special circumstances; Nursing students.

Original Contribution

Introduction : To assess the differences in the quality and self-perception of CPR performed with foot technique compared to the standard technique with the hands in nursing students.

Méthode : 65 university nursing students participated in a randomized simulation crossover design study. The participants randomly performed two CPR tests: CPR by foot and CPR by hands techniques. The compression-only protocol with a 2-min test was used with the Resusci Anne QCPR® manikin and Wireless Skill Reporter® software, both from Laerdal.

Résultats : Participants had lower quality when doing CPR by foot (72%) than when doing standard CPR (91%) (p = 0.006). 95% of the participants indicated standard CPR as the technique of choice, while 92% indicated that they would use CPR by foot if it was not possible to perform standard technique.

Conclusion : CPR quality was lower when performing foot technique, although with positive results. It would be advisable for people with acquired CPR skills to know that they can do foot compressions in situations where they cannot use their hands.

Conclusion (proposition de traduction) : La qualité de la RCP était inférieure lors de la réalisation de la technique au pied, bien qu'avec des résultats positifs. Il serait souhaitable que les personnes ayant acquis des compétences en RCP sachent qu'elles peuvent effectuer des compressions au pied dans des situations où elles ne peuvent pas utiliser leurs mains.

Commentaire : 

Surviving traumatic cardiac arrest: Identification of factors associated with survival.
Khalifa A, Avraham JB, Kramer KZ, Bajani F, Fu CY, Pires-Menard A, Kaminsky M, Bokhari F. | Am J Emerg Med. 2021 May;43:83-87
DOI: https://doi.org/10.1016/j.ajem.2021.01.020
Keywords: Blunt trauma; Cardiac arrest; Penetrating trauma; Resuscitation; Trauma.

Original contribution

Introduction : The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED)

Méthode : The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed.

Résultats : A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99).

Conclusion : Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.

Conclusion (proposition de traduction) : Au cours d'une récente période de neuf ans aux États-Unis, près de 25 000 patients traumatisés ont été traités dans des centres de traumatologie malgré l'absence de signe vital. Parmi ces patients, seulement 73 sont rentrés chez eux. Un centre de traumatologie devrait tenter plus d'une centaine de réanimations d'arrêt cardiaque traumatiques pour sauver un patient, confirmant des rapports antérieurs qui mettent en évidence un pronostic grave. Cela crée un dilemme dans le traitement des intervenants de première ligne et des médecins pour l'utilisation des ressources et la prise en compte de la sécurité de l'exposition, en particulier face au COVID-19.

Non-invasive positive pressure ventilation versus endotracheal intubation in treatment of COVID-19 patients requiring ventilatory support.
Daniel P, Mecklenburg M, Massiah C, Joseph MA, Wilson C, Parmar P, Rosengarten S, Maini R, Kim J, Oomen A, Zehtabchi S. | Am J Emerg Med. 2021 May;43:103-108
DOI: https://doi.org/10.1016/j.ajem.2021.01.068  | Télécharger l'article au format  
Keywords: COVID-19; Endotracheal intubation; Hypoxemia; Non-invasive positive pressure ventilation.

Original contribution

Introduction : Initial guidelines recommended prompt endotracheal intubation rather than non-invasive ventilation (NIV) for COVID-19 patients requiring ventilator support. There is insufficient data comparing the impact of intubation versus NIV on patient-centered outcomes of these patients.
Objective: To compare all-cause 30-day mortality for hospitalized COVID-19 patients with respiratory failure who underwent intubation first, intubation after NIV, or NIV only.

Méthode : Retrospective study of patients admitted in March and April of 2020.
Setting: A teaching hospital in Brooklyn, New York City.
Participants: Adult COVID-19 confirmed patients who required ventilator support (non-invasive ventilation and/or endotracheal intubation) at discretion of treating physician, were included.
Exposures: Patients were categorized into three exposure groups: intubation-first, intubation after NIV, or NIV-only.
Primary outcome: 30-day all-cause mortality, a predetermined outcome measured by multivariable logistic regression. Data are presented with medians and interquartile ranges, or percentages with 95% confidence intervals, for continuous and categorical variables, respectively. Covariates for the model were age, sex, qSOFA score ≥ 2, presenting oxygen saturation, vasopressor use, and greater than three comorbidities. A secondary multivariable model compared mortality of all patients that received NIV (intubation after NIV and NIV-only) with the intubation-first group.

Résultats : A total of 222 were enrolled. Overall mortality was 77.5% (95%CI, 72-83%). Mortality for intubation-first group was 82% (95%CI, 73-89%; 75/91), for Intubation after NIV was 84% (95%CI, 70-92%; 37/44), and for NIV-only was 69% (95%CI, 59-78%; 60/87). In multivariable analysis, NIV-only was associated with decreased all-cause mortality (odds ratio [OR]: 0.30, 95%CI, 0.13-0.69). No difference in mortality was observed between intubation-first and intubation after NIV. Secondary analysis found all patients who received NIV to have lower mortality than patients who were intubated only (OR: 0.44, 95%CI, 0.21-0.95).

Conclusion : Utilization of NIV as the initial intervention in COVID-19 patients requiring ventilatory support is associated with significant survival benefit. For patients intubated after NIV, the mortality rate is not worse than those who undergo intubation as their initial intervention.

Conclusion (proposition de traduction) : L'utilisation de la VNI comme intervention initiale chez les patients COVID-19 nécessitant un support ventilatoire est associée à un bénéfice de survie significatif. Pour les patients intubés après VNI, le taux de mortalité n'est pas pire que ceux qui bénéficient d'une intubation comme intervention initiale.

The impact of using different age-adjusted cutoffs of D-dimer in the diagnosis of pulmonary thromboembolism.
Uzel Şener M, Şahin Duyar S, Saral Öztürk Z, Şener A. | Am J Emerg Med. 2021 May;43:118-122
DOI: https://doi.org/10.1016/j.ajem.2021.01.070
Keywords: Age; Comorbidities; D-dimer; Pulmonary embolism.

Original contribution

Introduction : Background This study was conducted to evaluate the relationship of age-adjusted D-dimer value with different coefficients in diagnosis of pulmonary embolism (PE) in geriatric patients.

Méthode : The emergency admissions of the patients aged 65 and over with suspected PE during 2018 were reviewed retrospectively. The demographic characteristics, laboratory tests and radiologic findings of computed tomography pulmonary angiogram (CTPA) or single photon emission computed tomography ventilation/perfusion scintigraphy (V/Q) were recorded. The characteristics of the patients with PE were statistically compared with the patients without PE. The specificity and sensitivity for higher cut-off levels (age × 10-15) were presented.

Résultats : PE was detected in 39.2% (n = 246) of 628 patients aged 65 years and older included in the study. The multivariate analysis revealed that higher D-dimer level (OR = 1,00011; p < 0.001) and BUN level (OR = 1.025; p = 0.013) were independent risk factors for PE diagnosis in elderly patients. Diagnostic statistics for D-dimer cut-off levels selected from ROC analysis and calculated values as 10-15 times of age showed that if the D-dimer cut-off value used is chosen higher, lower sensitivity rates are obtained. Our results also indicated that the patients with malignancy, renal failure, central PE on CTPA and PE with high probability on SPECT VQ were presented with higher D-dimer values.

Conclusion : Our results do not support the use of higher D-dimer cut-off levels such as 15 times the age in geriatric population. The impact of the location of PE and comorbidities on the outcomes of these patients must be clarified for determining cut-offs with higher specificity.

Conclusion (proposition de traduction) : Nos résultats ne sont pas en faveur de l’utilisation de seuils de D-dimère plus élevés, comme 15 fois l’âge dans la population gériatrique. L’incidence du niveau de l’embolie pulmonaire et des comorbidités sur les résultats de ces patients doit être clarifiée afin de déterminer des seuils plus spécifiques.

An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia.
Lemoine L, Le Bastard Q, Batard E, Montassier E. | J Emerg Med. 2021 May;60(5):599-606
DOI: https://doi.org/10.1016/j.jemermed.2020.11.028
Keywords: calcium; emergency department; glucose; hyperkalemia; insulin; salbutamol.

Clinical Review

Introduction : The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly.

Méthode : This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician.

Résultats : We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management.

Discussion : In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized β2-agonists.

Conclusion : Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.

Conclusion (proposition de traduction) : L'hyperkaliémie est un trouble électrolytique fréquent aux urgences. En raison du risque d'arythmie mortelle due à l'instabilité de la membrane cardiaque, l'hyperkaliémie est une urgence médicale. Il y a un manque de preuves scientifiques sur la gestion optimale de l'hyperkaliémie et des recherches supplémentaires sont nécessaires pour établir des stratégies optimales de gestion de l'hyperkaliémie aiguë au service des urgences.

Commentaire :  Algorithme proposé pour la gestion de l'hyperkaliémie aiguë dans le service d'urgence.

Use of Point-of-Care Ultrasound to Confirm Central Venous Catheter Placement and Evaluate for Postprocedural Complications.
Montrief T, Auerbach J, Cabrera J, Long B. | J Emerg Med. 2021 May;60(5):637-640
DOI: https://doi.org/10.1016/j.jemermed.2021.01.032
Keywords: access; bubble study; central venous catheter; ultrasound.

Techniques and Procedures

Introduction : Central venous catheter (CVC) placement is commonly performed in the emergency department (ED), but traditional confirmation of placement includes chest radiograph.

Méthode : This manuscript details the use of point-of-care ultrasound (POCUS) to confirm placement of a CVC and evaluate for postprocedural complications.

Discussion : CVC access in the ED setting is an important procedure. Traditional confirmation includes chest radiograph. POCUS is a rapid, inexpensive, and accurate modality to confirm CVC placement and evaluate for postprocedural complications. POCUS after CVC can evaluate lung sliding for pneumothorax and the internal jugular vein for misdirected CVC. A bubble study with POCUS visualizing agitated saline microbubbles within the right heart can confirm venous placement.

Conclusion : POCUS can rapidly and reliably confirm CVC placement, as well as evaluate for postprocedural complications. Knowledge of this technique can assist emergency clinicians.

Conclusion (proposition de traduction) : L'échographie au point d'intervention peut confirmer rapidement et de manière fiable la mise en place d'un cathéter veineux central, ainsi que pour évaluer les complications de la procédure de placement. La connaissance de cette technique peut aider les urgentistes.

Commentaire :  Approche échographique pour évaluer le positionnement d'un cathéter veineux central placé dans la veine jugulaire interne droite.
(A) Vues transversales et (B) sagittales de la veine jugulaire interne gauche controlatérale au site d'insertion montrant un cathéter mal positionné (C, flèche rouge dans (A et B). IJ = veine jugulaire interne, CA = artère carotide.

The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis.
Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. | J Trauma Acute Care Surg. 2021 May 1;90(5):901-907
DOI: https://doi.org/10.1097/ta.0000000000003120
Keywords: Aucun

SYSTEMATIC REVIEW

Introduction : Tranexamic acid (TXA) is an antifibrinolytic drug associated with improved survival among trauma patients with hemorrhage. Tranexamic acid is considered a primary hemostatic intervention in prehospital for treatment of bleeding alongside blood product transfusion.

Méthode : A systematic review and meta-analysis was conducted to investigate the impact of prehospital TXA on mortality among trauma patients with bleeding. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advanced Search library which contain the following of databases: EMBASE, Medline, PubMed, BNI, EMCARE, and HMIC. Other databases searched included SCOPUS and the Cochrane Central Register for Clinical Trials Library. Quality assessment tools were applied among included studies; Cochrane Risk of Bias for randomized control trials and Newcastle-Ottawa Scale for cohort observational studies.

Résultats : A total of 797 publications were identified from the initial database search. After removing duplicates and applying inclusion/exclusion criteria, four studies were included in the review and meta-analysis which identified a significant survival benefit in patients who received prehospital TXA versus no TXA. Three observational cohort and one randomized control trial were included into the review with a total of 2,347 patients (TXA, 1,169 vs. no TXA, 1,178). There was a significant reduction in 24 hours mortality; odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99). No statistical significant differences in 28 days to 30 days mortality; OR of 0.69 (95% CI, 0.47-1.02), or venous thromboembolism OR of 1.49 (95% CI, 0.90-2.46) were found.

Conclusion : This review demonstrates that prehospital TXA is associated with significant reductions in the early (24 hour) mortality of trauma patients with suspected or confirmed hemorrhage but no increase in the incidence of venous thromboembolism.

Conclusion (proposition de traduction) : Cette revue démontre que l'acide tranexamique en préhospitalier est associé à des réductions significatives de la mortalité précoce (24 heures) des patients traumatisés avec une hémorragie suspectée ou confirmée, mais sans augmentation de l'incidence de la thrombophlébite veineuse.

Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease.
Jones WS, Mulder H, Wruck LM, Pencina MJ and al.; ADAPTABLE Team. | N Engl J Med. 2021 May 27;384(21):1981-1990
DOI: https://doi.org/10.1056/nejmoa2102137
Keywords: Aucun

ORIGINAL ARTICLE

Introduction : The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy.

Méthode : Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis.

Résultats : A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]).

Conclusion : In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily.

Conclusion (proposition de traduction) : Dans cet essai pragmatique incluant des patients présentant une maladie cardiovasculaire confirmée, il y a eu un changement substantiel de dose à 81 mg d’aspirine par jour et aucune différence significative dans les événements cardiovasculaires ou les saignements majeurs entre les patients affectés à 81 mg et ceux affectés à 325 mg d'aspirine par jour.

Management of the Difficult Airway.
Heidegger T | N Engl J Med. 2021 May 13;384(19):1836-1847
DOI: https://doi.org/10.1056/nejmra1916801
Keywords: Aucun

Review article

Editorial : Failure to establish an airway can be life-threatening. Although relatively rare, such cases tend to be underreported. Advances in visualization techniques may be helpful. Difficult intubation can often be anticipated and prepared for.

Conclusion : Management of the difficult airway is an important issue, since even small changes in the performance of airway management are highly relevant to the outcome. Airway management is a process that requires thorough preparation, which includes careful airway assessment, planning, and appropriate decision making. Management of the airway involves the use of appropriate techniques and skills, an appropriate response to difficulty or failure, and careful planning for tracheal extubation. Skills and human factors together are the key to successful airway management.

Conclusion (proposition de traduction) : La gestion des voies aériennes supérieurs difficiles est un problème important, car même de petits changements dans la performance de la gestion des voies aériennes sont très pertinents pour le résultat. La gestion des voies aériennes est un processus qui nécessite une préparation minutieuse, qui comprend une évaluation minutieuse des voies respiratoires, une planification et une prise de décision appropriée. La gestion des voies aériennes implique l'utilisation de techniques et de compétences appropriées, une réponse appropriée à la difficulté ou à l'échec, et une planification minutieuse pour l'extubation trachéale. Les compétences et les facteurs humains réunis sont la clé d'une gestion réussie des voies aériennes supérieures.

Commentaire :  Algorithme de gestion des voies aériennes supérieures.
Les praticiens effectuant la gestion des voies aériennes doivent appeler à l'aide lorsqu'ils ont des difficultés à maintenir l'oxygénation du patient. L'accès aux voies aériennes à la face antérieure du cou (Front-of-neck airway : FONA) pendant que le patient est éveillé ou suffisamment conscient et qu'il respire spontanément est rarement pratiqué mais n'est pas inhabituel dans des situations telles que celles impliquant un risque élevé d'échec de l'oxygénation si la gestion des voies aériennes est effectuée après l'induction de l'anesthésie générale ou un risque élevé d'échec de l'intubation trachéale chez un patient éveillé (p. ex., chez un patient présentant une tumeur massive dans la région supraglottique). Adapté de Law et Heidegger. FMV (face-mask ventilation) désigne la ventilation au masque facial et SGA (supraglottic airway) les voies aériennes supraglottiques.